Double Critically-ill Patients Ambulance Ride during Covid-19 Emergency in Emilia: a case report

Double Critically-ill Patients Ambulance Ride during Covid-19 Emergency in Emilia: a case report

Authors:

Andreotti Alberto: Anaesthesiologist and Emergency Physician, Azienda Ospedaliero Universitaria di Modena

Binda Daniele; Registered Nurse, Pronto Soccorso dell’Ospedale San Salvatore – AST Pesaro Urbino

Girardis Massimo; Università degli Studi di Modena e Reggio Emilia | UNIMO · Intensive Care Professor

During the period of the COVID-19 emergency, a major problem was the overcrowding of hospital wards in the worst-hit areas. This fact has made it necessary to move several numbers of critically ill patients to other hospitals in the logic of “Hub & Spoke” and “come to help.”

Therefore, critically ill patient transport represents one of the most delicate and vulnerable parts of the COVID-19 emergency management. Often, this problem has been seen as a marginal part of critical care, but it requires particular technical-organizational skills. Accurate planning needs to consider the patient’s physiologic reserve, available supplies of oxygen and electrical power, specific devices, and the crew’s ability to sustain high performance for the duration of the entire mission.

In this article, we report a case of transport of double critically-ill patients on a single ambulance, performed by a team composed of an intensive care doctor and nurse. The transport has been performed from the Piacenza hospital to the CoViD19-ICU in Modena Polyclinic, with a total distance of 125 km and 1 hour and 25 minutes of estimated travel (2h total, including patient loading and discharging time). The two patients suffering from severe CoViD19 pneumonia were:

• One woman with P / F <100 in Helmet-CPAP FiO2 100% ;

• One man with P / F <100 in reservoire mask 18 l / min FiO2 100%;

Careful planning was made, starting from the choice of the ambulance with the possibility, through dedicated hooks, to support a second stretcher (like a field stretcher) alongside the standard stretcher of the vehicle. In addition to the normal immobilization and emergency devices, the ambulance has been set up with advanced monitoring of the parameters (including EtCO2 and invasive ABP) infusion pumps and double pneumatic transport ventilator (Drager-Oxylog3000).

The first critical point was the complex preparation of the vehicle before departure. Utmost attention has been paid to the passage of the power cables, monitoring cables, and high-pressure hoses of the ventilators. The monitoring, the infusion pumps, and the fans have therefore been positioned to never cross the other patient and leave the central part of the ambulance walkable. This is fundamental to guarantee the safety of the transport, the order, and the possibility of intervening early on both patients, even simultaneously.

The second critical point was the poor O2 reserve. The total O2 requirement for the two patients to maintain SpO2 at a lower limit of 88-90% was calculated in 40 liter/min. If we consider the total service time of about two hours, the need for liters of oxygen was around 4800 l, to which at least 20-30% more should be added for safety reasons and in the face of unexpected events such as breakdowns or accidents (6200 l total). Considering that the ambulance’s medical gas system is built to attach 2 – 7 liter oxygen tanks (2800 liters of oxygen at full load), it would have been impossible to transport them in reservoir masks or HFNO, and it was necessary to use different strategies.

To reduce the hourly consumption of oxygen, it was decided to start adequate ventilation in NIMV (CPAP + PSV) for both patients. Ventilation was performed bed-side 15’ before loading the patients into the ambulance. In this way, with adjustable FiO2 pneumatic ventilators, it was possible to reduce FiO2 on the basis of lung recruitment, compliance optimization, and SpO2 value.

The third critical point was to ensure optimized sedation and analgesia during all the travel time for comfort, reduce oxygen consumption and optimize ventilation. Dexmedetomidine has been initiated in continuous intravenous infusion with particular attention to the hemodynamic effects. Also, due to this reason, an arterial catheter was placed to obtain continuous IBP.

The Female patient was sedated with dexmedetomidine 0,8 mcg/kg/h. and was ventilated with PASB 20cmH2O + PEEP 8cmH2O, well adapted to ventilation, with a progressive de-escalation of oxygen up to 60% FiO2 and pulmonary ventilation of 16 l/min (<10l/min of O2).

The Male patient was sedated with dexmedetomidine 0,6 mcg/kg/h. and was ventilated with PASB 16cmH2O + PEEP 6cmH2O, well adapted to ventilation, with a progressive de-escalation of oxygen up to 40% FiO2 and pulmonary ventilation of 14 l/min (<7 l/min of O2).

The fourth critical point was the safety of the crew. As recommended by the evidence, to minimize CoViD-19 aerosolization, the ambulance was put under negative pressure through the sanitary cell air expulsion systems while the operators were fully protected, also with positive pressure ventilated helmets (Proflow).

The transport was completed on schedule, with an amazing consumption of 2200 liters of Oxygen and maintaining excellent clinical stability of the patients. This complex approach also made it possible to initiate effective ventilatory support for both patients by reducing the inspiratory effort and the alveolar damage resulting from ARDS-Covid19 related.