Pediatric Anaesthesia in remote /rural areas

The Norwegian Challenges and Solutions

Øyvind Skraastad, MD, PhDAssistant Professor

Head of Division of Medical Emergencies and Critical CareOslo University Hospital

Welcome to Norway Welcome to Norway The home of wilderness and beauty

South – north distance Oslo – Finnmark equal to Oslo – Rome. North Cape 71° northEasternmost point of Norway, Vardø 31° east

Midnight at the arctic circle

Four seasons - but stormy weather all year

through

Norway – remote beauty and wilderness

Nordland 38 456 km2 Switzerland 41 290 km2

Troms 25 877 km2

Makedonia 25 333 km2

Finnmark 48 618 km2

Slovakia 48 845 km2

471 000 inhabitants .

4,2 inhabitants per km2

Each of them has 3 ½ m coast line

Svalbard 61000 km²Population : 2600

Svalbard - Coal mining and tourists in an arctic desert

UNN Tromsø – Regional University HospitalUNN Tromsø – Regional University Hospital

vik

Norwegian Health Care system - regions Norwegian Health Care system - regions

Health Reform in 2001

Hospitals in

1919 Counties

44 Health regions since 2007

ØstfoldAkershusOsloHedmarkOppland

262 417

505 185

543 585

188 639

182 746BuskerudVestfoldTelemarkAust-AgderVest-Agder

245 942

223 357

166 871

104 166

163 753

RogalandHordalandSogn og Fjordane

401 079

455 800

106 977

Møre og RomsdalSør-TrøndelagNord-Trøndelag

245 183

277 013

129 489

CountiesCountiesInhabitants

NordlandTromsFinnmark

236 553

153 475

73 163

5 0000005 000000

Helse NordHelse Nord

Helse Sør ØstHelse Sør Øst

Helse VestHelse Vest

Helse Midt-NorgeHelse Midt-Norge

Pediatric anaesthesia in Norway

• Mainly centralized– Planned surgery - pregnancies at risk,

(maternal and fetal risk)– Emergencies - initial local stabilisation,

transportation– Time before arriving in a regional hospital is up to 5-8 hrs after

trauma or other emergencies in remote areas; - 2-3 hrs incl time of stabilizing in local hospitals - 2-3 hrs transport.

Organisation of pediatric anesthesia and surgery - Local community hospitals• Children >2 years• Primary responders to all pediatric emergencies,

including traumas and neonates – stabilisation • Acute orthopedic cases, acute abdomen, planned

ENT surgery• Level of pediatric surgery and anesthesia

procedures dependent on local perioperative competence - turnover of staff

• Refer all other pediatric cases

Organisation of pediatric anesthesia and surgery - County Hospitals (19)

• Children > 1 year • Do more advanced surgery and anesthesia than

local community hospitals• Incl pediatric orthopedic trauma • Anaesthesia for MRI/CT scan • More advanced pediatric ENT service

• Refer children <1 yr to regional hospitals, incl neonates .

• Refer all advanced surgery and children with comorbidity, trauma after stabilisation

Organisation of pediatric anesthesia and surgery – Regional hospitals (4)

• Children above GA 44 wks• Pediatric traumatology, pediatric surgical programmes. All

hospitals have pediatric anaestetists• 3 hospitals refer advanced surgery, incl most neonates

and (intensive care) to national services at Rikshospitalet • Pediatric cardiac surgery • Major comorbidity• Primary surgery for congenital malformations to 1(2) specialized

hospital(s)

Neonatal surgery•Neonatal surgery – GA <44 wks is centralized to 1-(2) Regional hospitals. All other hospitals restrict themselves to give surgery of any kind to patients with GA>44 wks•Malformations:

–Cardiac malformations – 60-80 per year–Gastrointestinal - 30-60, incl diaphragmatic hernias–CNS - less than 10

•Complications of Low GA/LBW–Necrotizing enterocolitis–PDA closures

•Expremature –Closure of inguinal hernias -10-20 % of all premature born babies

Rikshospitalet - National HospitalPart of Oslo University Hospital

National pediatric surgical services

The hospital – 10 years old

A1

A2

B1B2

CE1

E2D1

D2

Dilemmas and solutions•The number of pediatric cases in the periphery is too small for training and developing skills and experience

– BEST (Better systematic team – training for children) •The distance from periphery to centralized care is too long when taking care of medical emergencies incl trauma cases.•Solution:

–Communication, Support and Transportation •Teleradiology •Emergency medical conferences •Highly competent and avaliable transportation system 24/7/365

Bolle, Lien, Mjaaseth, Gilbert. Tidsskr Nor Legeforen 2013; 133

Videobased emergency conferenceVideobased emergency conference

Air Transportation system •Aircrafts

–Helicopter emergency medical service - HEMS •EC 135, Sea King

–Air Ambulance planes•”Fixed wing” Beech 200 aircrafts

•Bases–HEMS

•EC135 – 11 bases – 3 in Northern Norway •Sea King – 6 bases - 2 i Northern Norway

–”fixed wing ” •6 bases – 4 in Northern Norway

•Roughly 1/6 of all patients younger than 10 years, the majority are below 1 years of age. 100-150 patients in incubators per year

National helicopter emergency medical service - HEMS

Air ambulance bases in Northern Norway

Air ambulance bases in Northern Norway

•Aircraft

•Airports

•Hospitals

•Aircraft

•Airports

•Hospitals

Strategy of transportation- availability and quality •Availability

–Aircrafts •Dependent on weather or seasonal conditions

– wind , reduced visibility, freezing humidity

•Quality –Competent transportation team/equipment

•Levels of specialization» Primary - nurse anesthestist or intensive care nurse» Secondary - anesthesist –(neonatologist) » Tertiary - highly specialized team – ECMO, iNO

•Response time – shorter for HEMS than fixed wing•Limitations – no alternative transportation on ground

Predictability of HEMS Air Ambulance Service , limited by geography, climate/season

Predictability of HEMS Air Ambulance Service , limited by geography, climate/season

Haug B, Åvall A, Monsen SA, Tidsskr Nor Legeforen 2009, 29:1089

Blue bars - accepted and performedRed bars - cancelled – weather conditionsGreen bars – limited capacity incl no available duty time for crew

HEMS is faster, but is less predictable

Air transport – pediatric patients

• 15-20 % of all air transports- most of them <1 yr of age.1% of neonates need transportation to a regional

hospital Fenton et al: Arch Dis Child Fetal Neonatal Ed 2004 89 : F 412-15

• Both primary referrals and transportation to a lower level of care

• In region Southern Norway 100-150 neonates- mostly transported in incubator

– Congenital malformations – ECMOs / major lung failure/ multiple organ failure, – Prematurity

•Bilder av helikoptere, fixed wing og Hercules med ECMO

ECMO patient transported in ambulance Ambulance transported in C-130 Hercules - RNAF

Optimising neonatal transfer • Transportation of neonates represents a

clinical risk (Senthilkumar et al Arch Dis Child 2011;96 A91, Berge et al Acta

Anaesthesiol Scand 2005;49:999-1003) – Normothermia– Normal pH – Normoventilation

• Transportation of premature infants increases risk of cerebral hemorrhage (Arch Dis Child Fetal Neonatal Ed 2010 95:F403-7)

People seem to accept that to stay or settle down in remote areas represents a positive quality of life, but also includes a minor medical risk for them and their children .

The glaciers at Galdhøpiggen 2469 m, the highest peak of Norway. From the summit in June

Thank You for Your attention !Thank You for Your attention !