Transport of surgical patients

INTRODUCTION — Perioperative transportation of surgical patients involves potential physiological impact of physical movement and logistic challenges that increase risk for adverse events. This topic addresses preparation, equipment, personnel, monitoring, and patient-specific considerations for surgical patient transport to or from the operating room.

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 patient transport minimizes delays by ensuring that patient condition is optimal before transport, and that appropriate equipment is readily available, considering factors such as individual patient acuity and body size and weight (form 1 and figure 1). This is true for routine, elective patients who will be transported to the post-anesthesia care unit (PACU), as well as for critically ill patients who may require transport to an intensive care unit (ICU) located further away from the operating room. In some cases, a checklist that is patient specific (eg, critically ill patients (table 1)) or destination specific (eg, transport to a magnetic resonance imaging [MRI] suite) is useful. (See "Anesthesia for magnetic resonance imaging and computed tomography procedures", section on 'Physical location of the MRI suite'.)

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

PERSONNEL — Institutional guidelines based on patient-specific factors guide decisions regarding which personnel are appropriate for intra-hospital transport. Examples for surgical patients include:

●A stable patient may be transported from the emergency department or an inpatient ward to the preoperative holding area by hospital transport services.

●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 a clinician or appropriately trained mid-level provider (eg, certified registered nurse anesthetist [CRNA], advanced practice nurse [APN], physician assistant [PA]).

●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 operating room (OR) or interventional suite by a clinician expert in airway management and mechanical ventilation (eg, anesthesia provider, intensivist, respiratory therapist) [1]. This clinician should be familiar with the specific mechanical ventilation equipment and medication infusion pumps used during transport to troubleshoot alarms or equipment malfunction.

●Critically ill patients dependent on specialized medications (eg, an inhaled pulmonary artery vasodilator agent such as epoprostenol) require the presence of specialized personnel who are familiar with the delivery device throughout transport and during transfer to use with OR equipment. (See "Delivery of inhaled medication in adults".)

Similarly, critically ill patients who are receiving extracorporeal membrane oxygenation (ECMO) or mechanical circulatory support (eg, with a ventricular assist device [VAD]) require the presence of specialized personnel who are familiar with the operation of the device during transport and to ensure that monitoring is continued in the OR. Details regarding device operation and monitoring are discussed separately:

•(See "Emergency care of adults with mechanical circulatory support devices".)

•(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)".)

●A patient who received sedative or anesthetic agents during a surgical or interventional procedure is transported to the post-anesthesia care unit (PACU) by a member of the anesthesia team [2].

EQUIPMENT AND MEDICATIONS — Equipment that may be used during transportation of surgical patients is noted in the table [3-5] (table 2). 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 suffering clinical deterioration [6].

Airway equipment and supplemental oxygen

Airway management equipment — The need for various types of airway equipment is dictated by the patient’s current need for respiratory support and risk for deterioration of respiratory status. In a multicenter cohort study of mechanically ventilated adult patients in an intensive care unit (ICU), complications occurred at a higher rate during transport, highlighting the need for both vigilance and preparedness [7]. Similarly, respiratory and airway events are the most common complications occurring during transport of critically ill pediatric patients [8,9].

Modalities of respiratory support may include providing only supplemental oxygen (O₂) in a spontaneously breathing patient, noninvasive positive pressure ventilation, or controlled ventilation via an endotracheal tube (ETT). (See "Continuous oxygen delivery systems for the acute care of infants, children, and adults".)

Notably, a bag valve mask and an O₂ cylinder are mandatory emergency equipment even for patients with stable respiratory status and for those who are already intubated (since accidental extubation may occur during the transport process). For many patients, it is necessary to have immediately available equipment to secure the airway, including different types of direct laryngoscopes (MacIntosh and Miller blades), indirect videolaryngoscope, various ETT sizes, as well as end-tidal carbon dioxide detector for verification of correct tracheal intubation if performed. For high-risk patients, an assortment of oral and nasopharyngeal airways may also be included [3,5,6]. Appropriate transport personnel who are familiar with airway management and mechanical ventilation are key to safe transport of intubated patients and those at risk for respiratory deterioration.

Oxygen support

●Determine level of O₂ support necessary for transport – The level of O₂ support appropriate for the patient’s condition is determined prior to transport whether O₂ is administered via a nasal cannula, face mask, nonrebreather mask, or ETT. For some patients, no supplemental oxygen may be necessary (eg, a healthy patient who did not receive sedation travelling for a short distance to a post-anesthesia care unit [PACU] immediately adjacent to the operating room [OR]). For other critically ill patients, controlled mechanical ventilation with a high concentration of oxygen may be necessary.

●Determine the supply of O₂ necessary for transport – If oxygen support is used, it is essential to ensure that the available O₂ supply will last throughout the transportation process. This depends on the required O₂ flow per minute, as well as the expected duration of transport. Clinicians should be familiar with both the operation of transport oxygen cylinders and estimating oxygen supply available at any given time.

The first step in calculating whether the O₂ supply will last for the duration of transport is to calculate the available O₂ volume. 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 [10]:

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

The flow of O₂ required per minute is determined, then the current volume of the O₂ tank is divided by this flow to calculate the minutes of O₂ that will be available using this tank. For example, if a patient is being ventilated via an ETT with a bag valve mask apparatus 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. However, it is prudent to allow for 30 extra minutes of O₂ flow beyond the anticipated transport time [4].

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) are included in the calculation. Many transport ventilators also require a certain O₂ pressure to function. This requires subtracting approximately 10 percent of the full tank (approximately 60 L or 200 psig) when calculating the minutes of oxygen flow that are available.

●Ensure that O₂ tank(s) are secured – O₂ tank(s) must be secured to the patient’s bed during transport rather than lying unsecured on top of or underneath the mattress at the head or foot of the bed.

Monitoring equipment — Portable monitors are necessary to achieve safe transport of many patients (see 'Monitoring' below). These monitors should have a clear illuminated screen and be able to show the electrocardiogram (ECG), oxygen saturation, noninvasive blood pressure, and two invasive pressures [11]. 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.

Transport gurney — Personnel participating in patient transport must be familiar with basic operation of the gurney that is used, including how to steer the bed, change its height or position, appropriately use securing devices and siderails, and lock/unlock the wheels.

The weight limit of the stretcher/bed being used for transport and the patient’s weight are noted. Safe use of hydraulic lifts and similar equipment may be necessary for some patients.

Emergency medications — Appropriate emergency medications should be immediately available during transport. Examples include:

●Medications necessary to accomplish 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 operating room (OR) or intensive care unit (ICU) setting [4]. However, even patients who have been sedated but remained awake during a surgical 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 "Overview of the management of postoperative pulmonary complications".)

●Even though phenylephrine, ephedrine, 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.

●An adequate supply of intravenous (IV) fluids (typically isotonic crystalloids) for drug delivery during endotracheal intubation or resuscitation and adequate IV access are also ensured prior to transport.

Clinical judgment is used to decide which, if any, medications should be placed with the patient on the transport gurney. For routine transfer of patients to or from preoperative or PACU areas that are immediately adjacent to the OR, emergency medications and IV fluids may be deemed readily available since both areas are well-stocked with these items.

Inhaled agents — Some critically ill patients may be dependent on inhaled pulmonary artery vasodilator agents (eg, epoprostenol). Similar to oxygen, adequacy of the supply of the inhaled agent should be verified prior to transport. In addition, someone familiar with the delivery device should be present throughout transport and during transfer of the delivery device to use with OR equipment.

MONITORING — We agree with the standards for post-anesthesia care published by the American Society of Anesthesiologists (ASA) and the Association of Anaesthetists, which include appropriate monitoring with ongoing

and necessary treatment for patients in the post-anesthesia recovery period, including during transportation to any post-anesthesia site (eg, post-anesthesia care unit [PACU], intensive care unit [ICU]) [2,12].

Respiratory monitoring — In addition to clinical monitoring of respiratory status, quantitative assessment of adequacy of oxygenation with continuous pulse oximetry is standard during transport. Real time capture of desaturation events allows for rapid assessment and management [13]. Examples of situations in which monitoring with pulse oximetry during transport is appropriate include:

●Preoperative transport when anxiolytics or analgesics have been administered

●Postoperative transport to a post-anesthesia care unit (PACU) after administration of general anesthetics, sedatives, analgesics, and/or neuromuscular blocking agents

In selected critically ill patients with severe respiratory disease, capnography can also be used (if available) to facilitate rapid recognition of cardiac arrest, respiratory depression and inadvertent extubation, or other problems with ventilation [4,14].

Hemodynamic monitoring — Electrocardiography (ECG) and blood pressure (BP) monitoring are standard, and additional cardiovascular monitoring is appropriate for selected patients. Examples include:

●For critically ill patients, hemodynamic monitoring may include continuous BP monitoring (ie, via an intra-arterial catheter if that is in place) in addition to the ECG and pulse oximetry [4].

●Although they are not typically necessary during a brief period of transport, selected hemodynamically unstable patients with a previously inserted pulmonary artery catheter (PAC) may benefit from continuous monitoring of pulmonary artery pressure (PAP) and/or central venous pressure (CVP) during transport [4]. For selected cardiac surgical patients who have clinical evidence of ongoing hemodynamic instability (eg, refractory hypotension, metabolic acidosis, persistent ECG changes [particularly ST-segment elevation]), or significant deterioration in regional or global left or right ventricular function noted on transesophageal echocardiography (TEE) examination, some centers will usually insert a PAC before patient transport from the operating room (OR) to the intensive care unit (ICU).

●For patients at high risk for cardiovascular deterioration, a combined monitor-defibrillator rather than a standard monitor may be used during 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. For devices that are power-dependent, ensure appropriate battery supply.

Management of chest tubes and cerebrospinal fluid drainage catheters is discussed below. (See 'Management of chest tubes and cerebrospinal fluid drains' below.)

INFECTION CONTROL — Precautions are necessary in surgical patients with potential or documented communicable diseases (airborne, droplet or contact) to prevent spread of infection to staff or other patients during intra-hospital transport. Institutional guidelines should be used to dictate personal protective equipment (PPE) worn by staff caring for infected patients, including those on isolation precautions (eg, use of gloves, surgical mask, eye protection). (See "Infection prevention: Precautions for preventing transmission of infection".)

For patients with COVID-19 infection or other aerosol-borne pathogens such as tuberculosis or measles, a surgical mask, preferably an N-95 level respirator, should be worn during transport within the hospital [15]. Some institutions use a portable tent system with HEPA filtration. For intubated patients, a high-quality heat and moisture exchanging filter (HMEF) should be inserted between the self-inflating (Ambu) bag or the transport ventilator and the patient. Clinicians who contact the patient should not touch environmental surfaces such as elevator buttons; this should be done by a security officer or another helper. COVID-19 patients should ideally be transported directly to the operating room (OR) or interventional suite, bypassing any holding area. (See "Overview of infection control during anesthetic care", section on 'Precautions during patient transport'.)

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

CONSIDERATIONS FOR CRITICALLY ILL PATIENTS — Institutional policies, guidelines and standards of care have been developed to maximize patient safety and minimize risk during transport of critically ill patients within the hospital and between facilities [11]. Techniques that may decrease morbidity in critically ill patients include optimizing patient condition before transport (table 1), checking transport equipment (table 2), use of standardized monitoring, availability of experienced personnel who are familiar with any specialized equipment that is used during transport, and transferring essential information via formalized handoffs (table 3 and table 4) [8,16].

Pre-transport assessment of risks — Medical, surgical, and anesthetic assessment of critically ill patients in the preoperative period is accomplished before transport (table 1) and determines whether the benefits of in-hospital or inter-interinstitutional transportation will likely outweigh the risks [17]. This assessment includes the reason for transport (eg, performance of a diagnostic or therapeutic procedure or intervention, need for a higher level of care). 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, urgent imaging to prevent organ or limb damage), then actions to stabilize the patient must proceed concurrently with preparations for transport. Non-urgent transport for a diagnostic intervention or elective procedures may be delayed to optimize the patient’s condition.

A 2022 meta-analysis noted that adverse events during intra-hospital transport of critically ill patients occurred with a pooled frequency of 26.2 percent, while 1.5 percent were life-threatening [18]. Events included respiratory or hemodynamic compromise, occurrence of severe pain, and dislodgement of intravenous catheters or drains. Serious adverse events (SAEs) included 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) [18-23].

Similarly, respiratory and airway events are common complications occurring during transport of critically ill pediatric patients [8,9].

Special considerations during preparation

Equipment — Continuous monitoring of pulse oximetry (SaO₂), the electrocardiogram (ECG), and continuous intra-arterial blood pressure during transport is described above. (See 'Monitoring' above.)

Since hemodynamic and/or respiratory compromise is more likely in a critically ill patient, equipment for management of airway compromise (eg, bag, mask, laryngoscope, endotracheal tube, anesthetic agent, neuromuscular blocking agent) 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. Nevertheless, rapid and effective emergency management may be challenging during transport due to the physical constraints of narrow hallways and elevators, with limited immediate availability of appropriate resuscitation staff and equipment.

Patient-related considerations — We use a checklist that addresses patient-related factors to ensure for safe transport of critically ill patients from an intensive care unit (ICU) to an operating room (OR) or interventional suit (table 1) [3].

Prior to transport from an OR, optimal patient condition is ensured as surgery concludes (eg, hemodynamic stability, control of bleeding and coagulopathy, adequate oxygenation and ventilation). An arterial blood gas may be obtained to assess PaO₂ and base deficit, and point-of-care tests can further check hemoglobin, potassium, and calcium levels. Data from other hemodynamic monitors such as pulmonary artery catheter (PAC) values or echocardiography examination can be used to evaluate ventricular function and volume status so that appropriate adjustments in inotropic, vasodilator, or fluid therapy can be made.

If there is concern for ongoing hemodynamic instability, ECG changes suggestive of myocardial ischemia, malignant arrhythmias, or worsening hypoxia or acidosis, every effort is made to stabilize the patient in the OR before transport. Information gleaned from diagnostic bloodwork, hemodynamic monitors, and/or point-of-care ultrasound may be useful to achieve optimal pre-transport status. It is critically important to notify 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.

Management of mechanical ventilation — Patients who are intubated and mechanically ventilated may be transported using assisted or controlled ventilation. In the OR setting, a continuous infusion of an intravenous (IV) sedative such as propofol or dexmedetomidine is initiated before discontinuing volatile inhalation anesthetics. Adequate time for the selected IV agent to reach steady plasma concentrations should be allowed in the final minutes before leaving an OR 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'.)

Assisted or controlled support of ventilation can be provided in the following ways during transport [17,24]:

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

●Use of a ventilator

•Standard ICU ventilators – ICU ventilators are equipped to deliver precise TV and high RR with close monitoring of airway pressure, allowing use of a variety of ventilator modes that can be personalized to patients with significant lung disease. ICU ventilators should be considered for the transport of patients with particularly high acuity of respiratory pathology. However, anesthesiologists and other clinicians outside of the ICU may be unfamiliar with their management. In some cases, 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 mechanical failure, oxygen failure, or incorrect ventilator settings.

•Transport ventilators – Transport ventilators are increasingly sophisticated and offer the advantages of consistent mechanical ventilation without the bulk associated with ICU ventilators [24]. Similar to use of an ICU ventilator during transport, personnel comfortable with use of the selected transport ventilator should accompany the patient.

Inhaled pulmonary artery vasodilators — Patients may be critically dependent on nitric oxide or inhaled vasodilator, and these agents should not be interrupted for transport. Transport personnel should be skilled in the management of and troubleshooting of the delivery devices.

Management of chest tubes and cerebrospinal fluid drains

●Chest tubes – Chest tubes and other thoracostomy catheters are frequently present in patients undergoing airway or thoracic surgery, or other procedures for 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".)

●Cerebrospinal fluid drainage devices – Patients with 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 OR, neuroimaging or neurointerventional suite, or ICU or stepdown unit. (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 to patient position, EVD position, overdrainage, or drain clamping may cause deleterious effects [26]. Similar to 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 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 intrathecal 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 (CSF) 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 for management of cardiogenic shock, cardiopulmonary failure, or to wean off cardiopulmonary bypass. Similarly, the growing use of extracorporeal membrane oxygenation (ECMO) for cardiopulmonary failure, respiratory failure, and in the setting of cardiac arrest has prompted guidelines for transport from 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".)

Personnel transporting patients on ECMO or other MCS should be familiar with device alarms and troubleshooting device malfunction in emergencies (algorithm 1) [28]. As with all special equipment, the handoff should include the reason for use of cardiopulmonary support, site(s) used for device insertion, and type of device and current settings and function. Details regarding operation and monitoring of these MCS devices are discussed separately:

•(See "Emergency care of adults with mechanical circulatory support devices".)

•(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)".)

Transport with ongoing cardiopulmonary resuscitation — Some patients being moved emergently to the OR from the trauma bay/emergency room or ICU may be undergoing cardiopulmonary resuscitation (CPR) that must be continued during transport, including chest compressions delivered manually or using a mechanical chest compression device. While it has not been established that the use of such compression devices leads to better outcomes, their advantages include ease of use and provision of high-quality CPR during transport [29,30]. Notably, clinicians transporting the patient should be familiar with appropriate placement and operation of the device in use. (See "Therapies of uncertain benefit in basic and advanced cardiac life support", section on 'Mechanical compression devices'.)

Interdisciplinary handoffs

●Transport from an ICU – During the preoperative handoff before transport to an OR or 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 3) [31]. 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 in the ICU, patient information is communicated from the surgical team to the ICU team using a formal handoff (table 4). In all cases, the anesthesiologist should remain with the patient to ensure stability until handoff is complete. Further details are available in a separate topic. (See "Handoffs of surgical patients", section on 'Operating room to intensive care unit'.)

INTER-FACILITY TRANSFERS — Inter-facility patient transfer may occur for reasons such as escalation of care, capacity issues (ie, lack of access to staffed critical care beds), repatriation back to a local hospital, or continuity of care in a lower acuity setting [32]. In general, transfers of critically ill patients are carried out safely by dedicated transfer and retrieval teams [33]. However, inter-facility transfer may be associated with short-term physiological deterioration or adverse outcomes in unstable patients. Examples include:

●In a study in the United Kingdom of 45 intra-hospital and 92 inter-facility transfers of critically ill COVID-19 patients who were undergoing mechanical ventilation of the lungs, a significant initial drop in PaO₂/FiO₂ ratio occurred from a median value of 25.1 (12.1–78.0) kPa pretransfer to 19.5 (9.8–52.0) kPa immediately posttransfer [34]. However, this decrease resolved24 hours after transfer (median value 25.4 [9.4–51.9 kPa]). In contrast, significant changes in PaO₂/FiO₂ ratio were not noted for intra-hospital transfers. However, there were no meaningful differences in pH, PaCO₂, base excess, bicarbonate, or norepinephrine requirements in either group.

●In a study of 4542 surgical intensive care unit (ICU) admissions, 416 were inter-facility transfers [35]. 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) [35].

Key points to optimize safe transport include the following (table 5):

●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) and determines whether the benefits of inter-interinstitutional transportation will likely outweigh the risks.

●The transferring clinician/intensivist is responsible for ensuring adequate resuscitation and, if possible, optimal stability prior to transport to the new facility [33,36]. In some cases, an invasive airway or intravascular catheter(s) for invasive monitoring may be inserted prior to transport.

●Mode of transport is determined by patient condition and resource availability (eg, ground or air transport, mobile intensive care unit [ICU]).

●Personnel responsible for inter-facility transport vary, but may include dedicated network transport teams, emergency medical services (EMS), and critical care medical transport teams [32,33]. Medical oversight during transport is patient specific and also varies according to institutional and regional regulations [37,38].

●Regulations governing transfers and clinical care during transport are determined at local, regional and national level [11,37]. Factors affecting planned transfers include environmental factors. For example, 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 emergent operative management of traumatic or head injuries, those with ongoing myocardial ischemia being transferred for 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.

Inter-facility maternal transport is discussed in a separate topic. (See "Inter-facility maternal transport".)

SUMMARY AND RECOMMENDATIONS

●Preparations – Systematic preparation minimizes delays by ensuring that the surgical patient’s condition is optimal and that appropriate equipment is readily available (form 1 and figure 1). In some cases, a checklist that is patient specific (eg, critically ill patients (table 1)), or destination specific (eg, transport to a magnetic resonance imaging [MRI] suite) is useful. (See 'Preparations' above.)

●Personnel – Institutional guidelines based on patient-specific factors guide decisions regarding which personnel are appropriate for intra-hospital transport (eg, transport staff, intensive care unit [ICU] nurse, mid-level provider [eg, CRNA, APN, PA], clinician [eg, anesthesiologist, intensivist]). (See 'Personnel' above.)

●Equipment – Equipment items that may be used during transport are noted in the table [3-5] (table 2). (See 'Equipment and medications' above.)

●Medications – Medications necessary to accomplish endotracheal intubation (ie, sedative-hypnotics, a neuromuscular blocking agent) should be available for patients who received anesthetic or sedative agents. For critically ill or unstable patients, medications required for resuscitation should be available in a standardized transport kit. Adequate intravenous (IV) access and supply of IV fluids must be ensured. (See 'Emergency medications' above.)

●Monitoring

•Respiratory monitoring – Continuous pulse oximetry is standard when anxiolytics or analgesics have been administered, and postoperative transport after administration of general anesthetics, sedatives, analgesics, and/or neuromuscular blocking agents. In selected critically ill patients, capnography may also be used to facilitate rapid recognition of cardiac arrest and respiratory decompensation (see 'Respiratory monitoring' above). The ability to detect ETCO2 should be available in case sudden (re)intubation is required.

•Hemodynamic monitoring – Electrocardiography (ECG) and blood pressure (BP) monitoring are standard, and additional cardiovascular monitoring is appropriate for selected critically ill patients (eg, intra-arterial catheter, pressures obtained from a previously inserted central venous or pulmonary artery catheter). (See 'Hemodynamic monitoring' above.)

●Indwelling catheters and drains – All indwelling intravascular catheters, the urinary catheter, and surgical drains should be appropriately labeled and secured prior to transport to avoid dislodgement. (See 'Management of indwelling catheters and surgical drains' above.)

Chest tubes should not be routinely clamped. The indication for the chest tube, drainage system in use, and amount of drainage measured determine whether portable suction is necessary during transport. While cerebrospinal fluid (CSF) drains are often clamped during transport to avoid overdrainage, this decision should be individualized. (See 'Management of chest tubes and cerebrospinal fluid drains' above.)

●Infection control – Precautions are necessary during transport of surgical patients with potential or documented communicable diseases (airborne, droplet or contact), as guided by institutional guidelines. (See 'Infection control' above.)

●Handoffs – We employ a standardized formal handoff protocol that includes both verbal and written communication for all phases of perioperative care. (See "Handoffs of surgical patients".)

●Transport of critically ill patients – Safe transport of critically ill patients involves optimizing patient condition (table 1), checking transport equipment (table 2), use of standardized monitoring and experienced personnel during transport, and transferring essential information via formalized handoffs (table 3 and table 4). (See 'Considerations for critically ill patients' above.)

Patients who are intubated and mechanically ventilated may be transported using assisted or controlled ventilation with an ICU or transport ventilator. In the OR setting, a continuous infusion of an IV sedative is initiated in the final minutes before leaving an OR to ensure that the patient remains adequately sedated during transport. (See 'Management of mechanical ventilation' above.)

●Inter-facility patient transfer – Key points to optimize safe inter-facility transfers are noted in the table (table 5). (See 'Inter-facility transfers' above.)