Transport of surgical patients

INTRODUCTION — 

Perioperative transportation of surgical patients involves logistic challenges that increase risk for adverse events. This topic addresses preparation, equipment and medications, monitoring, and other considerations during routine transport of surgical patients to or from an operating room. Transport of critically ill surgical patients is also addressed.

A separate topic discusses handoffs of surgical patients before and after transport to another hospital location. (See "Handoffs of surgical patients".)

PREPARATIONS — 

Systematic preparation for transport of a surgical patient from and to any location minimizes delays and improves patient safety by ensuring optimal patient condition and readiness of appropriate equipment for transport (form 1 and figure 1). This is true for routine, elective patients who will be transported from the operating room (OR) to the post-anesthesia care unit (PACU), as well as for critically ill patients who may require transport to or from an intensive care unit (ICU) (table 1), or another hospital setting that is remote from the main OR area. (See 'Transport of critically ill patients' below and "Considerations for non-operating room anesthesia (NORA)".)

Portable monitors are necessary to achieve safe transport of many patients (see 'Patients who require monitoring' below and 'Continuous monitoring' below). These monitors should have a clear illuminated screen and be able to show the electrocardiogram (ECG), oxygen saturation, noninvasive blood pressure, two invasive pressures, and capnography when appropriate and if available on the transport monitor [1]. In addition to continuous visual monitoring of vital signs, we use auditory pulse oximetry and alarms for early identification of abnormalities. Personnel participating in patient transport must be familiar with the monitoring equipment and be able to recognize and troubleshoot any in-built alarms. Adequate battery supply should be checked prior to use of any monitor.

An appropriate gurney is necessary for transport of inpatients. The weight limit of the gurney being used for transport and the patient's weight are noted. All personnel participating in patient transport on a hospital gurney must be familiar with its basic operation including how to steer the bed, change its height or position, appropriately use securing devices and siderails, and lock/unlock the wheels. Use of hydraulic lifts and similar equipment may be necessary for some patients. Appropriate mechanisms to secure oxygen cannisters are required when supplemental oxygen is necessary.

Personnel at the transport destination should be notified in advance of patient arrival, with preliminary handoff information transmitted at the time of notification. (See "Handoffs of surgical patients".)

ROUTINE PERIOPERATIVE TRANSPORT

Preoperative holding area to operating room — Typically, outpatients undergoing surgery and other interventional procedures are placed in a holding area before transfer to the operating room (OR) or other in-hospital setting. Some preoperative patients come directly from an inpatient hospital floor. Transport considerations depend on the acuity of the patient's condition and the nature and urgency of the planned procedure. Stable patients from an inpatient hospital ward may be transported to the preoperative holding area by hospital transport services. Transfer of information (handoffs) to holding area or OR personnel after arrival is discussed in a separate topic. (See "Handoffs of surgical patients", section on 'Outpatients: Holding area to operating room' and "Handoffs of surgical patients", section on 'Inpatients: Floor to operating room'.)

At our institution, an anesthesia provider typically transports the patient from the preoperative holding area into the OR or other interventional suite, although in other institutions this practice may depend on typical case staffing and expectations. Appropriate clinical monitoring is important if any intravenous (IV) sedative medications (eg, midazolam) or analgesics (eg, opioids) have been administered, in order to recognize and manage potential adverse effects of these medications (eg, respiratory depression). In addition to clinical assessment of adequacy of ventilation and wakefulness, peripheral oxygen saturation (SpO₂) using pulse oximetry is typically monitored during transport after moderate or deeper sedation or after placement of a neuraxial or regional anesthetic block, particularly when traveling for longer distances.

In some institutions, placement of cardiovascular monitors such as an intra-arterial catheter, central venous catheter (CVC), or pulmonary artery catheter (PAC) is accomplished in the preoperative area. In these cases, a portable monitor can be used to continuously monitor these intravascular pressures and transduce waveforms to recognize accidental disconnection or malfunction.

Operating room to post-anesthesia care unit

Airway and respiratory management — Some patients may be transported from the OR or other interventional suite to the post-anesthesia care unit (PACU) without any airway equipment or oxygen (O₂) support. An example is a healthy patient who received no or only minimal sedation travelling for a short distance to a nearby PACU. Other patients may need additional respiratory support or monitoring.

Respiratory support — If general anesthetics, sedatives, analgesics, and/or neuromuscular blocking agents were administered during a surgical or interventional procedure, the patient is at risk for respiratory compromise in the immediate postoperative period. Thus, an anesthesia provider transports the patient in the immediate postoperative period, equipped with a manual resuscitator with a self-inflating (Ambu) bag and mask with an O₂ cylinder if needed in an emergency. This system offers the advantage of simplicity without a requirement for additional bulky equipment during transport to a PACU or other destination such as an interventional radiology (IR) or magnetic resonance imaging (MRI) suite. This is necessary even if the patient has stable respiratory status or is already intubated (since accidental extubation may occur during the transport process) [2].

Respiratory support modalities may include providing only supplemental O₂ in a spontaneously breathing patient (via facemask or nasal cannulae), or noninvasive positive pressure ventilation (NIV), or manual ventilation in a patient who remains intubated (typically accomplished by using the self-inflating Ambu bag). (See "Continuous oxygen delivery systems for the acute care of infants, children, and adults".)

Airway support — The need for other airway equipment is dictated by the patient's current level of respiratory support and risk for deterioration of respiratory status during transport. If loss of the airway is a possibility, it is prudent to have additional airway equipment immediately available on the transport gurney. These may include an assortment of oral and nasopharyngeal airways, direct laryngoscope, videolaryngoscope, various endotracheal tube (ETT) sizes, as well as an end-tidal carbon dioxide detector for verification of correct tracheal intubation [3-5].

Oxygen support — The level of O₂ support and whether O₂ is to be administered via a nasal cannula, face mask, nonrebreather mask, or ETT is determined before transport. For some patients, no supplemental O₂ may be necessary (eg, a healthy patient who did not receive sedation travelling for a short distance to a nearby PACU).

If O₂ support during transport is necessary or prudent, ensure that the O₂ tank is secured to the gurney during transport rather than lying unsecured on top of or underneath the mattress at the head or foot of the bed. Also, ensure that the available O₂ supply will last throughout the transportation process. Needs depend on the required O₂ flow per minute, as well as the expected duration of transport, which may be prolonged for patients in remote locations such as an MRI or IR suite. Clinicians should be familiar with the operation of transport O₂ cylinders and be able to estimate the available oxygen supply in a cylinder. The following steps are used to calculate this:

●Calculate the available volume in the O₂ tank. The "E" size O₂ cylinder is most commonly used during transport. When full, the "E" cylinder has 680 L of O₂ at a pressure of 2200 psig. The relationship of volume to pressure is linear such that when the pressure is half of the original "full" pressure, the volume of O₂ is also half according to this formula [6]:

Current O₂ volume (L) = (volume of full tank [ie, 680L]) ÷ (pressure of full tank [ie, 2200 psig]) x current pressure (psig).

●Determine the flow of O₂ required per minute.

●Then calculate the minutes of O₂ supply available during a particular tank by dividing the current volume in the O₂ tank by the flow of O₂ required per minute. As an example, if a patient is being ventilated with a bag valve mask apparatus via an ETT with O₂ flow set at 10 L/minute of oxygen, a starting tank pressure of 2000 psig will allow for approximately 62 minutes of O₂ flow. Since transport from some locations (eg, an MRI suite located in another building) may require a longer time than estimated, it is prudent to allow for 30 extra minutes of O₂ flow beyond the anticipated transport time [7].

Patients who require monitoring — For some patients, only clinical assessment of adequacy of ventilation and wakefulness is necessary during transport to a nearby PACU (eg, a healthy patient who received no or minimal sedation). Other patients may need additional respiratory or hemodynamic monitoring.

●Respiratory monitoring – A portable monitor that provides continuous monitoring of SpO2 is used after moderate or deeper sedation, administration of general anesthetics and/or neuromuscular blocking agents (NMBAs), or use of a neuraxial anesthetic technique, particularly if travel over a longer distance is necessary [2,8]. In particular, patients with body mass index (BMI) >30 kg/min² and those with SpO2 <96 percent before leaving the OR are at risk for desaturation [9]. Quantitative assessment of adequacy of oxygenation and real time capture of desaturation events allows for rapid management [10]. Some professional society guidelines suggest use of capnography during transport of an intubated patient [1,8]. However, capnography is not a consistently available component of institutional transport monitors, and is not considered to be a standard monitor at this time.

●Hemodynamic monitoring

•Electrocardiogram (ECG) – ECG monitoring is standard.

•Blood pressure (BP) – Equipment to obtain intermittent noninvasive BP measurements with a cuff may be available. In patients with an intra-arterial catheter, BP is typically monitored continuously during transport and in the PACU until removal of the catheter.

Medications — Adequate IV access and an adequate supply of IV fluids are ensured prior to transport. This allows maintenance of IV patency and immediate administration of any necessary medications.

Clinical judgment is used to decide which, if any, IV medications should be placed on the patient's transport gurney for immediate access. Traveling with emergency medications is not typically necessary for routine transfer of patients from an OR to a PACU near the OR, since both areas are well-stocked with these items.

Handoff in the post-anesthesia care unit — A formal handoff from the anesthesia provider to personnel in the PACU is performed shortly after arrival, as discussed separately (figure 1 and table 2). (See "Handoffs of surgical patients", section on 'Operating room to post-anesthesia care unit'.)

TRANSPORT OF CRITICALLY ILL PATIENTS

Risk assessment and patient optimization

Transport to an operating room or interventional suite — Medical, surgical, and anesthetic assessment of critically ill patients in the preoperative period is typically accomplished before transport. We use a checklist that addresses patient-related factors before transport of critically ill patients (table 1) [3]. Risk assessment also includes determining the reason for transport (eg, performance of a diagnostic or therapeutic procedure or intervention), and whether benefits are likely to outweigh risks [11].

A 2022 meta-analysis in critically ill patients noted that adverse events occurred during intrahospital transport with a pooled frequency of 26.2 percent, with 1.5 percent being life-threatening adverse events [12]. Studies have noted that serious adverse events that occur include accidental extubation (up to 0.4 percent), removal of a central venous catheter (up to 0.4 percent), or cardiopulmonary arrest (up to 1.5 percent) [12-17]. Mechanically ventilated critically ill adult patients who were transported within the hospital were more likely to experience complication such as pneumothorax, atelectasis, ventilator-associated pneumonia, hypoglycemia, hyperglycemia, and hypernatremia than similar patients who did not undergo transport. [18]. In studies in critically ill pediatric patients, respiratory and airway events were the most common complications occurring during transport [19,20].

If transport for a diagnostic intervention or elective procedures is not urgent, it is prudent to delay transport while the patient's condition is optimized. However, if urgent or emergency transport is necessary for diagnosis or treatment of a primary source of instability (eg, treatment of bleeding in a patient with hemorrhagic shock, or urgent imaging to prevent potential organ or limb damage), then assessment and actions to stabilize the patient must proceed concurrently with preparations for transport.

Transport from an operating room or interventional suite — Information gleaned from diagnostic bloodwork (eg, arterial blood gases, hemoglobin, potassium and calcium levels) is used to correct abnormalities prior to transport. As the operation/procedure is concluding, obtaining data from other hemodynamic monitors such as a pulmonary artery catheter (PAC), echocardiography examination, or other point-of-care ultrasound examinations are useful to evaluate ventricular function and volume status so that appropriate adjustments in inotropic, vasodilator, or fluid therapy to can be made to achieve optimal pre-transport status.

In patients with hemodynamic instability, electrocardiographic (ECG) changes suggestive of myocardial ischemia, malignant arrhythmias, or worsening hypoxia or acidosis, every effort is made to stabilize the patient in the operating room (OR) before transport. It is critically important to notify intensive care unit (ICU) personnel regarding the patient's clinical condition and any ongoing organ support (eg, vasoactive medications) to facilitate appropriate preparations in anticipation of patient admission.

Specialized preparations — Institutional policies, guidelines and standards of care have been developed to maximize patient safety and minimize risk for morbidity before transport of critically ill patients [1]:

●Ensure optimal patient condition – This includes hemodynamic stability, control of bleeding and coagulopathy, and adequate oxygenation and ventilation (table 1) [3]. (See 'Risk assessment and patient optimization' above.)

●Check transport equipment (table 3). (See 'Equipment' below.)

●Check transport monitors. (See 'Patients who require monitoring' above and 'Continuous monitoring' below.)

●Ensure availability of experienced personnel who are familiar with any specialized equipment used during transport (see 'Personnel' below). Examples include administration of inhaled pulmonary artery vasodilators and use of mechanical circulatory support devices. (See 'Administration of inhaled pulmonary artery vasodilators' below and 'Management of mechanical circulatory support devices' below.)

●Transfer essential information via a formalized handoff (table 4 and table 5) [19,21]. (See "Handoffs of surgical patients", section on 'Inpatients: Intensive care unit to operating room' and "Handoffs of surgical patients", section on 'Operating room to intensive care unit'.)

Continuous monitoring — Continuous monitoring of pulse oximetry (SaO₂) and the ECG during transport is routine, as described above. (See 'Patients who require monitoring' above.)

Additional cardiovascular and respiratory monitoring for a critically ill patient may include [7]:

●Continuous blood pressure (BP) monitoring in patients with an intra-arterial catheter.

●Hemodynamically unstable patients with a previously inserted PAC may benefit from continuous monitoring of pulmonary artery pressure (PAP) and/or central venous pressure (CVP) during transport, particularly if refractory hypotension, metabolic acidosis, persistent ECG changes (particularly ST-segment elevation), or significant deterioration in regional or global left or right ventricular function is evident on transesophageal echocardiography (TEE) examination.

●Capnography in selected critically ill patients with severe respiratory disease. This facilitates rapid recognition of cardiac arrest, respiratory depression, accidental extubation, or other problems with ventilation [22].

●For patients at high risk for cardiovascular deterioration, a combined monitor-defibrillator device rather than a standard monitor is ideal for monitoring during transport.

Equipment — Equipment that may be used during transportation of critically ill patients is noted in the table (table 3) [3,5,7]. Equipment needs vary depending on the patient's condition and anticipated duration of transport. Standardized packaging of transport equipment at the unit or hospital level facilitates quick and efficient transport, enhances staff familiarity with routinely used equipment, and optimizes resuscitation efforts for patients who suffer clinical deterioration during transport [4].

Since hemodynamic and/or respiratory compromise is more likely in a critically ill patient, equipment for managing airway compromise (eg, bag, mask, laryngoscope, endotracheal tubes) or hemodynamic compromise (portable defibrillator and emergency drugs including bolus doses of vasopressors such as phenylephrine and epinephrine) are typically immediately available on the transport bed.

Respiratory support

Management of mechanical ventilation — Many critically ill patients are intubated and mechanically ventilated. Before transport from an OR or other in-hospital location to an ICU, a continuous infusion of an IV sedative such as propofol or dexmedetomidine is initiated before discontinuing volatile inhalation anesthetics to ensure that the patient remains adequately sedated during transport. In the final minutes before leaving an OR, adequate time for the selected IV agent to reach steady plasma concentrations should be allowed to ensure that the patient remains adequately sedated during transport. (See "Monitored anesthesia care in adults", section on 'Propofol' and "Monitored anesthesia care in adults", section on 'Dexmedetomidine'.)

Either assisted or controlled ventilation may be provided during transport using [11,23]:

●Manual ventilation – Manual ventilation is typically via a manual resuscitator with a self-inflating bag. This offers the advantage of simplicity without a requirement for additional bulky ventilator equipment.

However, manual ventilation can lead to either hypoventilation or hyperventilation. Furthermore, alveolar derecruitment has been associated with loss of positive end-expiratory pressure (PEEP) with deleterious effects on oxygenation. For this reason, a PEEP valve should be used with manual bag ventilation, with close attention given to respiratory rate (RR), tidal volume (TV), and overall minute ventilation. In addition, use of large TV can have deleterious effects on patients with lung injury and hypoxic respiratory failure.

●Ventilator equipment

•Standard ICU ventilators – ICU ventilators are equipped to deliver precise TV and high RR with close monitoring of airway pressures, allowing use of a variety of ventilator modes that can be personalized to patients with significant lung disease. ICU ventilators should be considered for transporting patients with particularly severe lung pathology.

In these cases, anesthesiologists and other clinicians outside of the ICU may be unfamiliar with management of these ventilators. It is typically prudent to have a respiratory therapist or intensivist who is familiar with the patient's ICU ventilator should accompany the patient during transport to avoid complications related to suboptimal ventilator settings, mechanical problems with the ventilator, or failure of oxygen (O₂) delivery.

•Transport ventilators – Transport ventilators are increasingly sophisticated and offer the advantages of consistent mechanical ventilation without the bulk associated with typical ICU ventilators [23]. Similar to use of an ICU ventilator during transport, personnel comfortable with use of the selected transport ventilator should accompany the patient.

High levels of oxygen support — Determine the level of O₂ support necessary for transport regardless of whether O₂ is to be administered via a nasal cannula, face mask, nonrebreather mask, or endotracheal tube (ETT) with assisted controlled ventilation (see 'Oxygen support' above). For some critically ill patients, controlled mechanical ventilation with a high concentration of oxygen may be necessary. Notably, if a transport ventilator is used, the amount of oxygen that will be delivered to the patient plus the additional O₂ flow that is necessary to operate the ventilator (approximately 2 L/minute) must be included in the calculation. Many transport ventilators also require a certain O₂ pressure to function. This requires subtracting approximately ten percent of the full tank (approximately 60 L or 200 psig) when calculating the minutes of oxygen flow that will be available.

Administration of inhaled pulmonary artery vasodilators — Some critically ill patients may be dependent on inhaled pulmonary artery vasodilator agents (eg, epoprostenol, nitric oxide). Adequacy of the supply of the inhaled agent and the supply of O₂ should be verified prior to transport. In addition, personnel familiar with the delivery device should be present throughout transport and during transfer of the delivery device to use with OR equipment. (See "Anesthesia for noncardiac surgery in patients with pulmonary hypertension or right heart failure", section on 'Chronic targeted therapy for pulmonary hypertension: Patient selection'.)

Emergency medications — Appropriate emergency medications should be immediately available during transport of potentially unstable patients. These typically include:

●Intravenous (IV) medications necessary to assist with endotracheal intubation or reintubation (ie, sedative-hypnotics, a neuromuscular blocking agent) for patients who received anesthetic or sedative agents for a surgical or interventional procedure. Such medications are particularly important during transportation of intubated patients to or from an ICU to another in-hospital location [7]. However, even patients who have been sedated but remained awake during a surgical or other interventional procedure may have received enough anxiolytic and/or analgesic drugs to cause respiratory depression. These patients should be monitored closely during transport. In some cases, reversal of the effects of an opioid or benzodiazepine may be necessary. (See "Postoperative airway and pulmonary complications in adults: Etiologies and initial assessment and stabilization", section on 'Ensure a patent upper airway and adequate ventilation'.)

●Even though ephedrine, phenylephrine, norepinephrine, and vasopressin are the most commonly used medications to treat hypotension in the perioperative setting, medications required for resuscitation as specified in adult cardiac life support (ACLS) algorithms should be available in a standardized transport kit for critically ill or unstable patients so that they are immediately available. (See "Advanced cardiac life support (ACLS) in adults".)

Furthermore, if the patient is already supported with one or more vasoactive agents, a sufficient supply of these agents should be available to last beyond the anticipated duration of transport. For any IV infusions administered via a power-dependent infusion device, ensure that the battery supply will be adequate to complete the transport process. (See "Intravenous infusion devices for perioperative use".)

●Ensure adequate IV access and supplies of IV fluids (typically isotonic crystalloids) before transport.

Personnel — Transport of critically ill surgical patients requires experienced personnel who are familiar with any specialized equipment that is used during transport. Examples include:

●A patient at high risk for developing clinical deterioration who is receiving continuous infusions of vasoactive medications may be transported by nursing staff familiar with that patient's condition and ongoing treatment. Hemodynamically unstable patients are accompanied by an anesthesiologist, intensivist, or other appropriately trained provider (eg, certified registered nurse anesthetist [CRNA], advanced practice nurse [APN], physician assistant [PA]) familiar with medication infusion pumps.

●A mechanically ventilated patient receiving continuous infusion(s) of sedative agents or with residual effects of general anesthetic agents is transported to or from the OR or interventional suite by a clinician expert in airway management and mechanical ventilation (eg, anesthesia provider, intensivist, respiratory therapist) [24]. This clinician should be knowledgeable about the specific mechanical ventilation equipment used during transport to adjust respiratory support as necessary and troubleshoot alarms or equipment malfunction.

●A critically ill patient dependent on specialized medications (eg, an inhaled pulmonary artery vasodilator) require the presence of specialized personnel familiar with the delivery device during transport and to set up use with a ventilator in the OR. (See "Delivery of inhaled medication in adults".)

Even personnel with specialized expertise may find rapid and effective emergency management challenging during transport because of the physical constraints of narrow hallways and elevators, with limited immediate availability of additional equipment or assistance from other resuscitation staff.

Handoffs in the ICU before and after transport — A standardized formal handoff protocol that includes verbal (and often written) communication for all phases of perioperative care should be used, as described in a separate topic. (See "Handoffs of surgical patients".)

●Transport from an ICU – During the preoperative handoff before transport to an OR or other interventional or imaging suite, a standardized protocol for the handoff includes structured communication with the patient's bedside nurse, the ICU clinician team, and the respiratory therapist when indicated (table 4). Such handoffs typically include the current hemodynamic and respiratory status of the patient (table 1), as well as transfer of hemodynamic monitors and multiple high-risk medications. (See "Handoffs of surgical patients", section on 'Inpatients: Intensive care unit to operating room'.)

●Transport to an ICU – Upon arrival to the ICU, patient information is communicated from the OR team to the ICU team using a formal handoff (table 5). In all cases, the anesthesia provider should remain with the patient to ensure stability until handoff is complete. (See "Handoffs of surgical patients", section on 'Operating room to intensive care unit'.)

SPECIAL CONSIDERATIONS

Additional precautions for patients with infectious disease — Considerations for transport of patients who require additional precautions against transmission of infectious disease are discussed separately. (See "Overview of infection control during anesthetic care", section on 'Precautions during patient transport'.)

Management of indwelling catheters and surgical drains — All indwelling intravascular catheters, urinary catheters, and surgical drains should be appropriately labeled and secured prior to transport to avoid dislodgement and patient injury. Also, any drainage apparatus (eg, bulb suction apparatus, drainage canister) should be secured.

Management of chest tubes — Chest tubes and other thoracostomy catheters are frequently present in patients undergoing airway or thoracic surgery, or other procedures to treat traumatic injuries or other pathology (eg, pneumothorax, hemothorax, pleural effusion). Insertion of a chest drain prior to transport is prudent for documented or likely pneumothorax in a critically ill patient. Considerations that determine whether portable suction is necessary during transport include the indication for the chest tube, drainage system in use (including level of ongoing suction), and amount of drainage measured. This information should be included in the handoff before and after patient transport to a new location. Notably, chest tubes are not routinely clamped since this may lead to respiratory and hemodynamic compromise if pleural or pericardial air or fluid reaccumulates during transport. (See "Thoracostomy tubes and catheters: Management and removal".)

Management of a cerebrospinal fluid drain — Patients with significant neurologic injury may have an external cerebral ventricular drain (EVD) placed for both monitoring of intracranial pressure (ICP) and for therapeutic drainage of cerebrospinal fluid (CSF) to optimize cerebral perfusion pressure. These patients often require transport to or from an intensive care unit (ICU) or stepdown unit to an operating room (OR), or to a neuroimaging or neurointerventional suite. (See "Evaluation and management of elevated intracranial pressure in adults", section on 'ICP monitoring' and "Anesthesia for patients with acute traumatic brain injury", section on 'Monitoring'.)

Transport personnel must be familiar with management of the EVD [25]. While CSF drains are often clamped during transport to avoid overdrainage [25], this decision should be individualized after discussion with the interdisciplinary team (eg, neurosurgeon, intensivist). Changes in patient position, EVD position, overdrainage, or drain clamping may cause deleterious effects [26]. As with all lines, drains, or tubes it is important to ensure that the EVD will travel with the patient and not endure any tension during rolling, turning, or moving the patient from their bed. Also, it is prudent to note the fluid levels in the drainage canister prior to and after transport.

Management for transport is similar for patients with a lumbar cerebrospinal fluid catheter inserted to optimize spinal cord perfusion during open or endovascular thoracic aortic surgery, or to treat a postoperative CSF leak. (See "Anesthesia for open descending thoracic aortic surgery", section on 'Cerebrospinal fluid pressure monitoring' and "Anesthesia for endovascular aortic repair", section on 'Monitoring and management of spinal cord ischemia'.)

Management of mechanical circulatory support devices — Mechanical circulatory support (MCS) devices are increasingly used to manage cardiogenic shock, cardiopulmonary failure, or for inability to wean from cardiopulmonary bypass. Similarly, venovenous or venoarterial extracorporeal membrane oxygenation (ECMO) devices are increasingly being used to treat respiratory and/or cardiac failure. Guidelines for transport of patient on ECMO are published by the Extracorporeal Life Support Organization (ELSO) [27]. (See "Short-term mechanical circulatory assist devices" and "Extracorporeal life support in adults in the intensive care unit: Overview".)

Patients on ECMO or other MCS, such as a ventricular assist device (VAD), require the presence of specialized personnel who can continue monitoring and troubleshoot device malfunction during transport to and from an OR or interventional suite. These personnel should ideally be present for the duration of the procedure (algorithm 1) [28]. Details regarding operation and monitoring of these devices are discussed separately:

●(See "Anesthesia for noncardiac surgery in adults with a durable ventricular assist device".)

●(See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Troubleshooting circuit dysfunction'.)

●(See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)".)

Ongoing cardiopulmonary resuscitation — In rare cases, a patient may be undergoing cardiopulmonary resuscitation (CPR) during emergency transport to an OR from a trauma bay/emergency department or ICU. In such cases, CPR must be continued during transport. CPR includes chest compressions that are typically delivered manually. An alternative is use of an automated mechanical device to deliver chest compressions. Advantages of such devices include ease of use and provision of high-quality CPR during transport so that the transporting clinicians can focus more effectively on maintaining respiratory and hemodynamic stability. However, it has not been established that their use leads to better outcomes [29,30]. Clinicians transporting the patient should be familiar with appropriate placement and operation of the compression device. (See "Therapies of uncertain benefit in basic and advanced cardiac life support", section on 'Mechanical compression devices'.)

INTER-FACILITY TRANSFERS — 

Inter-facility patient transfer before or after a surgical or other interventional procedure is occasionally necessary [31]. Inter-facility maternal transport is discussed in a separate topic. (See "Inter-facility maternal transport".)

In general, transfers of critically ill patients can be carried out safely by experienced transfer and retrieval teams [32]. Nevertheless, inter-facility transfers of unstable patients have been associated with short-term physiological deterioration and adverse outcomes. Examples include:

●In a study of 4542 surgical intensive care unit (ICU) admissions, 416 were inter-facility transfers [33]. Mortality rates in patients transferred between facilities were highest for those requiring emergency surgery (18 percent), transplant surgery (16 percent), and gastrointestinal surgery (8 percent) services. After adjusting for age and the Acute Physiology and Chronic Health Evaluation (APACHE) II score, inter-facility transfer remained as a risk factor for mortality in surgical ICU patients (odds ratio [OR] 1.60, 95% CI 1.04-2.45) [33].

●In one study of critically ill COVID-19 patients who were undergoing mechanical ventilation of the lungs, 45 transfers to another location within the same hospital were compared with 92 transfers to another facility [34]. For inter-facility transfers, a significant initial drop in ratio of the arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2 ratio) ratio occurred, from an initial median value of 25.1 kPa (188.3 mmHg) before transfer to a median value of 19.5 kPa (146.33 mmHg) immediately after transfer. However, this decrease resolved 24 hours later (median value 25.4 kPa [190.5 mmHg]). In contrast, significant changes in PaO₂/FiO₂ ratio were not noted after transfers within the same hospital. Meaningful differences in pH, carbon dioxide tension (PaCO₂), base excess, bicarbonate, or norepinephrine requirements were not noted in either group.

Key points to optimize safe transport include the following (table 6):

●Timing of transport is dictated by the reason for transfer and the patient's condition. Similar to intra-hospital transfers, medical, surgical, and anesthetic assessment of critically ill patients is accomplished before transport (table 1), with the goal of determining whether the benefits of transport to another facility will likely outweigh the risks [11].

●The transferring clinician/intensivist is responsible for ensuring adequate resuscitation and, if possible, optimal stability prior to transport to the new facility [32,35]. In some cases, an invasive airway or new intravascular catheter(s) for invasive monitoring may be inserted prior to transport.

●Mode of transport is determined by patient condition and resource availability (eg, ambulance, mobile ICU, or air transport via helicopter or fixed-wing aircraft).

●Personnel responsible for inter-facility transport vary, but may include dedicated network transport teams, emergency medical services (EMS), or critical care medical transport teams [31,32]. Medical oversight during transport is patient specific and also varies according to institutional and regional regulations [36,37].

●Regulations governing transfers and clinical care during transport are determined at local, regional, and national level [36,38]. Factors affecting planned transfers include environmental factors. Variations in altitude, temperature, and assessment of overall travel condition are particularly important during planned helicopter transport [39].

●Once the process begins, expeditious transfer is key in managing certain subgroups of surgical patients such as those who need urgent or emergency operative management of traumatic or head injuries, those with ongoing myocardial ischemia being transferred for operative or percutaneous coronary intervention, or those who require mechanical thrombectomy for stroke.

●Appropriate handoffs between the sending and receiving facility, with information exchange and complete documentation regarding plans for further care after transport (eg, immediate management of a surgical problem in the new facility’s operating room) are particularly important. (See "Handoffs of surgical patients".)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Management of inflight medical events".)

SUMMARY AND RECOMMENDATIONS

●Preparations – Preparation for transport of a surgical patient includes ensuring optimal patient condition and readiness of appropriate equipment (form 1 and figure 1). (See 'Preparations' above.)

●Routine transport from preoperative holding area to operating room – An anesthesia provider (though this varies at some institutions) typically transports patients from the preoperative holding area into the operating room (OR) or other in-hospital setting, particularly if any intravenous (IV) sedative medications (eg, midazolam) or analgesics (eg, opioids) were administered, or if a neuraxial or regional anesthetic block was placed. In addition to clinical assessment of adequacy of ventilation and wakefulness, we continuously monitor peripheral oxygen saturation (SpO₂) in patients who received moderate or deeper sedation or after placement of a neuraxial or regional anesthetic block. (See 'Preoperative holding area to operating room' above.)

●Routine transport from OR to post-anesthesia care unit

•Airway and respiratory management – Some patients may be transported from the OR or other in-hospital setting to a nearby post-anesthesia care unit (PACU) without any airway equipment or oxygen (O₂) support (eg, healthy patients who received no or minimal sedation). Others need:

-Respiratory support – If anesthetics, sedatives, analgesics, and/or neuromuscular blocking agents (NMBAs) were administered, a self-inflating (Ambu) bag and mask with an O₂ cylinder is available during transport. This is necessary even if the patient has stable respiratory status or is already intubated (since accidental extubation may occur during transport). Respiratory support modalities may include only supplemental O₂ in a spontaneously breathing patient, or noninvasive positive pressure ventilation (NIV), or manual ventilation in an intubated patient. (See 'Respiratory support' above.)

-Airway support – If airway loss is a possibility, additional equipment on the transport gurney typically includes oral and nasopharyngeal airways, direct laryngoscope, indirect videolaryngoscope, various endotracheal tube (ETT) sizes, and end-tidal carbon dioxide detector for verification of correct tracheal intubation. (See 'Airway support' above.)

-Oxygen support – Level of O₂ support administered via a nasal cannula, face mask, nonrebreather mask, or ETT is determined before transport. Ensure that the O₂ tank is secured to the gurney and adequate O₂ supply. (See 'Oxygen support' above.)

•Monitoring – For some patients, monitoring equipment is unnecessary during transport to a nearby PACU (eg, healthy patients who received no or minimal sedation). For those who received anesthetics, sedatives, analgesics, and/or NMBAs, electrocardiogram (ECG), pulse oximetry, are typically continuously monitored, as well as blood pressure (BP) if an intra-arterial catheter is in place. (See 'Patients who require monitoring' above.)

•Medications – Prior to transport, ensure that IV access and the supply of IV fluids are adequate. Clinical judgment is used to decide which, if any, IV medications should be placed on the transport gurney for immediate access. (See 'Medications' above.)

•Handoffs in the PACU – Use a formal handoff upon arrival in the PACU, as discussed separately (figure 1 and table 2). (See "Handoffs of surgical patients", section on 'Operating room to post-anesthesia care unit'.)

●Transport of critically ill patients

•Patient optimization and preparations – Before transport from or to an intensive care unit (ICU) (see 'Specialized preparations' above):

-Ensure optimal patient condition including hemodynamic stability, control of bleeding and coagulopathy, adequate oxygenation and ventilation (table 1). (See 'Risk assessment and patient optimization' above.)

-Check transport equipment (table 3). (See 'Equipment' above.)

-Check transport monitors. (See 'Patients who require monitoring' above and 'Continuous monitoring' above.)

-Ensure availability of experienced personnel familiar with any specialized equipment in use. (See 'Personnel' above.)

Examples include administration of inhaled pulmonary artery vasodilators or use of mechanical circulatory support devices. (See 'Administration of inhaled pulmonary artery vasodilators' above and 'Management of mechanical circulatory support devices' above.)

-Transfer essential information using a formalized handoff (table 4 and table 5) [19,21]. (See "Handoffs of surgical patients", section on 'Inpatients: Intensive care unit to operating room' and "Handoffs of surgical patients", section on 'Operating room to intensive care unit'.)

•Continuous monitoring – In addition to standard monitors (see 'Patients who require monitoring' above), cardiovascular or respiratory monitors may include (see 'Continuous monitoring' above):

-Continuous BP monitoring and continuous monitoring of central venous pressure (CVP) and/or pulmonary artery pressure (PAP) if a pulmonary artery catheter is in place

-Capnography in selected patients with severe respiratory disease

-Use of a combined monitor-defibrillator device rather than a standard monitor for patients at high risk for cardiovascular deterioration

•Respiratory support

-Management of mechanical ventilation – For mechanically ventilated patients, a continuous infusion of an IV sedative (eg, propofol, dexmedetomidine) is initiated to ensure adequate sedation during transport. Either assisted or controlled ventilation may be provided using manual ventilation with a self-inflating bag, or a portable ICU or transport ventilator for patients with severe lung pathology. (See 'Management of mechanical ventilation' above.)

-Oxygen support – Ensure availability of an adequate O₂ supply, which may be high for some transport ventilators and for selected critically ill patients. (See 'Oxygen support' above and 'High levels of oxygen support' above.)

•Emergency medications – Available emergency IV medications typically include (see 'Emergency medications' above):

-Medications necessary to accomplish endotracheal intubation or reintubation (ie, sedative-hypnotic, NMBA).

-Medications for adult cardiac life support – (See "Advanced cardiac life support (ACLS) in adults".)

-For patients supported with one or more vasoactive agents, a sufficient supply of each. For any IV infusions administered via a power-dependent infusion device, ensure adequate battery supply to complete transport. (See "Intravenous infusion devices for perioperative use".)

-Adequate supply of IV fluids (typically isotonic crystalloids).

●Special considerations

•Infectious disease considerations – (See "Overview of infection control during anesthetic care", section on 'Precautions during patient transport'.)

•Indwelling catheters and drains – All indwelling intravascular catheters, urinary catheters, and surgical drains, as well as any drainage apparatus, should be appropriately labeled and secured. (See 'Management of indwelling catheters and surgical drains' above.)

•Chest tubes – Portable suction may be necessary during transport depending on the type of drainage system and measured amount of drainage. Chest tubes are not routinely clamped. (See 'Management of chest tubes' above.)

•Cerebrospinal fluid drain – Intracranial or lumbar intrathecal cerebrospinal fluid (CSF) drains are often clamped during transport to avoid overdrainage; however, this decision is individualized. (See "Evaluation and management of elevated intracranial pressure in adults", section on 'ICP monitoring' and "Anesthesia for patients with acute traumatic brain injury", section on 'Monitoring'.)

•Ongoing cardiopulmonary resuscitation – (See 'Ongoing cardiopulmonary resuscitation' above.)

●Inter-facility patient transfer – Key points for safe inter-facility transfers are noted in the table (table 6). (See 'Inter-facility transfers' above.)