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Reprinted from the June 2002 issue of RESPIRATORY CARE [Respir Care 2002;47(6):721–723]

AARC Clinical Practice Guideline

In-Hospital Transport of the Mechanically Ventilated Patient—2002 Revision & Update

TMV 1.0 PROCEDURE:
Transportation of a mechanically ventilated patient for diagnostic or therapeutic procedures.

TMV 2.0 DESCRIPTION/DEFINITION:
Transportation of mechanically ventilated patients for diagnostic or therapeutic procedures is always associated with a degree of risk.(1-9) Every attempt should be made to assure that monitoring, ventilation, oxygenation, and patient care remain constant during movement. Patient transport includes preparation, movement to and from, and time spent at destination.

TMV 3.0 SETTINGS:
This guideline is intended for the critical care and acute care inpatient setting.

TMV 4.0 INDICATIONS:
Transportation of mechanically ventilated patients should only be undertaken following a careful evaluation of the risk-benefit ratio.

TMV 5.0 CONTRAINDICATIONS:
Transportation of the mechanically ventilated patient should not be undertaken until a complete analysis of potential risks and benefits has been accomplished.

5.1 Contraindications include
5.1.1 inability to provide adequate oxygenation and ventilation during transport either by manual ventilation, portable ventilator, or standard intensive care unit ventilator,(1,10-12)
5.1.2 inability to maintain acceptable hemodynamic performance during transport,(13-15)
5.1.3 inability to adequately monitor patient cardiopulmonary status during transport,(14)
5.1.4 inability to maintain airway control during transport.
5.1.5 Transport should not be undertaken unless all the necessary members of the transport team are present.

TMV 6.0 HAZARDS & COMPLICATIONS:
Hazards and complications of transport include the following:

6.1 Hyperventilation during manual ventilation may cause respiratory alkalosis, cardiac dysrhythmias, and hypotension.(1,10,11)
6.2 Loss of PEEP/CPAP may result in hypoxemia or shock.(16,17)
6.3 Position changes may result in hypotension, hypercarbia, and hypoxemia.(14)
6.4 Tachycardia and other dysrhythmias have been associated with transport.(13-15)
6.5 Equipment failure can result in inaccurate data or loss of monitoring capabilities.(8,9)
6.6 Inadvertent disconnection of intravenous access for pharmacologic agents may result in hemodynamic instability.(8,9,13)
6.7 Movement may cause disconnection from ventilatory support and respiratory compromise.(16,18)
6.8 Movement may result in accidental extubation.(13,19)
6.9 Movement may result in accidental removal of vascular access.(3-5,8,9)
6.10 Loss of oxygen supply may lead to hypoxemia.
6.11 Ventilator-associated pneumonia has been associated with transport.(20)

TMV 7.0 LIMITATIONS OF METHOD:
The literature suggests that nearly two thirds of all transports for diagnostic studies fail to yield results that affect patient care.(8,9)

TMV 8.0 ASSESSMENT OF NEED:
The necessity and safety for transport should be assessed by the multidisciplinary team of health care providers, eg, respiratory therapist, physician, nurse. The risks of transport should be weighed against the potential benefits from the diagnostic or therapeutic procedure to be performed.

TMV 9.0 ASSESSMENT OF OUTCOME:
The safe arrival of the mechanically ventilated patient at his/ her destination is the indicator of a favorable outcome.

TMV 10.0 RESOURCES:

10.1 Equipment
10.1.1 Emergency airway management supplies should be available and checked for operation before transport
10.1.2 Portable oxygen source of adequate volume
10.1.3 A self-inflating bag and mask of appropriate size
10.1.4 Transport ventilators have been shown to provide more constant ventilation than manual ventilation in some instances. If a transport ventilator is used, it should:(1,10-12,21,22)
10.1.4.1 have sufficient portable power supply for the duration of transport;(23)
10.1.4.2 have independent control of tidal volume and respiratory frequency;(16)
10.1.4.3 be able to provide full ventilatory support as in assist-control or intermittent mechanical ventilation (not necessarily both);
10.1.4.4 deliver a constant volume in the face of changing pulmonary impedance;
10.1.4.5 monitor airway pressure;
10.1.4.6 provide a disconnect alarm;
10.1.4.7 be capable of providing PEEP;
10.1.4.8 provide an FIO2 of 1.0.
10.1.5 A pulse oximeter is desirable.
10.1.6 Appropriate pharmacologic agents should be readily available.
10.1.7 Portable monitor should display ECG and heart rate and provide at least one channel for vascular pressure measurement.
10.1.8 An appropriate hygroscopic condenser humidifier should be used to provide humidification during transport.
10.1.9 Stethoscope
10.1.10 Hand-held spirometer for tidal volume measurement
10.2 Personnel: All mechanically ventilated patients should be accompanied by a registered nurse and a respiratory therapist during the entire transport.
10.2.1 At least one team member must be proficient in managing the airway in the event of accidental extubation.
10.2.2 At least one team member should be proficient in operating and troubleshooting all of the equipment described in Section 10.1.

TMV 11.0 MONITORING:
Monitoring provided during transport should be similar to that during stationary care.

11.1 Electrocardiograph should be continuously monitored for heart rate and dysrhythmias.
11.2 Blood pressure should be monitored continuously if invasive lines are present. In the absence of invasive monitoring, blood pressure should be measured intermittently via sphygmomanometer.
11.3 Respiratory rate should be monitored intermittently.
11.4 Airway pressures should be monitored if a transport ventilator is used.(24)
11.5 Tidal volume should be monitored intermittently to assure appropriate ventilation.(25)
11.6 Continuous pulse oximetry is appropriate during transport of all mechanically ventilated patients.
11.7 Breath sounds should be monitored intermittently.

TMV 12.0 FREQUENCY:
Patients should be transported only when indications are present as described in Section 4.

TMV 13.0 INFECTION CONTROL:

13.1 Universal Precautions should be observed.(26)
13.2 All equipment should be disinfected between patients.
13.3 Centers for Disease Control and Prevention recommendations for control of exposure to tuberculosis and droplet nuclei are to be implemented when patient is known or suspected to be immunosuppressed, is known to have tuberculosis, or has other risk factors for the disease.(27)

Revised by David W Chang EdD RRT, Athens Technical College, Athens GA, and approved by the 2002 CPG Steering Committee.

Original publication: Respir Care 1993;38(11):1169-1172.

References
  1. Braman SS, Dunn SM, Amico CA, Millman RP. Complications of intrahospital transport in critically ill patients. Ann Intern Med 1987;107(4):469-473.
  2. Edlin S. Physiological changes during transport of the critically ill. Intensive Care World 1989;6:131.
  3. Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Crit Care Med 1990;18(3):278-281.
  4. Insel J, Weissman C, Kemper M, Askanazi J, Hyman AI. Cardiovascular changes during transport of critically ill and postoperative patients. Crit Care Med 1986;14(6):539-542.
  5. Ehrenwerth J, Sorbo S, Hackel A. Transport of critically ill adults. Crit Care Med 1986;14(6):543-547.
  6. Andrews PJ, Piper IR, Dearden NM, Miller JD. Secondary insults during intrahospital transport of head-injured patients. Lancet 1990;335(8685):327-330.
  7. Gentleman D, Jennett B. Audit of transfer of unconscious head-injured patients to a neurosurgical unit. Lancet 1990;335(8685):330-334.
  8. Indeck M, Peterson S, Smith J, Brotman S. Risk, cost, and benefit of transporting ICU patients for special studies. J Trauma 1988;28(7):1020-1025.
  9. Hurst JM, Davis K Jr, Johnson DJ, Branson RD, Campbell RS, Branson PS. Cost and complications during in-hospital transport of critically ill patients: a prospective cohort study. J Trauma 1992;33(4):582-585.
  10. Hurst JM, Davis K Jr, Branson RD, Johannigman JA. Comparison of blood gases during transport using two methods of ventilatory support. J Trauma 1989;29(12):1637-1640.
  11. Gervais HW, Eberle B, Konietzke D, Hennes HJ, Dick W. Comparison of blood gases of ventilated patients during transport. Crit Care Med 1987;15(8):761-763.
  12. Weg JG, Haas CF. Safe intrahospital transport of critically ill ventilator-dependent patients. Chest 1989;96(3):631-635.
  13. Taylor JO, Chulay JD, Landers CF, Hood WB Jr, Abelman WH. Monitoring high-risk cardiac patients during transportation in hospital. Lancet 1970;2(7685):1205-1208.
  14. Waddell G. Movement of critically ill patients within hospital. Br Med J 1975;2(5968):417-419.
  15. Rutherford WF, Fisher CJ. Risks associated with inhouse transportation of the critically ill (abstract). Clin Res 1986;34:414.
  16. Branson RD. Intrahospital transport of critically ill, mechanically ventilated patients. Respir Care 1992;37(7):775-795.
  17. Komdeur R, van der Werf TS, Ligtenberg JJ, Tulleken JE, Zijlstra JG. [Hemodynamic and ventilatory complications of mechanical ventilation with high intrinsic positive end-expiratory pressure.] Ned Tijdschr Geneeskd 2000;144(30):1445-1450. article in Dutch
  18. Johannigman JA, Branson RD, Campbell R, Hurst JM. Laboratory and clinical evaluation of the max transport ventilator. Respir Care 1990;35(10):952-959.
  19. Christie JM, Dethlefsen M, Cane RD. Unplanned endotracheal extubation in the intensive care unit. J Clin Anesth 1996;8(4):289-293.
  20. Kollef MH, Von Harz B, Prentice D, Shapiro SD, Silver P, St John R, Trovillion E. Patient transport from intensive care increases the risk of developing ventilator-associated pneumonia. Chest 1997;112(3):765-773.
  21. Dockery WK, Futterman C, Keller SR, Sheridan MJ, Akl BF. A comparison of manual and mechanical ventilation during pediatric transport. Crit Care Med 1999;27(4):802-806.
  22. Tobias JD, Lynch A, Garrett J. Alterations of end-tidal carbon dioxide during the intrahospital transport of children. Pediatr Emerg Care 1996;12(4):249-251.
  23. Barton AC, Tuttle-Newhall JE, Szalados JE. Portable power supply for continuous mechanical ventilation during intrahospital transport of critically ill patients with ARDS. Chest 1997;112(2):560-563.
  24. Miyoshi E, Fujino Y, Mashimo T, Nishimura M. Performance of transport ventilator with patient-triggered ventilation. Chest 2000;118(4):1109-1115.
  25. McGough EK, Banner MJ, Melker RJ. Variations in tidal volume with portable transport ventilators. Respir Care 1992;37(3):233-239.
  26. Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other blood-borne pathogens in health-care settings. MMWR 1988;37(24):377-382,387-388.
  27. Dooley SW Jr, Castro KG, Hutton MD, Mullan RJ, Polder JA, Snider DE Jr. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues. MMWR Recomm Rep 1990;39(RR-17):1-29.

 

Interested persons may copy these Guidelines for noncommercial purposes of scientific or educational advancement. Please credit AARC and Respiratory Care Journal.

Reprinted from the June 2002 issue of RESPIRATORY CARE [Respir Care 2002;47(6):721–723]

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