Transfer Flashcards
What is the definition of:
1. Primary
2. Secondary
3. Tertiary
4. Quaternary
Transfers
- Movement from site of illness/injury to secondary care
- Movement from one secondary care facility to another (or tertiary)
- Movement from a secondary/tertiary care facility to an a site of national expertise
- International movement
What are the most common type of incident/event during transfer in order 1-3?
- Technical
- CV
- Resp
What proportion of transport events/incidents are thought to be preventable?
Up to 90%
Describe suitable transfer equipment? (4)
- Properly mounted in accordance with government regulations.
- Transfer trolleys should carry all the equipment
- Equipment should be mounted below the level of the patient for saferty
- Battery life of all electronic devices should be at least several hours and battery life expectancy should be displayed.
What are current recommendations on the transfer of critically ill patients?
- Should be specialist team
- Intensive care should not be interrupted by transfer
- Should be specific training for teams
- Should have physician (ideally ITU) and ITU nurse
- Transfer physician has overall say over who is transferrable and what treatment they get en route
- Should have governance system
What frequency of vibration will cause:
1. motion sickness
2. hyperventilation
3. muscle contraction
4. clot dislodgment
5. arrhythmia/BP fluctuation
- 0-2 Hz
- 3-4 Hz
- 20-100 Hz
- Higher frequency
- Close to frequency of HR
Describe the atmospheric layers from nearest-uppermost layers (5)
- Troposphere - 0-14.5km
Consistent temperaturedrop to -52 degrees, water vapour present - Stratosphere - 14.5km-50km
Increasing temp to -3 degrees - Mesophere - 50-85km
Rapid temp drop to -93 degrees C. - Thermosphere - 85-600km
Increasing temp due to absorption of solar radiation - Exosphere - uppermost layer, variable temp
What is:
1. Level 1
2. Level 2
3. Level 3
Care
- Single organ support, step down
- 2:1 nursing
-Basic support for two or more organs
- Invasive monitoring
- Advanced support for 1 organ (not resp)
- weaning from mechanical ventilation via tracheostomy in patient who is spontaneously ventilating
- 1:1 nursing
- advanced resp support alone
- advanced support for 2 or more organs
Describe:
1. Speed
2. Velocity
3. Weight
4. Acceleration
- The distance travelled in a given unit of time regardless
of direction - Speed applied to a given direction, e.g. 300 knotsWest.
- When the force of gravity is applied to a mass it gives rise to the force we sense as weight. If an 80-kg patient is subjected to an accelerative force of 2 G they would weigh 160 kg.
- A rate of change of velocity measured in metres per
second squared. Can be a positive number or a negative number (deceleration).
What is Newtons:
1. First law
2. Second law
3. Third law
- An object will remain at a constant velocity or state of rest unless a force is applied to it. Force therefore causes acceleration.
- Acceleration
is directly related to the force applied to it and inversely
proportional to the mass of the object - For every action or force, there is an equal and opposite reaction. Therefore when we are accelerated
by one force in one direction, we will be exposed to a force in the opposite direction, known as the reactive or inertial force.
What is an inertial/reactive force?
Newtons 3rd law: For every action or force, there is an equal and opposite reaction. Therefore when we are accelerated by one force in one direction, we will be exposed to a force in the opposite direction, known as the reactive or inertial force.
What is ‘G force?’
The reactive force felt during acceleration is known as G force and is labelled according to the magnitude (inmultiples of Gs) and the direction it is applied in relation to the body
What is:
1. Gz
2. Gx
3. Gy
- G force along the vertical access
- G force along the AP axis
- G force applied laterally
What is:
1. +Gx
2. - Gx
- Positive anteroposterior G force (+Gx) occurs when the body is accelerated forward and the reactive force pushes the body
backwards. - Negative anteroposterior G force (–Gx) occurs as the
body decelerates or accelerates in a backwards direction with the
reactive force pushing the body forward.
What is:
1. + Gz
2. - Gz
- Positive vertical G force (+Gz) when the body is accelerated upwards and the reactive force pushes down. This is felt as an
increased weight. - A negative vertical G force (–Gz) occurs when
the body is accelerated downwards with the reactive force pushing
upwards.
What is:
1. + Gy
2. - Gy
- Positive lateral G force (+Gy) occurs when the body
is accelerated to the right - Negative lateral G force (–Gy) when the body is accelerated to the left.
What is:
1. short duration acceleration
2. long duration acceleration
3. linear acceleration
4. radial acceleration
5. angular acceleration
- Acceleration < 1 sec
- Accleration >2 secs
- Change in rate of movement e.g take off/landing or DSA increasing/decreasing speed
- Change in direction
- Change in both rate and direction
Describe the difference in affect of G force depending on the patient being supine/seated patients in DSA and fixed wing
In a seated patient the
reactive G forces will be applied along the anteroposterior axis (Gx)
with little physiological effects. However if supine, the linear acceleration
will act along the vertical axis with greater displacement of
organs and fluid volumes in response to the vertical G force (Gz). In
rotary wing aircraft, lift off will cause the linear acceleration along
the vertical axis (Gz) in the seated patient and anteroposterior axis
in (Gx) in the supine patient.
In what axis is acceleration tolerated least?
Vertical (Gz) - more space for the organs to shift, and greater hydrostatic pressures are produced as the Gforce is applied across a longer column.
What is the CV physiological affect of sustained high positive vertical pressure (+ Gz)? (4)
BP falls in the head and increase in the feet.
Lower limb blood pools reducing venous
return.
At +5Gz blood flow to the brain ceases leading to LOC
> 6 seconds baroreceptors in the carotid
artery initiate compensatory mechanisms (increase HR/SV/SVR) but rarely returns to pre-exposure levels (much worse in sepsis/hypovolaemia)
What are the ventilatory changes seen in sustained high positive vertical pressure (Gz)? (2)
Increased residual capacity -Abdominal viscera and diaphragm are
pulled down
V/Q mismatch -
Descent of lung tissue causes distension of apical alveoli
and compression of basal alveoli leading to preferential ventilation of the lung apices. Simultaneously perfusion to the apical alveoli is reduced, with resultant ventilation perfusion (V/Q) mismatch
(exaggerated in hypovolaemic patients).
What is the CV physiological affect of sustained high negative vertical pressure (- Gz)? (3)
- Increase venous
return leading to a reflex bradycardia. - Sustained exposure causes peripheral vasodilation in lower body (lowers BP)
- Pooling of blood in the cerebral circulation will lead to raised intracranial pressure and reduced cerebral perfusion pressure.
What are the ventilatory changes seen in sustained high negative vertical pressure (- Gz)?
Gz forces the abdominal organs and diaphragm to be pushed up
reducing the residual capacity and causing a V/Q mismatch equal
and opposite to that described in +Gz.
Which patients should be loaded:
1. Feet first
2. Head first
- Hypovolaemia - will lead to increase venous return during acceleration phase
- Fluid overload, high ventilatory pressures, HI, eye injury
What is the best way to avoid the physiological changes caused by acceleration?
Limit the acceleration with smooth journey e.g long taxi /runway, easy driving, smooth flight path without bit turns etc.
What percentage of adverse events during transfer are due to equipment failure?
40%
What are the sources of and frequency of vibration in:
1. DSA
2. Helicopter
3. Fixed wing
- The most common source
is a turning land-based ambulance at low frequencies (0–2Hz). - Transmitted from the main rotor (12–15 Hz) and tail rotor (23–25Hz).
- Turbulence
(0–4Hz).
Who needs to decide to transfer a patient (aside from the physician doing the transfer)
The consultants in both the referring and receiving hospitals
How quickly should a patient be repatriated back to their local hospital when identified as suitable?
48 hours
What percentage of intensive care patients are transferred from another hospital?
5%
What percentage of critical care transfers occur at:
1. Night
2. Day (7am-18pm)
- 55%
- 45%
What is the proposed minimum documentation for transferring critically unwell patients (FICM) (10)
- Case identifier
- Transfer details
- Reason for transfer
- Diagnosis
- Dependency of patient e.g level 2/3
- Transfer timings
- Level of risk and risk assessment form
- Transferring personel
- Level of resp support
- Critical incidents during transfer
NB: CV support/infusions/obs not mentioned
What are the minimum standards for monitoring in critical transfer? (FICM) (6)
- Continous observation of patient
- ECG
- NIBP (no frequency stated)
- SATS
- I+V = ETC02 (does not have to be waveform)
- Temp (frequency not stated)W
What clinical factors are medium risk for patient transfer? (6)
- Maintaining own airway
- Fi02 <0.6
- BE -4 to -8
- Low dose ionotrope/vasopressor (<0.2mg/kg/min)
- GCS 9-13
- Mild hypo- hyper- thermia
Who can transfer medium risk patients?
- Nurse or clinical practitioner
AND
- Doctor or ACP with equal competencies + airway competencies
What clinical factors are low risk for transfer? (6)
- Maintaining airway
- Fi02 < 0.4
- BE 0 - -4
- No ionotropes/vasopressors
- GCS 14 or 15
- Normothermic
Who can transfer low risk patients
Nurse of clinical practitioner
What clinical factors make a patient high risk for transfer? (6)
- I+V
- Fi02 > 0.6
- BE > -8
- Ionotropes/vasopressors > 0.2mg/kg/hr or CV unstable)
- Moderate hypothermia/hyperthermia
- Major trauma
Who can transfer high risk patients?
- Nurse or clinical practitioner
AND
- Doctor or advanced practitioner with critical care and advanced airway competencies
What is the oxygen calculation for transfer?
Oxygen required (L)
= 2 x transport time (mins) x (MV x Fi02 +bias flow)
What is:
1. Boyles Law
2. Charles Law
3. Gay-Lussacs Law
4. Daltons Law
5. Henrys Law
- At a constant temperature, the volume of a fixed mass of gas is inversely proportional to the pressure
- At a constant pressure, the volume of a fixed mass of gas is proportional to the temperature
- At a constant volume, the pressure of a fixed mass of gas is proportional to the temperature
- The pressure exerted by a fixed mass of gas in a mixture of gases is the same pressure it would exert on its own
- At a constant temperature, the amount of gas dissolved in a liquid is proportional to the partial pressure of the gas above the liquid
In terms of transferring patients with pathologies involving gas filled cavities, which gas law is the most relevant?
Boyles Law = higher altitude where atmospheric pressure is lower, the gas in the cavities will have an increased volume
With regards to cabin decompression during transfer, what increases the rate of decompression? (4)
- Volume of the cabin
- Size of the breach
- Absolute pressure in the cabin at the beginning of the decompression
- Absolute pressure outside the cabin
With regards to cabin decompression during transfer, what factors affect the physiological response? (3)
- rate of the decompression
- the pressure change during the decompression
- the pressure in the cabin after the decompression.
What are the considerations with respects to ETT and altitude?
- Risk of tracheal mucosa pressure necrosis with altitude gain.
- Filling cuffs with water is difficult/impractical.
- If travelling
above 2–3000 feet let some air out of the cuff and monitor cuff pressure with a monometer.
Over what altitude can patients develop abdominal pain due to gas expansion?
> 25,000
What are the clinical effects of cabin decompression? (3)
- Hypobaric hypoxia - in rapid decompression oxygen rapidly diffuses out of the venous system into alveoli, leading to complete deoxygenation of blood in the circulation
- Expansion of gases (Boyles Law)
- Hypothermia (outside temp -50 degrees C)
What is decompression sickness (in altitude)?
- Group of effects produced by exposure to altitude that are not due to expansion of trapped gas or hypoxia.
- The aetiology is believed to be due to supersaturation
of body tissues with nitrogen, which then precipitates out on decompression, producing bubbles in various sites that - The same process occurs in diving decompression sickness, improves on descent
What increase chance of decompression sickness? (11)
- altitude: it is rare below 18,000 ft
- the change in absolute pressure to which the individual has been
exposed - time at altitude
- recent altitude exposure
- exercise at altitude
- cold
- hypoxia
- genetic susceptibility
- age
- obesity
- lower physical fitness.
Over what altitude does the affect of decreasing partial pressure of oxygen in patients blood start to have clinical affect?
> 3000m (>8000ft)
How can hypoxia at altitude be limited? (3)
- Low altitude flying
- Increasing inspired oxygen
- Pressurising cabin
To what altitude are commercial planes pressurised to?
5000-8000 ft
What are the 2 dangers with lithium battery fires?
- Thermal event is irreversible and fire cannot be extinguished
- Release toxic gases:
- Hydrogen fluoride
- Hydrogen cyanide
- Hydrogen chloride
- Carbon monoxide
What 4 gases do lithium battery fires release?
- Hydrogen fluoride
- Hydrogen cyanide
- Hydrogen chloride
- Carbon monoxide
In the case of lithium battery fires, what is the specific initial complication of hydrogen fluoride gas?
Causes direct corrosive injury to the pulmonary tissues leading to:
- profound mucosal irritation
- airway oedema
- bronchospasm
- pulmonary oedema
- ARDS
Can also lead to systemic fluorosis
What drugs does the AAGBI guidelines reccomend for TBI transfer?
- Hypnotics (propofolol/midazolam)
- Neuromuscular blocking agents
- Opoid analgesics
- Anticonvulsants
- Mannitol/hypertonic
- Vasoactive drugs
- Resus drugs
- IV fluids
- Cross matched blood (if trauma/bleeding)
What does the AAGBI states are indications for I+V in TBI? (8)
- GCS 8 or less
- Fall in GCS 2 or more or motor score 1 or more
- loss or laryngeal reflex
- Failure to maintain pa02 13Kpa or more
- PaC02 <4.0 OR >6.0 kPa
- Bilateral fractured mandible
- Significant haemorrhage in oral cavity
- Seizures
What are the 3 identified groups of threats to transfer?
(i) Technical: patient/equipment
(ii) Non-technical: crew resource management
(iii) Organizational: governance
Who have produced the framework of governance to ensure safe transfers of critically unwell patients?
AAGBI (in conjunction with Intensive Care Society)
What does AAGBI/ICS state with regards to equipment mounting for transfer of critically unwell patients? (3)
- All should be mounted on transfer trolley
- should be CEN compliant
- should be below level of patient (lower centre of gravity/makes more stable)
What does AAGBI/ICS state with regards to restraint in transfer of critically unwell patients, and who is responsible for this?
All patients on a transfer trolley need 5 point harness
It is the responsibility of the driver
If flying what should be done to a chest drain/underwater seal?
Replace underwater seal (can be knocked over easily) with a one-way (Heimlich) valve
What anti-emetic has been shown to be most effective at managing motion sickness and what is its main disadvantage?
Hyoscine hydrobromide
Can be more sedating in some people than anti-histamines
What is central venous pressure used to monitor and interpret?
RV pressure
What is does the following represent on a CVP waveform?
1. a wave
2. c wave
3. x descent
4. v wave
5. y descent
- Atrial contaction - end diastole (a=atrial)
- TV ‘C’usps into bulging RA - early systole
- RA relaXation - mid systole
- Late systole - rapid filling of RA
- earlY ventricular filling - early diastole
What happens to the CVP waveform in:
1. TR
2. Pulmonary HTN
3. Pulmonary stenosis
4. Contstrictive pericarditis
5. Kussmauls sign
- Dominant V wave, fusion of c and v waves blunting x descent (RA filling during RV contraction)
- dominant a wave - RA contraction against increased pressure
- dominant a wave - RA contarction against increased pressure
- Increased x and y descent
- Increased pre-load during inspiration leads to an increase in RA pressure and CVP (CVP should fall in inspiration) = constrictive pericardititis
What is the predominant affect of:
1. alpha -1
2. beta-1
3. beta-2
What is the affect of the following on alpha-1/beta-1/2:
1. Adrenaline
2. Noradrenaline
3. Metaraminol
4. Ephedrine
5. Dobutamine
Describe the National Advisory Commitee for Aeronautics (NACA) scoring system for medical emergencies? (8)
NACA 0 = no disease/injury
NACA I = minor disturbance, no medical intervention needed
NACA II = mild to moderate disturbance, no emergency medical intervention required
NACA III = Moderate-sever with no life threatening disorders
NACA IV = Severe with potential for deterioration to life threatening disorder
NACA V = acute or immediate danger
NACA VI = resp +/- cardiac arrest
NACA VII = Death
Why to children tire faster with increased respiratory effort than adults? (2)
- Smaller alveolar surface therefore decreased gaseous exchange
- Compliant chest wall with immature intercostal and diaphragm muscles (fewer fatigue-resistant type 1 fibres) makes them more
prone to exhaustion and respiratory failure.
If children need to increase their MV, how do they do this and why?
Unable to increase TV so must increase RR
Why do children need PEEP?
Smaller alveolar radius predisposes to collapse, thus in a mechanically
ventilated child it is very important to provide external PEEP.
Why do children get bronchi obstruction more than adults?
Growth of distal airways lag behind proximal < 5 years
As resistance to flow is inversely proportional to the fourth power of the radius (Poiseuille’s law) mild obstructions can cause significant difficulty
in ventilation.
What drugs are normally used to sedate children during transfer?
Morpine + midazolam > 6 months
Why isn’t propofol used to sedate children for transfer?
Risk of propofol infusion syndrome
Propofol-related Infusion Syndrome (PRIS) is a life-threatening condition characterised by acute refractory bradycardia progressing to asystole and one or more of:
metabolic acidosis
rhabdomyolysis
hyperlipidaemia
enlarged or fatty liver
What is propofol infusion syndrome?
Propofol-related Infusion Syndrome (PRIS) is a life-threatening condition characterised by acute refractory bradycardia progressing to asystole and one or more of:
metabolic acidosis
rhabdomyolysis
hyperlipidaemia
enlarged or fatty liver
Describe the changes in neonatal physiology at birth?
With the first breath, the lungs expand, pulmonary vascular resistance (PVR) falls and blood flows through the pulmonary arteries.
With increase in pulmonary venous return there is an increase in left atrial pressure and the foramen ovale closes.W
Why do babies get cold quickly? (3)
- Minimal subcutaneous fat stores
- unable to shiver to
generate heat - large surface
area to body weight ratio.
Why must we be cautious with IVI in young children? (2)
- Renal blood flow and glomerular filtration are low in the first 2 years of life due to high renal vascular resistance.
- Tubular function
is immature until 8 months so infants are unable to excrete a
large sodium load
What are the changes in neonatal haematology? (2)
- Predominant haemoglobin is HbF, it binds avidly
to oxygen but releases it slowly, hence at birth babies are relatively polycythaemic (Hb 18–20 gm/dL). - Deficiency of vitamin K-dependent clotting factor (hence given vit K)
With premature babies what is the predominant respiratory condition that affects them and how is it managed?
Respiratory Distress Syndrome
- I+V
2. Exogenous surfactant
What are the indications for I+V in neonates undergoing transfer? (4)
- Rising oxygen requirement >50%
- Hypercapnia leading to acute respiratory acidosis on blood gases
- Clinically tiring
- Intubation prior to transfer is mandatory for apnoea
What needs to be ensured when using iNO in aircraft?
Needs clearance from the
European Aviation Safety Agency (EASA) to ensure that all directives under the Dangerous Goods Convention (Class 2 Division 2.3) have been satisfied.
What condition is iNO used for in neonates?
Persistent Pulmonary HTN of Newborn (PPHN) - it is a potent pulmonary vasodilator
What is the recommend Hb of premature neonates undergoing transfer to ensure sufficient oxygen carrying capacity?
12g/DL
What neurological investigation should be performed before transferring a premature neonate and why?
Cranial USS to assess for intraventicular haemorrhage (IVH) influences
the decision to transfer and prognosis.
Ex utero transfer is known to increase the risk of IVH in extremely immature neonates.
What is the most common GI issue needing transfer for premature neonates and what should be considered before transfer? (4)
Necrotising enterocolitis. .
Impairs ventilation:
1. discuss drain insertion with neonatal surgeons
2. adjusting ventilator settings
- Sepsis is common and
broad-spectrum antibiotic cover advised
4/Analgesia is essential
and IVmorphine is required pre-transfer.
What mean systemic pressures should be targeted in premature neonates?
> gestational age (Weeks) in first day of life
Under what size should a umbilical cord catheter be considered?
< 800g
How far should an cannula be advances in an emergency into the umbilical vein?
In an emergency, it’s acceptable to advance the catheter 1-2 cm beyond the point of blood return without radiographic confirmation
If not an emergency - where should a formal umbilical vein be advanced to and how should this be checked?
IVC above the diaphragm (between T8-9)
Describe the anatomy of the vasculature of the umbilical cord
How is Meconium Aspiration Syndrome Managed?
- Sedation and muscle relaxation
- Exogenous surfactant 200mg/kg
- Mean systemic pressure of 50mmHg
- Hydrocortisone 2mg/kg BD for hypotension
- Nitric oxide 20ppm is evidence of persistent pulmonary htn of newborn on echo
If using Nitric Oxide for neonatal transfer what should be monitored?
Methaemoglobinaemia monitoring (<2%)
What is Meconium Aspiration Syndrome?
Affects postmature
infants and is associated with ventilation/perfusion mismatch and a pneumothorax risk through excessive pulmonary
expansion.
Can lead to PPHN
In neonates what is the most common organism causing sepsis?
Group B Strep
In confirmed hypoxic ischaemic encephalopathy what:
1. Is the temperature target?
2. When should it be initiated by?
3. For how long?
4. Who recommends it?
1.Rectal temp 33.5 degrees
2. < 6 hours birth
3. for 72 hours
4. NICE + British Association of Perinatal Medicine (BAPM)
If transporting a child being cooled post hypoxic ischaemic encephalopathy what should be done in addition to usual measures?
- Reduce monitor alarms (HR normally 80-90bpm)
- Sedation
- May need phenobarbitol or phenytoin for seizures
- Cerebral function monitoring beneficial
If transferring neonates with Transposition of Great Arteries what should be done? (3)
Circulation dependent of PDA and foramen ovale
- Prostaglandin infusion (dinoprostone 5ng/kg/min)
- Emergency septostomy maybe indicated pre-transfer if echo shows intact atrial septum - d/w cardiac surgeons
- Avoid I+V if possible
How should a neonate with hypoplastic left heart syndrome be managed during transfer? (5)
Difficult balance between systemic and pulmonary flow
- CVP
- Prostaglandin infusion (dinoprostone 5ng/kg/min)
- Avoid I+V
- Accept PaC02 7-8kPA and SATs 75-80%
- Systemic vasodilators (Milrinone, sodium
nitroprusside) may be used when peripheral perfusion deteriorates, indicated by a pink baby with oxygen saturations >90%, a rising
serum lactate and worsening base deficit.
What defines Persistent Pulmomary HTN of Newborn? (PPHN)
Pre/post-ductal oxygen saturation difference
of >5% (frequently >20%)
How should neonates with Congenital Diaphragmatic Hernia be managed for transfer? (5)
Will present severely hypoxic
- i+v
- decompress stomach with gastric tube
- TV 3-4ml/kg
- Mean systemic BP >50mmHg if term
- PPHN common - iNO if present
How quickly should neonates with anterior abdominal wall defects (e.g gatroschisis) be transferred for surgical review?
< 4 hours
What should be done when transferring neonates with anterior abdominal wall defects (e.g gatroschisis)?
- Nurse right side down to relieve pressure on mesentery
- NGT
- Cling film over lesion
- Monitor fluid loss closely and replace as needed
How should neonates with neural tube defects be transferred? (4)
- Assess lower limb neurological, anal and bladder function.
- Cover lesion (Mepitel dressings)
- Abx if CSF is leaking.
- Transfer prone
Neonates with bilious vomiting should be assumed to have what condition and how should they be transferred?
Malrotation or volvulus
- NGT
- Abx for sepsis
How much fluid loss can very premature babies have due to immature skin?
40ml/kg
How can neonates be kept warm during transfer? (3)
- Servo controlled incubators
- Chemical mattress e.g Transwarmer
- Humidification
For paeds I+V with airway obstruction
who should perform it and what should be used ideally?
Must senior anaesthetist and ENT surgeon should be present
Gas induction preferences
With respects to CV status in asthma what should be considered?
- Venous return can be compromised with lung hyperinflation
- Vasodilation during anaesthetic induction.
Adequate circulatory resuscitation is therefore essential
When should steroids be considered in paeds resus/transfer?
If still shock following 40ml/kg fluid and ionotropes
1-2mg/kg hydrocortisone
What is the most common cause of trauma in:
1. < 5 yrs
2. > 5 years
- Burns
- Blunt trauma
What is the best way to secure a childs ETT?
‘Red tape strapping’ method
How much will the following preserve neonates temperature?
1. Insulating clothing
2. Radiant heaters
- 30%
- 77%
What considerations should be made when transporting a child being actively cooled? (5)
- Continual rectal temperature monitoring is vital.
- Check placement regularly throughout the journey
- Rapid rewarming is associated with an increased risk of seizures
- HR will be lower
- Cooling is uncomfortable - analgesia
How do active cooling systems work in neonates?
Enveloping wrap which circulates cold water under the control of a microprocessing system
regulated by a rectal temperature probe.
How does Nitric oxide improve oxygenation in neonates with PPHN?
- acts locally on the
smooth muscle of the pulmonary vasculature increasing levels of
cGMP, causing relaxation and vascular dilatation. - Decreases ventilation-perfusion mismatch.
- The rapid breakdown
of iNO prevents any systemic vasodilatory effect.
What is the indication for the following in neonates with PPHN?
1. iNO
2. ECMO
- Oxygenation index >20
- Consider of OI > 35, mandatory > 40
What colour are Nitric oxide cannisters?
Light green with dark green neck
Why is it essential to have sufficient NO for a transfer?
Patient can get significant rebound hypoxia if it is stopped
How is the oxygenation index calculated?
FiO2 × mean alveolar pressure (mmHg)/PaO2
If transferring a neonate using iNO what should be monitored? (3)
- Continuous pre- and post-ductal oxygen saturation monitoring (seperate probes)
- systemic blood pressure at the upper range of normal
for gestational age to decrease right-left shunting across the PDA. - N02 (toxic) monitoring
What is High Frequency Oscillation Ventilation (HFOV)?
- Rescue treatment of respiratory failure; it is particularly useful in meconium aspiration syndrome and CDH
- Very high frequency (300-600 breaths/min) with low TV (sometimes lower than the dead space)
- maintains lung volume and reduces shear stress, improving gaseous exchange
What is pulmonary over-circulation in the context of cyanotic heart disease and how should it be prevented?
Pulmonary and systemic circulations are in parallel rather than in series.
Aim SATs 75-85% and PaC02 5kPa to avoid pulmonary vasodilation and over circulation at expense of the systemic circulation
What can lead commonly to intracranial haemorrhage in neonates?
I+V
What gestation does the following start:
1. pulmonary surfactant production
2. Alveolar development
- 24 weeks
- 32 weeks
Why are neonates unable to tolerate a bradycardia?
Because they are unable to increase SV and therefore bradycardias can lead to CV collapse
What does FHb do to the oxygen dissociation curve and what is the clinical impact of this
Shift to the left
High affinity for 02 means ‘holds on’ to it and therefore need a higher concentration of Hb to ensure tissue oxygen delivery.
Consequently unable to tolerate anaemia
What are the age adjusted blood volumes for the following:
1. Preterm
2. Newborn
3. 6 weeks - 2 yrs
4. 2 years - puberty
5. Adult
- 100ml/kg
- 90ml/kg
- 85ml/kg
- 80ml/kg
- 70ml/kg
What is the recommended physiological targets for hypoxic ischaemic encephalopathy? (KIDS) (5)
- 33-34 degrees
- SATs > 94% (avoid hyperoxia)
- PaC02 5.0-7.0 kPa
- Glucose > 2.6
- HR normal 80-100bpm (if higher consider pain/low volume)
When and how should seizures be managed following HIE? (KIDS)
If evidence EEG/physiological parameters:
- > 3mins
- > 3 x an hour
Phenobarbitone 20mg/kg over 20 mins
What percentage of heat loss in anaesthetised patients is:
1. Radiation
2. Convection
3. Evaporation
4. Conduction
- 40%
- 30%
- 25%
- 5%
What is the gas principle related to using nebulisers and venturi?
Bernoulli principle - as fluid patients through a constriction the flow, and therefore kinetic energy, increases.
As kinetic energy increases, the pressure decreases and can cause fluid entrainment
What are the target CPPs in children with neurosurgical emergencies? (3)
- 55mm Hg in infants
- 60mm Hg in pre-school age children
- 70mm Hg in older children
CPP = MAP - ICP
Estimate ICP = 20mmHg
What are the ventilation targets for PARDS:
1. TV
2. Plateau pressure
3. PEEP
4. sp02
5. PH
- 5-8ml/kg (3-6ml/kg if poor resp compliance) predicted body weight
- 28 cmH20 or less
- 10-15 cmH20
- 92-97%
- 7.15-7.30 (permissive hypercapnoea)
What are the ventilation targets for ARDS;
1. TV
2. Plateau pressure
3. PEEP
4. SpO2
5. 7.30-7.46
- 6ml/kg predicted body weight
- <30cmH20
3.10 cmH20 or more incrementally increasing with Fi02, up to PEEP 24cmH20 - 88-95%
- 7.30-7.45
If transferring a patient with a POP via fixed wing what should be considered?
Splitting the cast
What considerations should be made secondary to the reduction in barometric pressure and therefore an increase in volume of gas filled cavities during air transfer? (5)
- ETT cuff pressure should be monitored.
- Drain PTX - no clamp
- NGTs placed and put on free drainage
- Split plaster casts
- Pneumo-peritoneum and intracranial air are relative contraindications to air transport.
