Mortality and Resource Utilization After Critical Care Transport of Patients With Hypoxemic Respiratory Failure

Wilcox, Susan R.; Richards, Jeremy B.; Genthon, Alissa; Saia, Mark S.; Waden, Heather; Gates, Jonathan D.; Cocchi, Michael N.; McGahn, Susan J.; Frakes, Michael A.; Wedel, Suzanne K.

doi:10.1177/0885066615623202

Cited by 14 publications

(8 citation statements)

References 23 publications

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“… 15 16 These were not cases of ARDS, at least at the time of transport. Compared with other studies of tertiary interhospital transports of severely hypoxaemic patients, the mortality rate is lower in our cohort, 17–19 while being higher than long-term mortality rates in secondary interhospital transferred trauma patients at 3,6 and 12 months. 20–22 Of course, expected mortality will be based on a number of different patient factors, including age, comorbidity, extent of injury or illness and more.…”

Section: Discussioncontrasting

confidence: 85%

Respiratory and circulatory insufficiency during emergent long-distance critical care interhospital transports to tertiary care in a sparsely populated region: a retrospective analysis of late mortality risk

et al. 2022

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ObjectivesTo test if impaired oxygenation or major haemodynamic instability at the time of emergency intensive care transport, from a smaller admitting hospital to a tertiary care centre, are predictors of long-term mortality.DesignRetrospective observational study. Impaired oxygenation was defined as oxyhaemoglobin %–inspired oxygen fraction ratio (S/F ratio)<100. Major haemodynamic instability was defined as a need for treatment with norepinephrine infusion to sustain mean arterial pressure (MAP) at or above 60 mm Hg or having a mean MAP <60. Logistic regression was used to assess mortality risk with impaired oxygenation or major haemodynamic instability.SettingSparsely populated Northern Sweden. A fixed-wing interhospital air ambulance system for critical care serving 900 000 inhabitants.ParticipantsIntensive care cases transported in fixed-wing air ambulance from outlying hospitals to a regional tertiary care centre during 2000–2016 for adults (16 years old or older). 2142 cases were included.Primary and secondary outcome measuresAll-cause mortality at 3 months after transport was the primary outcome, and secondary outcomes were all-cause mortality at 1 and 7 days, 1, 6 and 12 months.ResultsS/F ratio <100 was associated with increased mortality risk compared with S/F>300 at all time-points, with adjusted OR 6.3 (2.5 to 15.5, p<0.001) at 3 months. Major haemodynamic instability during intensive care unit (ICU) transport was associated with increased adjusted OR of all-cause mortality at 3 months with OR 2.5 (1.8 to 3.5, p<0.001).ConclusionMajor impairment of oxygenation and/or major haemodynamic instability at the time of ICU transport to get to urgent tertiary intervention is strongly associated with increased mortality risk at 3 months in this cohort. These findings support the conclusion that these conditions are markers for many fold increase in risk for death notable already at 3 months after transport for patients with these conditions.

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Section: Discussioncontrasting

confidence: 85%

Respiratory and circulatory insufficiency during emergent long-distance critical care interhospital transports to tertiary care in a sparsely populated region: a retrospective analysis of late mortality risk

et al. 2022

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“…26 Studies have shown that transferring patients with ARDS to tertiary care centers, especially those with ECMO capabilities, improved survival over patients remaining in referring hospitals. 1,2,27,28 Although initiating ECMO prior to transport is possible and in some series, improved the safety of traveling, [29][30][31] ECMO cannulation is not universally available. Therefore, the onus is on centers with ECMO capabilities to provide safe passage for accepting patients into their centers, by air or ground.…”

Section: Discussionmentioning

confidence: 99%

The Importance of Ground Critical Care Transport

Wilcox

Ries

Bouthiller

et al. 2016

J Intensive Care Med

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Critical care transport (CCT) teams are specialized transport services, comprised of highly trained paramedics, nurses, and occasionally respiratory therapists, offering an expanded scope of practice beyond advanced life support (ALS) emergency medical service teams. We report 4 cases of patients with severe acute respiratory distress syndrome from influenza in need of extracorporeal membrane oxygenation evaluation at a tertiary care center, transported by ground. Our medical center did not previously have a ground CCT service, and therefore, in these cases, a physician and/or a respiratory therapist was sent with the paramedic team. In all 4 cases, the ground transport team enhanced the intensive care provided to these patients prior to arrival at the tertiary care center. In 2 of the cases, although limited by the profound hypoxemia, the team decreased the pressures and tidal volumes in an effort to approach evidence-based ventilator goals. In 3 cases, they stopped bicarbonate drips being used to treat mixed metabolic and respiratory acidosis, and in 1 case, they administered furosemide. In 1 case, they started cisatracurium, and in 3 others, they initiated inhaled epoprostenol. Existing literature supports the use of CCT teams over ALS teams for transport of the most critically ill patients, and helicopter CCT is not always available or practical. Therefore, offering comparable air and ground options, with similar staffing and resources, is a hallmark of a mature medical system with an integrated approach to CCT.

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“…9 Patients with respiratory failure transported by a highly trained CCT team have improved outcomes as compared to their predicted mortality by severity of illness scores. 10 A cohort of hypoxemic respiratory failure patients with a predicted mortality of approximately 64% by APACHE II score had a mortality rate of 35% 10 after transport to tertiary care ECMO centers. Transport by a skilled CCT team is the best way to mitigate the increased risk of transporting hypoxemic respiratory failure patients.…”

Section: Discussionmentioning

confidence: 99%

“…19 Therefore, in most instances, the benefits of tertiary care for patients with hypoxemic respiratory failure outweigh the risks of transport with a dedicated CCT team, when considered in the context of remaining at a community hospital with limited resources. 9,10 In these four cases, no patient was cannulated for ECMO at the receiving hospital. Two patients died within 24 hours of arrival, but the other two survived to hospital discharge.…”

Section: Discussionmentioning

confidence: 99%

“…8,9 Therefore, the benefits of tertiary care for patients with hypoxemic respiratory failure likely outweigh the risks of remaining at a community hospital with limited resources. 9,10 Transport by a skilled critical care transport (CCT) team is the best way to mitigate the increased risk of moving hypoxemic respiratory failure patients. With ventilator management by a highly trained CCT team, patients have a significant improvement in their oxygenation after transport, 11 despite temporary desaturations in transit.…”

Section: Introductionmentioning

confidence: 99%

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Inhaled Epoprostenol to Facilitate Safe Transport in Legionnaires’ Disease

Foster¹,

Frakes²,

Puopolo

et al. 2020

Prehosp. Disaster med.

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Hypoxemic patients often desaturate further with movement and transport. While inhaled epoprostenol does not improve mortality, improving oxygenation allows for transport of severely hypoxemic patients to tertiary care centers with a related improvement in mortality rates. Extracorporeal membrane oxygenation (ECMO) use is increasing in frequency for patients with refractory hypoxemia, and with increasing regionalization of care, safe transport of hypoxemic patients only becomes more important. In this series, four cases are presented of young patients with severe hypoxemic respiratory failure from Legionnaires’ disease transported on inhaled epoprostenol to ECMO centers for consideration of cannulation. With continued climate changes, Legionella and other pathogens are likely to be a continued threat. As such, optimizing oxygenation to allow for transport should continue to be a priority for critical care transport (CCT) services.

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Mortality and Resource Utilization After Critical Care Transport of Patients With Hypoxemic Respiratory Failure

Cited by 14 publications

References 23 publications

Respiratory and circulatory insufficiency during emergent long-distance critical care interhospital transports to tertiary care in a sparsely populated region: a retrospective analysis of late mortality risk

Respiratory and circulatory insufficiency during emergent long-distance critical care interhospital transports to tertiary care in a sparsely populated region: a retrospective analysis of late mortality risk

The Importance of Ground Critical Care Transport

Inhaled Epoprostenol to Facilitate Safe Transport in Legionnaires’ Disease

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