Air Medical Transportation for Severe Acute Pancreatitis Patients over ...

Hindawi Gastroenterology Research and Practice Volume 2018, Article ID 3826084, 8 pages https://doi.org/10.1155/2018/3826084

Research Article Air Medical Transportation for Severe Acute Pancreatitis Patients over an Extra Long Distance: Is It Safe Enough? Lin Gao ,1 Jingzhu Zhang ,1 Kun Gao ,1 Yiyuan Pan ,2 Xiaotao Qin,3 Jie Zhang,3 Jing Zhou ,1 Guotao Lu,1,4 Weiqin Li ,1 and Zhihui Tong 1 1

Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210002 Jiangsu, China 2 Department of Intensive Care Unit, Suzhou Hospital Affiliated to Nanjing Medical University, No. 16 Baita West Road, Suzhou, 215002 Jiangsu, China 3 Hope Assist Medical Assistance Service Company, No. 1111 Tower A, Chaoyang SOHO, Beijing 100020, China 4 Department of Gastroenterology, Affiliated Hospital of Yangzhou University, No. 386 Hanjiang Media Road, Yangzhou, 225000 Jiangsu, China Correspondence should be addressed to Zhihui Tong; [email protected] Received 22 March 2018; Accepted 24 April 2018; Published 2 July 2018 Academic Editor: Piero Chirletti Copyright © 2018 Lin Gao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. Severe acute pancreatitis (SAP) patients usually develop persistent organ dysfunction which causes the majority of deaths. It is important for SAP patients to receive centralized diagnosis and treatment in an experienced tertiary center. China, as a vast country with uneven distribution of medical resources, should take advantage of air medical transportation to meet the challenge of patient transfer among different regions. The aim of this study was to evaluate the safety and effectiveness of air transport for SAP patients via extra long distance. Methods. This was a retrospective analysis of all air medical transportations for SAP patients admitted to Jinling Hospital from January 2010 to December 2016. The general characteristics, transportation process, and clinical outcomes of these patients were recorded, and the safety and effectiveness of air transport were evaluated. Results. All the 20 SAP patients were successfully transferred by chartered aircraft without any occurrence of severe transportassociated complications. The mean transport time was 5.86 hours and the average transport distance was 1530 kilometers. The majority of SAP patients got timely intervention and the ultimate mortality rate was 15%. Conclusions. Air medical transport appears to be safe and effective for SAP patients with vital organ dysfunctions during the extra long-distance transportation.

1. Introduction Acute pancreatitis (AP) is a severe inflammatory disorder of the pancreas and one of the most fatal diseases of the gastrointestinal tract around the world. Recent studies showed that the annual incidence of AP varied between 13 and 45 cases per 100,000 people [1]. The majority of AP patients have a mild disease course and recover within several days; however, about 15%–20% of the patients will develop severe AP (SAP) [2–4]. Persistent organ failure poses the greatest threat and causes the majority of mortality cases in SAP patients [5]. In view of the low incidence and the complicated pathophysiological process of SAP, the Japanese guideline recommends

that severe cases should be transferred immediately to a facility capable of providing treatment for SAP [6]. The Jinling Hospital SAP treatment center was established in 1997. In recent years, more than 300 SAP patients have been admitted each year and till now, more than 2000 cases have been admitted to our center of whom the mortality rate was below 5%. Our center is located in eastern China, and the extra long distance (in this study defined as over 1000 kilometers) between our center and the remote areas has hindered these remote SAP patients to get timely and effective treatment measures. Hence, it is of great challenge to transfer these SAP patients to our center safely and quickly. In the past, patients were mainly transported by ambulances which

2 had the disadvantages of long travel time, limited onboard equipment and bumpy ride. These problems restricted the application of ambulances in SAP patient transportation over an extra long distance [7]. It usually took ambulances more than a whole day to transfer patients to our center which was extremely dangerous for SAP patients, hence most of them had to give up transportation. A few transferred patients had worsened disease conditions because of the lack of monitoring of close vital signs and lack of organ function support during the distant transport process. The aforementioned dilemma had stimulated the growing need for air medical transport. Air medical transport in China had been put into practice for decades and experienced accelerating demand in the past few years [8]. There is no doubt that air transfer has created a new era for the transportation of SAP patients. However, controversy has existed for a long time regarding the safety, benefits, and potential risks of air transportation [9, 10]. Although SAP patients often benefit from transfer to tertiary care for services not available at the sending hospital, the risks of adverse clinical outcomes associated with transport and aviation accidents cannot be ignored [11]. Hence, it is of great importance to assess the safety and explore the benefits and risks of air transport for SAP patients over an extra long distance, considering the lack of relevant literature reported until now. In the present study, we aimed to analyze cases that underwent air medical transport between 2010 and 2016 in terms of general characteristics, transportation process, transport-related data, and clinical outcomes, as well as to assess the safety of air transfer for SAP patients over an extra long distance.

2. Materials and Methods This was a retrospective analysis of all air medical transportations for SAP patients admitted to Jinling Hospital, Medical School of Nanjing University from January 2010 to December 2016. Diagnosis and disease severity classification of AP were according to the Revised Atlanta Classification [12]. Inclusion criteria were SAP patients with single or multiple persistent organ failure (>48 h) and with transport distances over 1000 kilometers. It was important to note that all transport of patients was carried out by professional medical transfer organizations, after a request from the next of kin or legal guardian of the patient. This study was approved by the institutional review board of Jinling Hospital. Our study was carried out in accordance with the relevant guidelines and regulations of our hospital and oral informed consent was obtained from all participants. The disease-associated data before and during the transport were recorded and provided by the professional medical staff from Hope Assist Medical Assistance Service Company, and disease-associated data after the transport were recorded in our treatment center. 2.1. Definition 2.1.1. Systemic Complication. The definitions of organ dysfunction were based on a score of ≥2 in the sequential organ failure assessment (SOFA) scoring system. According to the

Gastroenterology Research and Practice Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), sepsis should be defined as a lifethreatening organ dysfunction caused by a dysregulated host response to infection [13]. 2.1.2. Local Complications. Apart from the common complications (acute peripancreatic fluid collection, pancreatic pseudocycts, acute necrotic collection, and walled-off necrosis) which involve the pancreas itself, in this study, we focused more on severe AP-induced complications, including intra-abdominal hemorrhage, gastrointestinal fistula and portal vein thrombosis [12]. 2.1.3. Transfer Time and Transfer Distance. Transfer time was defined as time from actual delivery of the patient at the sending hospital to handing over to the primary medical team at our hospital. Transfer distance was defined as the sum of ground transportation distance from the sending hospital to the discharge disposition in the airport, intercity flight distance, and ground transportation distance from the admitting disposition in the airport to our hospital. 2.1.4. Vital Signs of Transferred SAP Patients before and after Transport. Vital signs of transferred SAP patients before and after transport (Table 1) refer to the vital signs and blood gas analysis recorded before departing from the sending hospital and the vital signs and blood gas analysis recorded immediately after arriving at our hospital. 2.1.5. The Definition of Abnormal Events of Vital Signs during Transfer (Table 2). The baseline values of vital signs refer to the values recorded for the first time during the transfer process. The heart rate, respiratory rate, blood pressure, and blood oxygen saturation were automatically measured by the ECG monitor, the axillary temperature was measured by the thermometer, and the urine volume per hour was collected by the sterile catheter and recorded by the nurse. 2.1.6. Increased Body Temperature. Axillary temperature was measured every half hour and if the temperature of a single measurement increased by 0.5 degrees compared to the baseline value, it was defined as an increased in body temperature. 2.1.7. Heart Rate Elevation. If the heart rate was elevated by 20% compared to the baseline value and lasted longer than 10 min, it was defined as heart rate elevation. 2.1.8. Tachypnea. If the respiratory rate was elevated by 5 times per minute compared to the baseline value and lasted longer than 10 min, it was defined as tachypnea. 2.1.9. Decreased Blood Pressure. Noninvasive blood pressure was measured every 10 minutes, and if the average arterial pressure dropped below 65 mmHg for two consecutive measurements, it was defined as decreased blood pressure. 2.1.10. Decreased Blood Oxygen Saturation. If oxygen saturation dropped by 5% compared to the baseline value and lasted longer than 5 minutes, it was defined as decreased blood oxygen saturation.

Gastroenterology Research and Practice

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Table 1: Vital signs of transferred severe acute pancreatitis patients before and after transport. Variables, number (%) Heart rate ≤120 beats/min >120 beats/min Blood pressure Without vasopressors Norepinephrine ≤ 0.1 μg/kg/min Norepinephrine > 0.1 μg/kg/min PaO2/FiO2 (mmHg) >200 100–200 and mechanically ventilated 40 ml/h pH >7.45 7.35–7.45 2 PaCO2 >45 35–45 500 km): (1) Railway stations cover the majority of cities in China and is much more widespread than airports. (2) There are many trains going back and forth between two cities and it really

7 saves a lot of time without complicated screening procedures. (3) The speed of a railway averages up to 300 km/h and it is timesaving. (4) The cost of the railway transport is extremely lower than airplanes, and is within the economical reach of most Chinese people. Hence, we have reasons to believe that the high-speed railway will be used for medical transport in the future and will undoubtedly play an important role in critically ill patients’ transportation. 4.1. Limitations. Limitations of this study include the small number of SAP cases via air transport, a lack of a control group of AP patients transported by ground ambulance, as well as a lack of records and analyses of weather and traffic conditions at the time of each transfer. In conclusion, during the extra long-distance transportation for SAP patients with vital organ dysfunctions, air medical transport appears to be an alternative choice to ensure that patients receive timely intervention and obtain better clinical outcomes.

Abbreviations SAP: SOFA: IPN: AKI: ARDS: MODS: ICU:

Severe acute pancreatitis Sequential organ failure assessment Infected pancreatic necrosis Acute kidney injury Acute respiratory distress syndrome Multiple organ dysfunction syndrome Intensive care unit.

Data Availability The data in this study are available for other researchers to verify the results of our article, replicate the analysis, and conduct secondary analyses. Other researchers can send e-mails (e-mail addresses: [email protected] or [email protected]) to contact us to obtain our data.

Conflicts of Interest The authors declare that there is no conflict of interest regarding the publication of this paper.

Authors’ Contributions Zhihui Tong and Weiqin Li formulated the idea of the paper and supervised the research, and both authors reviewed and revised the manuscript. Lin Gao and Jingzhu Zhang performed the research and wrote the manuscript. Kun Gao and Yiyuan Pan provided comments and technical advice. Xiaotao Qin and Jie Zhang participated in preparing the figures and tables and in data analyzing. Jing Zhou and Guotao Lu revised the manuscript and provided comments. All authors reviewed the manuscript.

Acknowledgments This work was supported by the National Natural Science Foundation of China (nos. 81570584 and 81670588) and

8 the Key Research and Development Program Foundation of Jiangsu Province of China (nos. BE2015685 and BE2016749).

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