Stabilisation and Transfer of the Critically Ill Child

• Paediatric critical care in the UK is centralised into tertiary paediatric critical care units (PICUs)
• Critically ill children can present to any hospital with an ED or walk-in centre, so non-tertiary hospitals must be able to:
  • Resuscitate and stabilise
  • Refer
  • Maintain critical care until the transport team arrives
  • Perform time-critical transfers themselves when needed


• Operational oversight of paediatric critical care networks is provided by Operational Delivery Networks, while Specialist Paediatric Transport Services undertake the majority of PICU transfers


• Standards for non-time-critical transfers:
  • Mobilise within 30 minutes of the decision to transfer
  • At the bedside within 3 hours

Adapted from Paediatric stabilisation and transfer. Part 1: preparation and standards of care

• Structured APLS (ABCDE) assessment to minimise errors and missed diagnoses
• Balance necessary interventions and imaging against delaying transfer
• Use checklists, especially for emergency paediatric intubation
• Senior input throughout: paediatric, anaesthetic and ED consultants with formal handovers as leadership changes
• The child should not leave until the airway is safe with adequate vascular access and monitoring

• Standardised concentrations categorised by weight (2023 national statement); bespoke weight-based concentrations are considered unsafe
• Smart pumps with drug libraries
• Use the SPTS drug chart; matching concentrations with the SPTS and PCCU reduces errors at handover

• Conditions where time to definitive treatment significantly affects outcome; usually life-, limb- or organ-threatening
• Undertaken by the referring hospital team as waiting for the SPTS would cause delay
• The benefit of a rapid transfer must outweigh the risk of a less experienced, non-specialist team
• The SPTS consultant can still advise, and may assist if a team is nearby or the local team is overwhelmed

• At least 2 senior clinicians, ideally trained in paediatric critical care, transfer and advanced airway management
• STOPP (Safe Transfer of the Paediatric Patient) tools, available from the SPTS:
  • Risk assessment that determines team composition
  • Checklists for equipment, drugs and fluids
  • Prompts for communication, clinical and administrative tasks
• Equipment checked daily, with recorded regular training
• Pre-departure checks reinforce a shared mental model, much like a pre-anaesthetic brief
• Ensure a safe local service: if a consultant leaves, arrange senior cover (e.g. second on-call); plan for theatres being occupied

• Almost all UK time-critical paediatric transfers are by road
• Interfacility transfers are mapped to ambulance response categories:
  • Usually Category 2 (18-minute target response); transport only
  • Escalate to a Level 1 response (paramedic crew, 7-minute target) if additional clinical help is needed
• Hospitals and ambulance providers should have an agreed process for requesting a non-SPTS ambulance

• Acceleration, deceleration and cornering forces; small babies and under-resuscitated children are most affected
• Blue lights and sirens increase accident risk and physiological stress; risk assess with the crew and favour a smooth, steady drive

Adapted from Paediatric stabilisation and transfer. Part 1: preparation and standards of care

• Protocols and drugs immediately available to treat raised ICP and major haemorrhage
• Proformas for burns triage, assessment and fluid resuscitation

• All hospitals must stock dinoprostone (prostaglandin E2) to maintain or reopen the ductus arteriosus, with a regionally agreed protocol
• Ventilated neonates and infants with cardiac lesions may need FiO₂ below 0.3, so the transport ventilator must allow this

• Time-critical transfer for consideration of haemodiafiltration
• Ammonia scavenging drugs must be started within 30 minutes of the decision to treat

• Under 3 kg requires specialist equipment and expertise: involve the local neonatal team or regional neonatal transport service early
• Transport incubators or 'babypods' may be needed

• Trolleys standardised across the organisation, with a local risk assessment for anything extra
• Intraosseous kits on every resuscitation trolley; all clinicians trained in their use
• Resuscitation drugs (always including adrenaline) must not be locked away; stored in tamper-evident containers with daily documented checks
• Immediate access to algorithms and resource tables for equipment sizes and drug doses

• Non-specialists should focus on good basic airway support first
• Clinicians competent in paediatric intubation should use cuffed tubes
• Standardised paediatric difficult airway trolley with a videolaryngoscope suitable for all ages; an adult trolley is not sufficient
• Cuff pressure manometer to keep cuff pressure below 20 cmH₂O

• Transport ventilator suitable for any size, with regular training and protocols for circuit set-up by age (reducing dead space, humidification, non-invasive support)
• Portable monitoring with configurable paediatric alarm limits
• Paediatric transfer 'grab bag' with a resource folder: SPTS drug chart, STOPP tool, observation charts, guidelines and regional contact numbers
• Patient restraint:
  • Over 2.5 to 3 kg: adult transport trolley with an age and weight-appropriate child restraint
  • Under 2.5 kg: babypod or transport incubator
  • Vacuum mattress if a specific harness is unavailable

• Caregivers can choose their level of presence during emergencies, provided safety and teamwork are maintained; a family support worker can help
• Offer the chance to travel with their child, after assessing:
  • Patient stability
  • Parental behaviour and separation anxiety
  • Space in the ambulance
• Brief any travelling parent on the transfer and safety procedures
• Those not travelling should not follow the ambulance; give them the address and contact details of the destination ward
• Access to support e.g. social workers, chaplaincy, counselling