P3D326: Prolonged Air Transport of a Critically Ill Child: Lessons Learned

Introduction: Critical Care Air Transport (CCAT) teams are a crucial military asset to transport critically ill patients and to provide ICU management en route. Although most CCAT missions transport active-duty members, pediatric CCAT missions comprise up to 8% of CCAT missions in some theatres. CCAT-trained critical care pediatricians exist but lack a formal activation system, which results in most pediatric CCAT missions to be staffed by adult-care teams. We present a pediatric CCAT case notable for its length and severity of patient illness with lessons learned by the pediatric transport team.

Case Description: A 4-year-old former 26-week premature male presented to the US Naval Hospital Guam emergency department in respiratory failure secondary to a human metapneumovirus requiring intubation, which was complicated by a 15 minute cardiac arrest. After significant fluid resuscitation, he was admitted to the adult ICU due to lack of a PICU on the island. He was managed via pediatric telecritical care from San Diego, but nonetheless developed ARDS, acute renal failure, hypotension requiring multiple pressors, and fluid overload requiring bilateral chest tubes and two peritoneal drains. A pediatric CCAT team departed San Antonio within 36 hours of activation. The team transported the patient via C-17 to Hawaii and performed a tail swap to a KC-135. Before takeoff, engine issues caused prolonged ground-time with doors closed. Due to lack of temperature control on a KC-135, the patient’s temperature rapidly climbed resulting in hyperthermia to 104.2 F despite ice packing. The ambient temperature also caused equipment malfunction (suction, iSTAT, and ventilator), resulting in manually bagging the patient. En route, the team removed 1 liter of peritoneal fluid and substantially improved the patient’s ventilator settings. After 22 hours of patient care, the KC-135 landed in California and the team transported the patient to a civilian PICU. Over several weeks, the patient made a full recovery.

Discussion: The military has the unique capacity to deliver ICU care during air transport. Careful selection of age-specific equipment, medications, and air frame significantly impact the patient’s condition and ability to respond to unexpected events. Adult providers have no required pediatric training, so pediatric critical care physicians are uniquely equipped to navigate situations like those highlighted here. CCAT literature has an abundance of adult cases but lacks pediatric case reports or practice guidelines. Civilian data supports reduced morbidity and mortality with pediatric transport teams, thus supporting systems utilizing pediatric CCAT in the military.

Conclusion: This successful pediatric CCAT mission highlights the unexpected complications intrinsic to air transport. Missions of this severity and length benefit from utilization of trained pediatric specialists to minimize morbidity and mortality. Highlighting the challenges related to preparation, air frame, and equipment malfunction should help others prepare for future pediatric air transports.