No abstract

The practice of pediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile ICUs capable of delivering state-of-the-art critical care during pediatric and neonatal transport. The most recent document regarding the practice of pediatric/neonatal transport is more than a decade old. The following article details changes in the practice of interfacility transport over the past decade and expresses the consensus views of leaders in the field of transport medicine, including the American Academy of Pediatrics’ Section on Transport Medicine.

Improved monitoring during pediatric transport has the potential to improve outcomes of critically ill children. Clinical trials, including randomized controlled trials, can be accomplished during pediatric transport. Future studies should evaluate optimal equipment, protocols, procedures, and interventions during pediatric transport, aimed at improving the clinical and functional outcomes of critically ill patients.

Overwhelming adenovirus infection requiring extracorporeal membrane oxygenation (ECMO) support carries a high mortality in pediatric patients. The objective of this study was to retrospectively review data from the Extracorporeal Life Support Organization (ELSO) registry for pediatric patients with adenovirus infection and define for this patient cohort: 1) clinical characteristics, 2) survival to hospital discharge, and 3) factors associated with mortality before hospital discharge. In this retrospective registry study, pediatric patients with adenovirus infection requiring ECMO support identified in an international ECMO registry from 1998 to 2009 were compared for clinical characteristics (demographics, pre-ECMO variables, and complications on ECMO) between survivors and nonsurvivors to hospital discharge. Descriptive statistics and univariate and multivariate logistic analysis were used to compare clinical characteristics among survivors and nonsurvivors. For children requiring ECMO support for adenovirus, the survival at hospital discharge is 38% (62/163). Among neonates (<31 days of age), the survival at hospital discharge was only 11% (6/54). Among patient factors, neonatal age (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.62-10.87), a decrease of 0.1 unit in pre-ECMO pH (OR, 1.77; 95% CI, 1.3-2.42), the presence of sepsis (OR, 4.55; 95% CI, 1.47-14.15), and increased peak inspiratory pressures (OR, 1.04; 95% CI, 1.01-1.08) were all independently associated with in-hospital mortality. ECMO complications independently associated with in-hospital mortality were presence of pneumothorax (OR, 3.57; 95% CI, 1.19-10.7), pH less than 7.2 (OR, 5.94; 95% CI, 1.04-34.1), and central nervous system hemorrhage (OR, 25.36; 95% CI, 1.47-436.7). In this retrospective cohort study of pediatric patients with adenovirus infection supported on ECMO, survival to hospital discharge was 38% but was much lower in neonates. Neonatal presentation, degree of acidosis, sepsis, and increased PIP are factors present before decisions are made regarding a trial of ECMO, whereas pneumothorax and brain hemorrhage were ECMO-related complications independently associated with mortality.

Pediatric transport has evolved significantly since its inception >2 decades ago. Advancements in technology and therapeutic interventions now afford an opportunity to extend intensive care into the transport environment. However, misapplication of the concept of the golden hour has led to a focus on speed of transfer to tertiary care facilities, often delaying early, goal-directed therapeutic interventions. If we are to further improve outcomes for critically ill children, we must extend early institution of goal-directed therapy into the pretertiary hospital setting and bring expertise to the child.