Monitoring

Technological improvements now allow sophisticated monitoring to continue during transfers. Continuous ECG, pulse oximetry, and arterial pressure measurement should always be used, although pulse oximetry may be difficult in the vasoconstricted patient. It should be possible to measure the blood pressure both non-invasively and directly (intra-arterial blood pressure).

Multimodal monitors, which are small, portable, and battery powered, are strongly recommended. Many can now offer ECG, pulse oximetry, temperature measurement, non-invasive blood pressure measurement, two pressure channels, and capnography. They minimize the number of items of equipment that must be transported with the patient and allow easier identification of alarms and changes in the patient's condition.

Ideally, the monitor should have multiple pressure channels. Where possible intra-arterial blood pressure should be measured directly. This is more accurate than non-invasive methods, particularly at the extremes of measurement (Runcie efa/ 1990), and automated non-invasive blood pressure monitoring significantly reduces battery life.

Other channels can be used for central venous, pulmonary artery, or intracranial pressure monitoring. Many critically ill patients benefit from measurement of both continuous central venous pressure and pulmonary artery occlusion pressure measurement in the ICU. Most commonly only two pressure channels will be available during transport, and in these circumstances most clinicians will choose continuous monitoring of intra-arterial blood pressure and pulmonary artery pressure, and intermittent measurement of pulmonary artery occlusion pressure to assess left ventricular filling pressures. When a pulmonary artery catheter is in situ, a continuous display of its waveform is recommended to recognize inadvertent pulmonary artery occlusion.

Carbon dioxide (CO2) monitoring offers considerable advantages in the care of the critically ill and should be used more widely in transfers. Portable battery-powered

CO2 monitors have recently become available (Donnelly.et.a/., 199,5). They provide a guide to the adequacy of ventilation and an apnea alarm which alerts the transfer team to disconnection. The expired CO2 concentration should be compared with arterial blood gas analysis prior to departure.

Where battery power may be limited, static inverters can provide a 'mains voltage' during transfer. They are already used in many specialized transfer vehicles to power equipment without the need for internal batteries (e.g. continuous cardiac output monitors). Static inverters are also a useful back-up for battery failure.

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