British Journal of Anaesthesia 1991; 66: 141-144
INTERHOSPITAL TRANSFER OF A PATIENT UNDERGOING EXTRACORPOREAL CARBON DIOXIDE REMOVAL S. S. KEE, J. SEDGWICK AND A. BRISTOW
Extracorporeal circulation techniques are being used increasingly in patients with acute cardiac or pulmonary failure. Some of these patients may subsequently require transportation, which has limited the use of these techniques in hospitals without on site transplantation facilities. We report a case of adult respiratory distress syndrome that demonstrates a solution to this problem. KEY WORDS Equipment: extracorporeal circulation adult respiratory distress syndrome.
techniques. Lung,
CASE REPORT
An 18-yr-old male was admitted to hospital following a road traffic accident in which he was the driver. Initially, his arterial pressure was 100/70 mm Hg with a sinus tachycardia of 180 beat min"1. His ventilatory frequency was 30 b.p.m., with evidence of distress. There were bilateral basal crepitations and the initial chest xray was suggestive of pulmonary oedema. There had been a period of unconsciousness, but he was responding to his name and moving all limbs. Facial examination revealed a mobile le Fort type III fracture with blood in the oropharynx. Orthopaedic examination showed avulsion of the superior pole of the left patella, rupture of the right posterior cruciate ligament and superficial lacerations. There was no radiological evidence of spinal injury. Peritoneal lavage was performed, with negative results. Resuscitation with Gelofusin 1 litre and group O Rhesus negative blood 2 u produced a systolic
arterial pressure of 200 mm Hg. Rapid deterior, ation in conscious level with evidence of pulmonary oedema necessitated urgent treatment. The trachea was intubated under barbituraterelaxant anaesthesia and ventilation was controlled artificially. Computed tomography revealed diffuse brain injury with no focal lesions and patent basal cisterns. A subdural intracranial pressure catheter was inserted and demonstrated a pressure of 5 mm Hg. The patient was admitted to the intensive care unit for further management. He remained hypoxic and hypercapnic despite ventilation with 100% oxygen (minute volume 12 litre; PaOi 7.5 kPa, PaCOi 6.8 kPa). His main problem was respiratory failure. He was sedated and given anticonvulsant and H4-antagonist therapy. The intracranial pressure was monitored and this remained normal for 3 days. The 12-lead ECG was normal. Enteral feeding continued to day five when bowel sounds disappeared, so parenteral nutrition was commenced. Although the patient was pyrexial, there was no bacterial evidence of infection at any stage, so the patient continued to receive cefotaxime and selective decontamination with gentamicin, amphoteracin and polymixin to prevent nosocomial pneumonia. His second chest x-ray on the day of admission showed collapse of the right lower lobe, with overdistension of the left lung, therefore a bronchoscopy was performed, but this showed no
S. S. KEE,
M.B.,
CH.B.,
F.C.ANAES.;
A. BRISTOW,
M.B.,
F.C.ANAES.; Department of Anaesthesia, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE. J. SEDGWICK, B.M., F.C.ANAES., Department of Anaesthesia, Southampton Genera] Hospital, Tremona Road, Southampton SO9 4XY. Accepted for Publication: July 29, 1990. Correspondence to S. S. K.
Downloaded from http://bja.oxfordjournals.org/ at Karolinska Institutet on May 29, 2015
SUMMARY
142
Forward
Space for medical equipment
FIG. 1. Layout of helicopter ambulance: placement of patient, pilot and medical attendants. The anaesthetist was at the head of the patient. The position of the medical equipment, the sliding stretcher and the door exits are also shown. LOx = Liquid oxygen cylinder. (Reproduced by permission of Careflight and McAlpine Helicopters.)
the patient was critically ill, it was imperative that all monitoring was continued throughout the transfer. Careflight was able to provide portable monitors and equipment to replace the hospital's pulse oximeter, ECG, direct arterial and central venous pressures, core temperature, capnography and inflation pressures. Dopamine, dobutamine, heparin and blood infusions were maintained during transfer. The ventilator used during the journey was a portable gas driven, time cycled, rate set, pressure limited machine capable of delivering PEEP. Portable liquid oxygen cylinders were used to power and supply the ventilator and the ECCO2R system. Ordinary oxygen cylinders would have proved too heavy and bulky to use on the helicopter. The chest drains remained in place and presented no problems. The oxygen flow rate through the oxygenators
Downloaded from http://bja.oxfordjournals.org/ at Karolinska Institutet on May 29, 2015
evidence of aspiration or obstruction and that the major airway structures were intact. The collapse was treated with asynchronous differential lung ventilation using a 41-gauge leftsided Bronchocath, and produced immediate haemodynamic improvement but no immediate improvement in respiratory function. Arterial blood-gas tensions were PzOt 10.1 a n d -Paco, 5.5 kPa, with pH 7.25 (FiOi = 1.0). The mean pulmonary artery wedge pressure was 14 mm Hg and the cardiac index 3.1 litre min"1 m~2. Both oxygen delivery and oxygen consumption were within normal limits. By the following day the right lower lobe had re-expanded and the respiratory function had improved, allowing conventional tracheal ventilation to be recommenced. However, left lung shadowing developed on chest x-ray and deteriorating pulmonary function necessitated pressure-controlled, inverse-ratio ventilation. This produced the best blood-gas tensions: PaOj 14kPa on 60% oxygen. Over the subsequent 3 days, respiratory function deteriorated. Static lung compliance was 56 ml/cm H2O and the clinical and radiological appearances were typical of adult respiratory distress syndrome. A trial of high frequency positive pressure ventilation (HFPPV) and cooling to a core temperature of 34 °C were unhelpful. Extracorporeal carbon dioxide removal with low frequency positive pressure ventilation (ECCO2R-LFPPV) was commenced using femoro-femoral venous cannulation with a Biomedicus 540 extracorporeal pumping system and silicon membrane oxygenator with heat exchanger. The patient was heparinized to an activated clotting time of 200 s. The initial bloodflowthrough the extracorporeal circuit was 1.45 litre min"1 and there were no haemodynamic changes on commencing venous bypass with LFPPV and apnoeic oxygenation. PaOj improved to 10.2 kPa, but two membrane oxygenators in series were required to reduce Pa cnj to 4.2 kPa. The following 36 h were characterized by bilateral pneumothoraces. The ARDS worsened and it was decided that lung transplantation should be considered. The cardiothoracic team at Harefield Hospital were consulted and they requested that the patient be transferred. Transfer by helicopter was deemed the most appropriate, as this provided substantially reduced transport times, a stable environment and the ability to power the ECCOjR system. Because
BRITISH JOURNAL OF ANAESTHESIA
INTERHOSPITAL TRANSFER 1
DISCUSSION
Extracorporeal membrane oxygenation (ECMO) is indicated for acute cardiac and respiratory failure not responding to conventional therapy [1]. The type of membrane support is determined by the method of vascular access, which may be venoarterial or venovenous. Venovenous ECMO provides gas exchange but no cardiac support [2]. The effects of embolization are fewer, and there may be a decrease in pulmonary hypertension because the oxygenated blood is distributed evenly throughout the pulmonary circulation [1-3]. However, venovenous ECMO is dependent on adequate cardiac function and compared with venoarterial bypass, venovenous bypass requires between 20% and 50% greater flow for total respiratory support because of recirculation of previously oxygenated blood [3-5]. Gattinoni and colleagues have demonstrated good survival outcomes in severe adult respiratory failure of parenchymal origin using LFPPV -ECCOjR [6]. The rationale with this method is to prevent further damage to diseased lungs by dissociating oxygen uptake and carbon di-
oxide removal. Oxygenation is accomplished primarily through the lungs by apnoeic oxygenation at a continuous positive pressure of 10-25 cm H2O. Carbon dioxide removal is facilitated through the extracorporeal circuit. Three to five "sighs" per minute are required to preserve functional residual capacity. For the 51 % of patients who did not wean from LFPPV-ECCO2R, lung transplantation was the only viable alternative [6]. With the advent of percutaneous cardiopulmonary bypass as an emergency procedure, and an extension of the role of bypass to refractory myocardial infarction, massive pulmonary emboli and trauma cases [7], there is a need to transfer an increasing number of patients receiving extracorporeal support to cardiothoracic transplantation centres. The major difficulty has been interhospital transfer. Land ambulances are generally not equipped with the power or monitoring equipment necessary to a mobile intensive care unit. A prospective study comparing helicopter and land ambulances demonstrated a significant reduction in predicted mortality of 25 % in severely injured patients by use of the former mode of transport [8]We are not aware of any patients receiving extracorporeal support being transferred in the U.K., and there is only one report from overseas, namely the transfer of a neonate with ECMO [9]. The helicopter not only overcomes the difficulties of land transfer, but also reduces the transit time significantly. This in turn allows ECMO and ECCO2R systems to be used throughout the country with the option of transplantation if the underlying pathology does not resolve. The development of such a system would be dependent on specialized transfer teams. Transfer systems such as this also offer benefits for other critically ill patients. Work in California has emphasized that critically ill patients can be safely transported to tertiary centres if they are stabilized adequately and monitored carefully before and during transport [10]. The Clinical Shock Study Group at Glasgow has demonstrated that interhospital transfer of critically ill patients is safe with a dedicated specialized team of medical personnel and equipment [11]. Despite this, a recent questionnaire of general intensive care units in the United Kingdom revealed that 41 % of respondents were dissatisfied with existing arrangements for secondary transport of patients [12].
Downloaded from http://bja.oxfordjournals.org/ at Karolinska Institutet on May 29, 2015
was reduced to 15 litre min" to conserve oxygen use. The patient was attended by an anaesthetist and a perfusionist throughout the transfer. The patient was carried so that the body was parallel to the long axis of the aircraft and the head of the patient was placed aft to minimize haemodynamic shifts in blood volume caused by the helicopter's motion (fig. 1). The 96-km journey took 30 min, during which time the patient remained stable. The heater on the ECCO2R system required 960 W necessitating 4 A at 240 V. The helicopter provided the power through a 28-V d.c. inverter to 240 V a.c. with a maximum current of 4.5 A. The monitors and infusion pumps drew 2.4 A, leaving 2.1 A for the perfusion equipment. This was sufficient to power the pump, but the reduction of 2.5 °C in core temperature was probably a reflection of the power limitation. Fortunately, the helipad at Harefield Hospital is adjacent to the hospital buildings, thus reducing the time of transfer between helicopter and hospital bed. Thoracotomy after transfer failed to identify any specific bleeding sites. The patient remained critical but stable for 2 days, but no donor organs became available and death followed on the fourth day after transfer.
143
BRITISH JOURNAL OF ANAESTHESIA
St Bartholomew's Careflight is a dedicated secondary transport unit staffed by an immediate on-call medical, technical and aviation team.
Fumagalli R, Rossi F, Iapichino G, Romagnoli G, Uziel L, Agostoni A, Kolobow T, Damia G. Low-frequency positive pressure ventilation with extracorporeal CO, removal in severe acute respiratory failure. Journal of the American Medical Association 1986; 2S6: 881-886. Phillips SJ, Robert HZ, Kongtahwom C, Skinner JR, Toon RS, Grignon A, Kennerly M, Wickemeyer W, Iannone LA. Percutaneous cardiopulmonary bypass: application and indication for use. Annals of Thoracic Surgery 1989; 47: 121-123. Boyd CR, Corse KM, Campbell RC. Emergency interhospital transport of the major trauma patient: Air versus ground. Journal of Trauma 1989; 29: 789-794. Cornish JD, Gerstmann DR, Begnaud MJ, Null DM, Ackerman NB. Inflight use of extracorporeal membrane oxygenation for neonatal respiratory failure. Perfusion 1986; 1: 281-287. Ehrenwerth J, Sorbo S, Hackel A. Transport of critically ill adults. Critical Care Medicine 1986; 14: 543-547. Wright IH, McDonald JC, Rogers PN, Ledingham I McA. Provision of facilities for secondary transport of seriously ill patients in the United Kingdom. British Medical Journal 1988; 296: 543-545. Reeve WG, Runcie CJ, Reidy J, Wallace PGM. Current practice in transferring critically ill patients among hospitals in the west of Scotland. British Medical Journal 1990; 300: 85-87.
7. REFERENCES 1. Hirschl RB, Bartlett RH. Extracorporcal membrane oxygenation suppon in cardiorcspiratory failure. Advances in Surgery 1987; 21: 189-212. 8. 2. Lamy M, Eberhart RC, Fallat RJ. Effects of extracorporeal membrane oxygenation (ECMO) on pulmonary hacmodynamics, gas exchange and prognosis. 9. Transactions—American Society for Artificial Internal Organs 1975; 21: 188-198. 3. Andrews AF, Toomasian J, Oram A. Total respiratory support with venovenous (W) ECMO. Transactions— 10. American Society for Artifical Internal Organs 1982; 28: 350-353. 11. 4. Klein MD, Andrews AF, Wesley JR. Venovenous perfusion in new born respiratory insufficiency. Annals of Surgery 1985; 201: 520-526. 5. Slota MC. Extracorporcal membrane oxygenator support 12. of the infant. Dimensions in Critical Care Nursing 1982; 1: 70-79. 6. Gattinoni L, Present! A, Mascheroni D, Marcolin R,
Downloaded from http://bja.oxfordjournals.org/ at Karolinska Institutet on May 29, 2015
144
INTERHOSPITAL TRANSFER OF A PATIENT UNDERGOING EXTRACORPOREAL CARBON DIOXIDE REMOVAL S. S. KEE, J. SEDGWICK AND A. BRISTOW
Extracorporeal circulation techniques are being used increasingly in patients with acute cardiac or pulmonary failure. Some of these patients may subsequently require transportation, which has limited the use of these techniques in hospitals without on site transplantation facilities. We report a case of adult respiratory distress syndrome that demonstrates a solution to this problem. KEY WORDS Equipment: extracorporeal circulation adult respiratory distress syndrome.
techniques. Lung,
CASE REPORT
An 18-yr-old male was admitted to hospital following a road traffic accident in which he was the driver. Initially, his arterial pressure was 100/70 mm Hg with a sinus tachycardia of 180 beat min"1. His ventilatory frequency was 30 b.p.m., with evidence of distress. There were bilateral basal crepitations and the initial chest xray was suggestive of pulmonary oedema. There had been a period of unconsciousness, but he was responding to his name and moving all limbs. Facial examination revealed a mobile le Fort type III fracture with blood in the oropharynx. Orthopaedic examination showed avulsion of the superior pole of the left patella, rupture of the right posterior cruciate ligament and superficial lacerations. There was no radiological evidence of spinal injury. Peritoneal lavage was performed, with negative results. Resuscitation with Gelofusin 1 litre and group O Rhesus negative blood 2 u produced a systolic
arterial pressure of 200 mm Hg. Rapid deterior, ation in conscious level with evidence of pulmonary oedema necessitated urgent treatment. The trachea was intubated under barbituraterelaxant anaesthesia and ventilation was controlled artificially. Computed tomography revealed diffuse brain injury with no focal lesions and patent basal cisterns. A subdural intracranial pressure catheter was inserted and demonstrated a pressure of 5 mm Hg. The patient was admitted to the intensive care unit for further management. He remained hypoxic and hypercapnic despite ventilation with 100% oxygen (minute volume 12 litre; PaOi 7.5 kPa, PaCOi 6.8 kPa). His main problem was respiratory failure. He was sedated and given anticonvulsant and H4-antagonist therapy. The intracranial pressure was monitored and this remained normal for 3 days. The 12-lead ECG was normal. Enteral feeding continued to day five when bowel sounds disappeared, so parenteral nutrition was commenced. Although the patient was pyrexial, there was no bacterial evidence of infection at any stage, so the patient continued to receive cefotaxime and selective decontamination with gentamicin, amphoteracin and polymixin to prevent nosocomial pneumonia. His second chest x-ray on the day of admission showed collapse of the right lower lobe, with overdistension of the left lung, therefore a bronchoscopy was performed, but this showed no
S. S. KEE,
M.B.,
CH.B.,
F.C.ANAES.;
A. BRISTOW,
M.B.,
F.C.ANAES.; Department of Anaesthesia, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE. J. SEDGWICK, B.M., F.C.ANAES., Department of Anaesthesia, Southampton Genera] Hospital, Tremona Road, Southampton SO9 4XY. Accepted for Publication: July 29, 1990. Correspondence to S. S. K.
Downloaded from http://bja.oxfordjournals.org/ at Karolinska Institutet on May 29, 2015
SUMMARY
142
Forward
Space for medical equipment
FIG. 1. Layout of helicopter ambulance: placement of patient, pilot and medical attendants. The anaesthetist was at the head of the patient. The position of the medical equipment, the sliding stretcher and the door exits are also shown. LOx = Liquid oxygen cylinder. (Reproduced by permission of Careflight and McAlpine Helicopters.)
the patient was critically ill, it was imperative that all monitoring was continued throughout the transfer. Careflight was able to provide portable monitors and equipment to replace the hospital's pulse oximeter, ECG, direct arterial and central venous pressures, core temperature, capnography and inflation pressures. Dopamine, dobutamine, heparin and blood infusions were maintained during transfer. The ventilator used during the journey was a portable gas driven, time cycled, rate set, pressure limited machine capable of delivering PEEP. Portable liquid oxygen cylinders were used to power and supply the ventilator and the ECCO2R system. Ordinary oxygen cylinders would have proved too heavy and bulky to use on the helicopter. The chest drains remained in place and presented no problems. The oxygen flow rate through the oxygenators
Downloaded from http://bja.oxfordjournals.org/ at Karolinska Institutet on May 29, 2015
evidence of aspiration or obstruction and that the major airway structures were intact. The collapse was treated with asynchronous differential lung ventilation using a 41-gauge leftsided Bronchocath, and produced immediate haemodynamic improvement but no immediate improvement in respiratory function. Arterial blood-gas tensions were PzOt 10.1 a n d -Paco, 5.5 kPa, with pH 7.25 (FiOi = 1.0). The mean pulmonary artery wedge pressure was 14 mm Hg and the cardiac index 3.1 litre min"1 m~2. Both oxygen delivery and oxygen consumption were within normal limits. By the following day the right lower lobe had re-expanded and the respiratory function had improved, allowing conventional tracheal ventilation to be recommenced. However, left lung shadowing developed on chest x-ray and deteriorating pulmonary function necessitated pressure-controlled, inverse-ratio ventilation. This produced the best blood-gas tensions: PaOj 14kPa on 60% oxygen. Over the subsequent 3 days, respiratory function deteriorated. Static lung compliance was 56 ml/cm H2O and the clinical and radiological appearances were typical of adult respiratory distress syndrome. A trial of high frequency positive pressure ventilation (HFPPV) and cooling to a core temperature of 34 °C were unhelpful. Extracorporeal carbon dioxide removal with low frequency positive pressure ventilation (ECCO2R-LFPPV) was commenced using femoro-femoral venous cannulation with a Biomedicus 540 extracorporeal pumping system and silicon membrane oxygenator with heat exchanger. The patient was heparinized to an activated clotting time of 200 s. The initial bloodflowthrough the extracorporeal circuit was 1.45 litre min"1 and there were no haemodynamic changes on commencing venous bypass with LFPPV and apnoeic oxygenation. PaOj improved to 10.2 kPa, but two membrane oxygenators in series were required to reduce Pa cnj to 4.2 kPa. The following 36 h were characterized by bilateral pneumothoraces. The ARDS worsened and it was decided that lung transplantation should be considered. The cardiothoracic team at Harefield Hospital were consulted and they requested that the patient be transferred. Transfer by helicopter was deemed the most appropriate, as this provided substantially reduced transport times, a stable environment and the ability to power the ECCOjR system. Because
BRITISH JOURNAL OF ANAESTHESIA
INTERHOSPITAL TRANSFER 1
DISCUSSION
Extracorporeal membrane oxygenation (ECMO) is indicated for acute cardiac and respiratory failure not responding to conventional therapy [1]. The type of membrane support is determined by the method of vascular access, which may be venoarterial or venovenous. Venovenous ECMO provides gas exchange but no cardiac support [2]. The effects of embolization are fewer, and there may be a decrease in pulmonary hypertension because the oxygenated blood is distributed evenly throughout the pulmonary circulation [1-3]. However, venovenous ECMO is dependent on adequate cardiac function and compared with venoarterial bypass, venovenous bypass requires between 20% and 50% greater flow for total respiratory support because of recirculation of previously oxygenated blood [3-5]. Gattinoni and colleagues have demonstrated good survival outcomes in severe adult respiratory failure of parenchymal origin using LFPPV -ECCOjR [6]. The rationale with this method is to prevent further damage to diseased lungs by dissociating oxygen uptake and carbon di-
oxide removal. Oxygenation is accomplished primarily through the lungs by apnoeic oxygenation at a continuous positive pressure of 10-25 cm H2O. Carbon dioxide removal is facilitated through the extracorporeal circuit. Three to five "sighs" per minute are required to preserve functional residual capacity. For the 51 % of patients who did not wean from LFPPV-ECCO2R, lung transplantation was the only viable alternative [6]. With the advent of percutaneous cardiopulmonary bypass as an emergency procedure, and an extension of the role of bypass to refractory myocardial infarction, massive pulmonary emboli and trauma cases [7], there is a need to transfer an increasing number of patients receiving extracorporeal support to cardiothoracic transplantation centres. The major difficulty has been interhospital transfer. Land ambulances are generally not equipped with the power or monitoring equipment necessary to a mobile intensive care unit. A prospective study comparing helicopter and land ambulances demonstrated a significant reduction in predicted mortality of 25 % in severely injured patients by use of the former mode of transport [8]We are not aware of any patients receiving extracorporeal support being transferred in the U.K., and there is only one report from overseas, namely the transfer of a neonate with ECMO [9]. The helicopter not only overcomes the difficulties of land transfer, but also reduces the transit time significantly. This in turn allows ECMO and ECCO2R systems to be used throughout the country with the option of transplantation if the underlying pathology does not resolve. The development of such a system would be dependent on specialized transfer teams. Transfer systems such as this also offer benefits for other critically ill patients. Work in California has emphasized that critically ill patients can be safely transported to tertiary centres if they are stabilized adequately and monitored carefully before and during transport [10]. The Clinical Shock Study Group at Glasgow has demonstrated that interhospital transfer of critically ill patients is safe with a dedicated specialized team of medical personnel and equipment [11]. Despite this, a recent questionnaire of general intensive care units in the United Kingdom revealed that 41 % of respondents were dissatisfied with existing arrangements for secondary transport of patients [12].
Downloaded from http://bja.oxfordjournals.org/ at Karolinska Institutet on May 29, 2015
was reduced to 15 litre min" to conserve oxygen use. The patient was attended by an anaesthetist and a perfusionist throughout the transfer. The patient was carried so that the body was parallel to the long axis of the aircraft and the head of the patient was placed aft to minimize haemodynamic shifts in blood volume caused by the helicopter's motion (fig. 1). The 96-km journey took 30 min, during which time the patient remained stable. The heater on the ECCO2R system required 960 W necessitating 4 A at 240 V. The helicopter provided the power through a 28-V d.c. inverter to 240 V a.c. with a maximum current of 4.5 A. The monitors and infusion pumps drew 2.4 A, leaving 2.1 A for the perfusion equipment. This was sufficient to power the pump, but the reduction of 2.5 °C in core temperature was probably a reflection of the power limitation. Fortunately, the helipad at Harefield Hospital is adjacent to the hospital buildings, thus reducing the time of transfer between helicopter and hospital bed. Thoracotomy after transfer failed to identify any specific bleeding sites. The patient remained critical but stable for 2 days, but no donor organs became available and death followed on the fourth day after transfer.
143
BRITISH JOURNAL OF ANAESTHESIA
St Bartholomew's Careflight is a dedicated secondary transport unit staffed by an immediate on-call medical, technical and aviation team.
Fumagalli R, Rossi F, Iapichino G, Romagnoli G, Uziel L, Agostoni A, Kolobow T, Damia G. Low-frequency positive pressure ventilation with extracorporeal CO, removal in severe acute respiratory failure. Journal of the American Medical Association 1986; 2S6: 881-886. Phillips SJ, Robert HZ, Kongtahwom C, Skinner JR, Toon RS, Grignon A, Kennerly M, Wickemeyer W, Iannone LA. Percutaneous cardiopulmonary bypass: application and indication for use. Annals of Thoracic Surgery 1989; 47: 121-123. Boyd CR, Corse KM, Campbell RC. Emergency interhospital transport of the major trauma patient: Air versus ground. Journal of Trauma 1989; 29: 789-794. Cornish JD, Gerstmann DR, Begnaud MJ, Null DM, Ackerman NB. Inflight use of extracorporeal membrane oxygenation for neonatal respiratory failure. Perfusion 1986; 1: 281-287. Ehrenwerth J, Sorbo S, Hackel A. Transport of critically ill adults. Critical Care Medicine 1986; 14: 543-547. Wright IH, McDonald JC, Rogers PN, Ledingham I McA. Provision of facilities for secondary transport of seriously ill patients in the United Kingdom. British Medical Journal 1988; 296: 543-545. Reeve WG, Runcie CJ, Reidy J, Wallace PGM. Current practice in transferring critically ill patients among hospitals in the west of Scotland. British Medical Journal 1990; 300: 85-87.
7. REFERENCES 1. Hirschl RB, Bartlett RH. Extracorporcal membrane oxygenation suppon in cardiorcspiratory failure. Advances in Surgery 1987; 21: 189-212. 8. 2. Lamy M, Eberhart RC, Fallat RJ. Effects of extracorporeal membrane oxygenation (ECMO) on pulmonary hacmodynamics, gas exchange and prognosis. 9. Transactions—American Society for Artificial Internal Organs 1975; 21: 188-198. 3. Andrews AF, Toomasian J, Oram A. Total respiratory support with venovenous (W) ECMO. Transactions— 10. American Society for Artifical Internal Organs 1982; 28: 350-353. 11. 4. Klein MD, Andrews AF, Wesley JR. Venovenous perfusion in new born respiratory insufficiency. Annals of Surgery 1985; 201: 520-526. 5. Slota MC. Extracorporcal membrane oxygenator support 12. of the infant. Dimensions in Critical Care Nursing 1982; 1: 70-79. 6. Gattinoni L, Present! A, Mascheroni D, Marcolin R,
Downloaded from http://bja.oxfordjournals.org/ at Karolinska Institutet on May 29, 2015
144
