Anaesthesia, 2001, 56, pages 82±97
Correspondence
.
...............................................................................................................................................................................................................................................
it is the safest option. Why not extend
The 1997 Troop report stated quite Intensive Care Medicine. However, even
this to all patients? Our sceptics have clearly that children with single system for paediatric anaesthetists, who perform
been convinced and would not go back failure requiring intubation do not numerous inhalational inductions each
to the former use of the anaesthetic necessarily need to be transferred to a day, the inhalational induction of a child
room. Try it ± you might like it, or Paediatric Intensive Care Unit (PICU) with upper airway obstruction is a
perhaps you feel that, as in the Guinness if the admitting hospital and their ICU
advert, `I've never tried it because I meet certain predefined standards [1]. In
relatively rare and challenging event.
In our opinion it seems totally inappro-
priate that the paediatricians amongst
us, even those with some previous
anaesthetic experience, should attempt
this technique, either in our institution
or while out with the retrieval team.
Thus, when organising the retrieval
of such children, one must consider
carefully who is going to perform the
intubation. To a large extent this will
depend upon the skills available at the
referral hospital, the degree of urgency
involved and the transfer distance. For
the most part, in our region, this means
that the intubation will be performed by
anaesthetists at the referral hospital.
With reference to the notion of `deskill-
ing', children will continue to require
all the skills of the DGH clinicians with
regards to resuscitation, stabilisation and
initiation of specific management. The
retrieval service must be seen as com-
plementary to those skills.
don't like it'.
these circumstances, common sense
should prevail; children who are expected
to make a rapid recovery, say within
J. W. Broadway
M. G. Smith
T. J. Archer
Ipswich Hospital NHS Trust,
Ipswich IP4 5PD, UK
2
4 h, need not be transferred, especially
if the transfer distance is large. For such
children, ongoing intensive care may be
undertaken by the DGH clinicians, who
should liaise with their lead centre
PICU. However, on a cautious note, it
must be remembered that although
many senior clinicians in referring
hospitals may feel confident of their
ability to deal with the ongoing
management of children in primarily
adult ICUs, this confidence is not
always shared by other staff who may
feel exposed in terms of training,
experience and professional liabilities.
If the standards laid down in the
Troop report are not met, or if the child
continues to deteriorate, then, once
stabilised, the child should be trans-
ferred to a PICU. It has never been
suggested that transfers take place `when
physiology is most compromised';
References
1
2
Meyer-Witting M, Wilkinson DJ. . A
safe haven or dangerous place ± should
we keep the anaesthetic room?
Anaesthesia 1992; 47: 1021±2.
AAGBI. Recommendations for Standards of
monitoring during Anaesthesia and
Recovery. London: The Association of
Anaesthetists of Great Britain and
Ireland, 1988.
3
Campling EA, Devlin HB, Hoile RW,
Lunn JN. The report of the National
Confidential Enquiry Into Perioperative
Deaths 1991/1992. London: 1993.
Brahams D. Series of errors which
culminated in death. Anaesthesia 1990;
4
5
When the complexity of the case
demands, we send a consultant intensi-
4
5: 332±3.
indeed, this goes against the whole vist with the retrieval team and, when
philosophy of transferring children the referral involves a difficult airway,
safely. Full resuscitation and maximal this intensivist is usually a paediatric
stabilisation should be achieved by the anaesthetist. All lead-centre PICUs
referring hospital and subsequently by should eventually be able to achieve
the retrieval team prior to any child this standard, so long as they maintain a
being moved. Well-documented studies good balance between senior paediatric
have shown that children may be moved and anaesthetic staff.
College of Anaesthetists. Basic Specialist
Training Guide. London: College of
Anaesthetists, 1991: 8±9.
Paediatric intensive care
transfers
safely without physiological deteriora-
In summary, the recommendations of
the Troop report have been formulated
in the best interests of critically ill
children. In the final analysis, the safe
management of a child with upper
airway obstruction, or any critically ill
child for that matter, depends on team-
work, close co-operation between the
referring clinicians and the PICU team,
and a good deal of common sense.
We write in reply to the recent tion [2, 3]. Moreover, the suggestion
correspondence (Griffiths and Smith. that clinicians in DGHs be encouraged
Anaesthesia 2000; 55: 610) that raised to undertake the first 24±48 h of
concerns about the safe conduct of intensive care, only to call a PICU
paediatric intensive care retrievals. They when they get into difficulty, has been
highlighted the case of an 18-month-old generally felt to be both inappropriate
child with epiglottitis and the difficulties and unsafe [4, 5].
surrounding his re-intubation while
The issue of transport personnel and
under the care of the Paediatric Inten- their ability to intubate children with
sive Care Team despatched to pick him upper airway obstruction is more diffi-
up. Whilst this case graphically illus- cult. All consultant paediatric intensi-
trates the value of a well trained and vists should have training in the
experienced senior anaesthetist in secur- management of acute paediatric airway
ing a compromised airway, the authors obstruction, as is stipulated in the
draw other conclusions, which we feel requirements of the Intercollegiate
P. J. Murphy
I. Jenkins
J. Fraser
S. Marriage
Royal Hospital for Sick Children,
Bristol BS2 8BJ, UK
are unwarranted.
Committee for Training in Paediatric
q 2001 Blackwell Science Ltd
83
Lauth
