This content has been generated for SALG by the Association of Paediatric Anaesthetists of Great Britain and Ireland

A previously well [paediatric] patient was referred to the retrieval team by the emergency department of a hospital without specialist paediatric services  in the early hours of the morning. The child had a one-day history of vomiting and abdominal distension. Abdominal x-ray showed dilated loops of bowel. The patient was hypotensive and had a lactic acidosis (pH6.89) despite 40ml/kg fluids via intraosseous (IO) access. Following arrival of the retrieval team, the patient was intubated and was given 80ml/kg fluid and  1 unit PRBCs. An adrenaline infusion was started via a femoral line. Following multiple phone calls it was agreed that the patient would go straight to theatre on arrival at the receiving centre.

Despite phone warning of imminent arrival, it took one hour from arrival in emergency department of the receiving hospital until theatres were ready.  

Surgical exploration revealed congenital malrotation, volvulus and ischaemia affecting 90% of the bowel. The bowel was drained through the appendix and the abdomen left open to facilitate reperfusion.

The reporter was of the opinion that the extent of ischaemia would have been less had there not been the delay in getting this patient to theatre.

Commentary

This case was clearly challenging clinically and logistically. Adult critical care staff may be required to resuscitate, stabilise and transfer critically ill children.¹. There should be local hospital protocols in place that clarify the roles and responsibilities of MDT members in caring for critically ill children.²

For transfer there should be portable age-appropriate monitors, transfer equipment (including a portable ventilator) and drugs readily available.²

The need for urgent surgical intervention (not available in the referring centre) for an acute abdomen necessitates a time-critical transfer - this should usually be undertaken by the referring hospital team to allow rapid transfer. In this case the degree of instability and access difficulties instead led the retrieval team to undertake the transfer – highlighting the importance of discussion with the retrieval services to allow all options to be considered carefully.

It is important that clear lines of communication are maintained between referral and receiving teams to ensure timely management of  time-critical pathologies.

References

1. The Faculty of Intensive Care Medicine / Intensive Care Society. Guidelines for the Provision of Intensive Care Services (2022). 4.11 Care of the Critically Ill Child in an Adult Intensive Care Unit.
2. Royal College of Anaesthetists. Guidelines for the Provision of Anaesthesia Services. Chapter 10 – Guidelines for the Provision of Paediatric Anaesthesia Services (2025).