Raymond F. Walsh

Reduction of morbidity in interhospital transport by specialized pediatric staff

ObjectiveWe prospectively compared the occurrence of morbidity during high-risk interhospital transport in two types of transport systems: specialized tertiary center-based vs. nonspecialized, referring hospital-based. DesignConcurrent, prospective comparison of morbidity at two pediatric centers that use different types of transport team. SettingTwo tertiary care pediatric intensive care units (ICU). The specialized team consisted of a pediatric resident, pediatric intensive care nurse, and a pediatric respiratory therapist. Comparison was made with referring institution transports by nonspecialized personnel to a second center. The two centers were similar in size and patient mix, with referral areas of similar population and rural/urban ratio. PatientsOne hundred forty-one patients transported to two tertiary pediatric ICUs. InterventionsNone. Measurements and Main ResultsTwo types of events were assessed: vital signs and other observable clinical events were described as “physiologic deteriorations.” Events such as loss of intravenous access, endotracheal tube mishaps, and exhaustion of oxygen supply were described as “intensive care-related adverse events.” Pretransport severity of illness and therapy were described by Pediatric Risk of Mortality (PRIoM) and Iherapeutic Intervention Scoring System (TISS) scores. Only high-risk patients with PRISM scores of >10 were analyzed.Intensive care-related adverse events occurred in one (2%) of 49 transports by the specialized team and 18 (20%) of 92 transports by nonspecialized personnel. The difference is statistically significant (p < .05). Physiologic deterioration was similar in the two groups occurring in five (11%) of 47 specialized team transports and 11 (12%) of 92 transports by the nonspecialized team. ConclusionWe conclude that specialized pediatric teams can reduce transport morbidity. This is the first published study to compare two models of pediatric transport using identical definitions of severity and morbidity. (Crit Care Med 1994; 22:1186–1191)

Obstructive aortic and renal thrombosis in the newborn — spontaneous recovery

A 13-day-old infant presented with acute renal failure secondary to a large thrombus formation involving the umbilical aorta and both renal arteries. The initial clinical manifestations were hematuria, followed by anuria, severe dehydration, grunting respirations, and cyanosis of her feet. She was treated with intravenous fluids and peritoneal dialysis. At the onset, there was no blood flow into the abdominal aorta or into the kidneys. Heparinization and fibrinolytic therapies were unsuccessful in dissolving the clot. However, the aortic clot recanalized spontaneously a few weeks later, but the renal arteries remained permanently occluded. Despite this, her kidneys showed blood flow bilaterally and she recovered her renal function, probably by reperfusing her kidneys through collateral circulation. Malignant hypertension ensued after improvement of renal function, but it could be controlled by appropriate antihypertensive therapy.