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Øyvind Skraastad, MD, PhD Assistant Professor

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.

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Øyvind Skraastad, MD, PhD Assistant Professor

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  1. 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

  2. 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

  3. Norway – remote beauty and wilderness Midnight at the arctic circle Four seasons - but stormy weather all year through

  4. 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

  5. Svalbard - Coal mining and tourists in an arctic desert

  6. UNN Tromsø – Regional University Hospital

  7. Helse Sør Øst Helse Vest Helse Midt-Norge Helse Nord Counties Inhabitants Østfold Akershus Oslo Hedmark Oppland 262 417 505 185 543 585 188 639 182 746 Buskerud Vestfold Telemark Aust-Agder Vest-Agder 245 942 223 357 166 871 104 166 163 753 Rogaland Hordaland Sogn og Fjordane 401 079 455 800 106 977 Møre og Romsdal Sør-Trøndelag Nord-Trøndelag 245 183 277 013 129 489 Nordland Troms Finnmark 236 553 153 475 73 163 5 000000 Norwegian Health Care system - regions Health Reform in 2001 Hospitals in 19 Counties 4 Health regions since 2007

  8. 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.

  9. 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

  10. 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

  11. 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)

  12. 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

  13. Rikshospitalet - National HospitalPart of Oslo University HospitalNational pediatric surgical services

  14. The hospital – 10 years old E2 D2 D1 E1 C B2 B1 A2 A1

  15. 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

  16. Videobased emergency conference Bolle, Lien, Mjaaseth, Gilbert. Tidsskr Nor Legeforen 2013; 133

  17. 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

  18. National helicopter emergency medical service - HEMS

  19. Air ambulance bases in NorthernNorway • Aircraft • Airports • Hospitals

  20. 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

  21. 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

  22. 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 hospitalFenton 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

  23. Bilder av helikoptere, fixed wing og Hercules med ECMO ECMO patient transported in ambulance Ambulance transported in C-130 Hercules - RNAF

  24. 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)

  25. 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

  26. Thank You for Your attention !

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