A majority of institutions do not have a written policy for mechanical ventilation during intrahospital transport of children with congenital heart disease. That was the finding from a survey of pediatric anesthesia program directors throughout North America.
Presented at the 2017 meeting of the Society for Pediatric Anesthesia/American Academy of Pediatrics Section on Anesthesiology and Pain Medicine (abstract CA2-50), the study reflected responses from 29 of 127 participants who responded to the survey (see sidebar).
Noting the lack of national standards or guidelines for transport of intubated children with congenital heart disease, as well as the paucity of data, the investigators sent out a six-question survey via email or fax to determine practice patterns at the responding institutions.
Of the 29 program directors surveyed, only two (6.9%) said their institutions had written policies for preferred methods of transport. Other findings: 34.48% reported preference for a transport ventilator, 31.03% a Jackson-Rees circuit, 17.24% an Ambu bag, and the rest reported using a combination of different devices (Table).
|Table. Preferred Mechanical Ventilation During Intrahospital Transport Of Children With Congenital Heart Disease|
|Preferred Ventilation Device Question||Jackson-Rees Circuit, %||Ambu Bag, %||Transport Ventilation, %||Other, %|
|What is the preferred device for mechanical ventilation during intrahospital transport of neonates (intubated) with unrepaired CHD?||31.30||17.24||34.48||17.24|
|What is the preferred device for mechanical ventilation during transport from the OR to pediatric cardiac ICU for patients immediately after cardiac surgery?||41.38||34.48||10.34||13.79|
|What is the preferred device for mechanical ventilation during intrahospital transport of intubated patients with history of CHD surgery undergoing nonsurgical procedures (e.g., radiology)?||44.83||27.59||20.69||6.90|
|What is the preferred mechanical ventilation mode for patients with single-ventricle physiology?||24.14||24.14||27.59||24.14|
|CHD, congenital heart disease; OR, operating room|
Immediately after cardiac surgery, during transport to the ICU, the responses were somewhat different: 41% of respondents said they prefer the Jackson-Rees circuit, 34% prefer the Ambu bag, 10% indicated they use a transport ventilator, and the rest reported a combination of other devices.
For patients with single-ventricle physiology, respondents were evenly divided among all of the options—at about 25% each. The investigators noted that a few institutions use Neopuff (Fisher & Paykel) with an oxygen (O2) blender for both neonates and single-ventricle patients.
Muhammad Rafique, MD, associate professor in the Department of Anesthesiology at McGovern Medical School of the University of Texas Health Science Center at Houston, said while his institution has guidelines for ventilation during transport, in the absence of a standardized protocol, he and his colleagues were curious to see what other institutions were doing. He added that the survey is the first part of a study examining outcomes before and after transport as a result of using the three most widely preferred options—the Jackson-Rees circuit, the Ambu bag and the transport ventilator—in order to determine whether there are significant differences between the three in terms of O2 saturation and arterial blood gas at the beginning and end of transport.
“There should be guidelines, and we are hoping that once we complete our study and publish our findings, we can offer some guidance about what should be the way forward from here,” Dr. Rafique said.
Rosemary Foster, MD, a pediatric anesthesiology fellow at Nationwide Children’s Hospital, in Columbus, Ohio, said the survey results were interesting and in keeping with her experience.
“I agree that there’s not really a consensus … for what to do in this scenario. It’s more at the discretion of the provider,” she said. “So it’s interesting to see actual documentation of percentages of what people use.”
Dr. Foster also agreed with Dr. Rafique’s assessment that there ought to be guidelines in place. “I think if you have inexperienced people that don’t necessarily know the risks and benefits of the different types of bags or ventilators, it may be helpful,” particularly in choosing a device for patients in whom rebreathing of carbon dioxide needs to be closely managed, patients for whom high pressures are required, and patients requiring specific O2concentrations. “The amount of blood flow to the lungs compared to the body can be altered by how much oxygen you provide to the patient,” Dr. Foster said.
Study Reveals a Need: A Better List!
The response to the survey was lower than he would have liked, said Muhammad Rafique, MD, associate professor in the Department of Anesthesiology at McGovern Medical School of the University of Texas Health Science Center at Houston. He noted that the percentage of directors who responded (22.83%) was on par with what can generally be expected from a cold survey. SurveyMonkey, the service used in the study, has noted that a response rate above 5% is considered fair while 10% or above is considered average, he added.
Moreover, Dr. Rafique said, the process of conducting this study alerted him to the absence of a comprehensive list of pediatric cardiac anesthesia providers. “Although we used the best available data that was out there to reach out to the whole country and Canada who do pediatric cardiac anesthesia, the list we had was in no way up-to-date or complete,” he said.
“In this day and age, we should have a database available where we can look up what people are doing at different hospitals in different states, so if we want somebody’s opinion, it is easy to find them and contact them.”