CASE 1

A patient who had recently undergone a laparoscopic procedure to the oesophagus at a tertiary centre was transferred back to their local hospital for post-operative care. They suffered a delayed bleed and were admitted to ICU at their local hospital, where they developed airway compromise. Intubation was difficult during which they suffered cardiac arrest. A CT scan revealed mediastinal bleeding.

Transfer back to ICU at the tertiary centre was undertaken by the adult ICU transfer service. En route they were informed that a thoracic surgeon at the receiving hospital concluded that the mediastinal bleed was so severe, the patient should be transferred directly to theatres on arrival, but that the patient should have been managed at the local hospital.

Commentary

The Faculty of Intensive Care Medicine and the Intensive Care Society have published guidance on Transfer of the Critically Ill Adult¹. They state that ‘prior to the transfer of a critically ill patient, a risk assessment must be undertaken and documented by a senior clinician to determine the level of anticipated risk during transfer. The outcome of the risk assessment should be used to determine the competencies of the staff required to accompany the patient during transfer.’ Senior multi-disciplinary input is required when planning transfer of complex and unstable cases.

Reference

1. Faculty of Intensive Care Medicine and Intensive Care Society. Guidance on Transfer of the Critically Ill Adult. 2021

CASE 2

A patient was taken back to theatres for repair of an anastomotic leak following hemicolectomy. The procedure was complicated by major haemorrhage and a vascular surgeon attended from another hospital. Surgery was still ongoing after the time theatres normally closed with no overnight anaesthetic cover. The patient was eventually taken to ITU with the abdomen packed and left open. The need for further surgery was considered substantial but as there were no facilities for overnight surgery, the patient required transfer to another hospital. Transfer was delayed and the patient’s condition worsened, with a significant lactic acidosis on arrival.

Commentary

Life threatening complications requiring emergency surgery can occur during any procedure. If surgery is undertaken in units that do not have 24/7 facilities including anaesthetic cover, there must be robust arrangement for early transfer for such patients.