Stabilise-then-transfer: deciding when and how to move a critically ill child within or between hospitals, communication with the receiving PICU, team, equipment and oxygen planning, in-transit monitoring and handover — adapted to Indian ambulance realities.
At the bedside
Timed steps- 1
Is transfer needed and is the child safe to move?
DecideTransfer when the child needs care you cannot provide (ventilation, inotropes, dialysis, neurosurgery, ECMO). Risks of the journey must be lower than the risks of staying. Discuss with the receiving PICU consultant early — they can advise on stabilisation before a bed is free.
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A — airway
StabiliseIf the airway may deteriorate en route (GCS ≤8, worsening work of breathing, refractory shock, status epilepticus, severe croup), intubate before leaving. Confirm tube position on X-ray, record size and depth at lips, secure well, ETCO₂ attached.
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B and C — breathing and circulation
StabiliseTransfer ventilator or bag with PEEP valve; NG/OG tube on free drainage. Two secure IV/IO lines; vasoactive infusions running and stable on syringe drivers with spare syringes; resuscitation fluid ready.
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D, E — glucose, seizures, temperature
StabiliseCheck glucose before leaving and treat <3 mmol/L (54 mg/dL); control seizures; keep infants warm (cap, wraps, warmed ambulance) — hypothermia worsens acidosis and coagulopathy. Splint fractures; cervical immobilisation if trauma.
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ISBAR call and documents
CommunicateDoctor-to-doctor call (ISBAR): situation, background, assessment with latest vitals/gas, recommendation and ETA. Send notes, drug chart, fluid chart, imaging (on disk/phone), investigations, consent and referral letter. Explain to parents; one parent usually accompanies.
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Team, equipment and drugs
EquipEscort: a doctor skilled in paediatric airway and resuscitation plus a trained nurse for any ventilated or unstable child. Portable monitor (ECG, SpO₂, NIBP/arterial line, ETCO₂), suction, age-appropriate airway kit, defibrillator with paediatric pads, pre-calculated drug chart for that weight.
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Oxygen planning
EquipOxygen needed (L) = (minute ventilation or flow in L/min + ventilator driving gas) × journey minutes × 2 (safety). Check cylinder sizes and pressures before departure; carry at least 30 min reserve beyond the doubled estimate.
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Monitor and record
In transitContinuous ECG, SpO₂, ETCO₂ if ventilated, BP at least every 5–15 min; record observations and interventions. Stop the vehicle for procedures if needed. Pre-defined plan for deterioration (DOPE, arrest dose chart).
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Structured handover
ArrivalHands-off, eyes-on handover at the bedside: patient, events, current therapy, outstanding issues; then transfer monitors and infusions one by one.
Arrest during transfer
Adrenaline (epinephrine) — paediatric
- Dose
- 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL), max 1 mg
- Worked example
- Pre-draw for 15 kg: 0.15 mg = 1.5 mL of 0.1 mg/mL, labelled.
Hypoglycaemia before/during transfer
Dextrose 10% — paediatric
- Dose
- 2–5 mL/kg of 10% dextrose
- Worked example
- 15 kg: 30–75 mL D10.
Sedation/analgesia for ventilated transfer
Fentanyl — paediatric
- Dose
- 1–4 mcg/kg/h (boluses 1 mcg/kg)
- Range
- 1–4 mcg/kg/h
Pre-departure checklist (say it aloud)
| Domain | Check |
|---|---|
| Airway | ETT size and depth recorded, secured, CXR checked, ETCO₂ waveform; spare tube one size smaller, bag-mask, suction |
| Breathing | Transport ventilator settings and alarms checked; SpO₂ stable on transport settings for 10–15 min before leaving |
| Circulation | Two working IV/IO lines; infusions labelled, on fully charged syringe drivers, spare syringes; fluid bolus drawn up |
| Disability | Glucose checked; seizures controlled; pupils recorded; analgesia/sedation adequate |
| Exposure | Temperature recorded; warming for infants; fractures splinted |
| Equipment | Monitor and defibrillator charged; oxygen calculated ×2 plus reserve; suction; paediatric drug chart for weight |
| People | Doctor with paediatric airway skills + trained nurse; parent informed and accompanying if possible |
| Paperwork | Referral letter, notes, imaging, consent, ISBAR call made, receiving team and bed confirmed, ETA given |
Oxygen planning example
| Item | Value |
|---|---|
| Child on HFNC 20 L/min (FiO₂ 0.6) or ventilator | Assume ~20 L/min total gas use |
| Journey time | 60 min (estimate) |
| Required | 20 × 60 = 1,200 L; × 2 safety = 2,400 L |
| Cylinder content | Content (L) ≈ water capacity (L) × pressure (bar); e.g. 10 L water capacity at 150 bar ≈ 1,500 L |
| Decision | Carry ≥2 such cylinders plus 30 min reserve, or use a larger cylinder |
Indian cylinder sizes and fill pressures vary — read the label and the gauge (see module 40 oxygen planning).
Calculators for this topic
References
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Transferring a critically ill child
Step 1 of ~8
Stabilise, communicate, equip, monitor, hand over.
Call receiving PICU consultant (ISBAR); agree plan and bed
Based on Zirpe KG, Tiwari AM, Kulkarni AP, et al; Warren J, Fromm RE Jr, Orr RA, et al. Educational use; follow local protocol.
Pathophysiology
Transport adds vibration, acceleration, noise, cramped access, limited oxygen and battery supplies and cold — all of which can destabilise a child with little physiological reserve. Infants lose heat quickly (large surface area-to-weight ratio), and movement can dislodge short endotracheal tubes.
Evidence
- ACCM/SCCM guidelines (Warren 2004) for inter- and intrahospital transport: pre-transport communication, accompanying personnel (minimum two, one a critical care nurse or physician for unstable patients), minimum equipment and monitoring; mostly consensus-based.
- ISCCM position statement on intrahospital transport (Zirpe 2025): risk stratification, checklists, trained teams, equipment standards and documentation for Indian ICUs.
- Adverse events during transport occur in a substantial minority of critically ill transfers; specialist paediatric retrieval teams are associated with fewer critical incidents than non-specialist teams in observational studies.
Controversies
- Specialist retrieval team vs referring team escort (resource-dependent; specialist teams are rarely available in India outside a few metros).
- Timing: delaying transfer to stabilise vs urgent transfer for definitive care.
🇮🇳 India notes
- Most public '108/102' ambulances in India are basic life support; advanced life support ambulances with ventilators and paediatric equipment are limited and often private — confirm capabilities before departure.
- Long distances and road conditions make journeys longer than expected: plan oxygen, batteries and drugs for at least double the estimated time.
- Families often arrange transport themselves; insist on a trained escort for unstable children and document the risks discussed.
- Keep a printed paediatric transfer checklist and weight-based dose chart in every emergency department and ICU.
References
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Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.