Pediatric Anaesthesia in remote
/rural areas
The Norwegian Challenges and
Solutions
Øyvind Skraastad, MD, PhD
Assistant Professor
Head of Division of Medical Emergencies and Critical Care
Oslo University Hospital
Welcome to Norway
The home of wilderness and beauty
South – north distance Oslo – Finnmark
equal to Oslo – Rome. North Cape 71° north
Easternmost point of Norway, Vardø 31° east
Norway – remote beauty and wilderness
Midnight at the arctic
circle
Four seasons - but
stormy weather all year
through
Svalbard 61000 km²
Population : 2600
Finnmark 48 618 km2
Slovakia 48 845 km2
Troms 25 877 km2
Makedonia 25 333 km2
Nordland 38 456 km2
Switzerland 41 290 km2
471 000 inhabitants .
4,2 inhabitants per km2
Each of them has 3 ½ m
coast line
Svalbard - Coal mining and tourists
in an arctic desert
UNN Tromsø – Regional University Hospital
Norwegian Health Care system - regions
Health Reform in 2001
Hospitals in
19 Counties
Helse Nord
Inhabitants
4 Health regions since 2007
Helse Midt-Norge
262 417
505 185
543 585
188 639
182 746
245 942
223 357
166 871
104 166
163 753
401 079
455 800
106 977
245 183
277 013
129 489
236 553
153 475
73 163
Helse Vest
v
i
k
Helse Sør Øst
5 000000
Counties
Østfold
Akershus
Oslo
Hedmark
Oppland
Buskerud
Vestfold
Telemark
Aust-Agder
Vest-Agder
Rogaland
Hordaland
Sogn og Fjordane
Møre og Romsdal
Sør-Trøndelag
Nord-Trøndelag
Nordland
Troms
Finnmark
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 Hospital
Part of Oslo University Hospital
National pediatric surgical services
The hospital – 10 years old
E2
D2
D1
E1
C
B2
B1
A2
A1
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
Videobased emergency conference
Bolle, Lien, Mjaaseth, Gilbert. Tidsskr Nor Legeforen 2013; 133
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
National helicopter emergency
medical service - HEMS
Air ambulance bases in Northern
Norway
•Aircraft
•Airports
•Hospitals
Strategy of transportationavailability 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
Blue bars - accepted and performed
Red bars - cancelled – weather conditions
Green bars – limited capacity
incl no available duty time for crew
HEMS is faster, but is less predictable
Haug B, Åvall A, Monsen SA, Tidsskr Nor Legeforen 2009, 29:1089
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 !