Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

Originally Posted by JoPACURN

Did you all paralyze him?
Use Midazolam instead?
Why did they go straight to ECMO without trying him on Jet ventilation first? Was his ARDS that bad? If it were, why wasn't he paralyzed and not just sedated?

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Yes, he was immediately switched to Versed. We did paralyze him on Monday (he's still on the paralytics). He is doing a little better today. We are slowly seeing improvements in his Cr.

We rarely use oscillators at my facility.

They did end up running a PCR test and he is confirmed H1N1+

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

We've stepped into the ring as of Thursday. We have a preschooler with pre-existing issues on ECLS but this child has not moved or responded to anything pretty much since admission. CT head shows a large bleed that is visible on more than half the slices and many small infarcted areas, but a perfusion scan doesn't support brain death. There's fulminant DIC in both patient and circuit... not a hopeful picture at all.

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

So glad this thread is still going! I had to post a note about the physician in Sweden who commented on ECMO patients "feeling pretty good on ECMO". I thought it was funny, too. Then I had the chance to meet up with some representatives of the Karolinska Institute program at the 20th anniversary ELSO conference in Ann Arbor, Michigan. They were presenting on update on analgesia and sedation in ECMO patients. Granted the majority of their adult patients are chemically paralyzed and sedated at the time of cannulation to minimize oxygen demand...but they begin to wean sedation after 24-48 hours and within 2 days the adult patients are fully awake and aware! They argue that ECMO is not inherently painful and paralytics/sedatives are unnecessary after adequate oxygen delivery is established. Pain medication is provided as needed but...

They brought pictures of adult patients on ECMO sitting up in bed eating popsicles, patients waving at the camera, even patients playing cards with their families! They say that the patients feel SO GOOD that it is not uncommon for them to ask to be taken off the machines so they can go home! Can you imagine? My program provides ECMO to primarily neo/pediatric patients, but we have ramped up our adult program in response to H1N1, and we are very much in demand. I don't think it is very practical for young peds cases (how do you explain to a 2 year old not to pull on the cannulas please?) but it is something to consider when working with older patients.

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

Littlestown, Pennsylvania

http://www.publicopiniononline.com/c...ce=most_viewed

Originally Posted by www.publicopiniononline.com

Kyree, a student in Mrs. Erin Hahn's kindergarten class, died at Penn State Hershey Medical Center after a three-week
battle with swine flu, Shreve said. Kyree was taken to Gettysburg Hospital on Oct. 11 with a fever, was moved to Hershey
on the same day and tested for swine flu soon after, she said.
The boy went into respiratory arrest during his first night in the hospital and while he seemed to improve after several weeks of being connected to a heart-lung machine, he died on Saturday from pneumonia and hemorrhaging in his lungs, Shreve said. Kyree had no pre-existing health conditions, she said.

(hat tip flutrackers/BC)

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

We have had about 5 H1N1 pt's on ECMO this year, most last month. Now we have no one on ECMO (weird), but I'm assuming the next 'wave' will come. We'll see. The current issue is that we're a Children's Hospital and many of the super sick H1N1 patients are young adults. In the past, we did adult ECMO (in the PICU), but due to politics (and available PICU beds) we stopped a few years ago. That being said, we had 2 'adults' (early 20's) on last month. The other problem is that we only do 4 pt's simultaneously and we're the only center (other then a small neo center) in the state.
This leads to one of the current debates surrounding this flu, which is whether to transfer the adults to ECMO centers (even if they're children's hospitals), or send the patients to established adult ECMO centers (there aren't many in the US, and only 2-3 that cannulate, then transfer). This delima, combined with promising results of ECMO for H1N1 in Australia, has led many adult instututions to 'try ECMO' in some form or fashion. This scares me. I work at a high volume, well established ECMO center and I can't imagine just configuring a pump and throwing it on a patient, especially those that require long runs (many of our H1N1's have been on several weeks, even over 1 month). Many of these institutions are using perfusionists, which I'd imagine will cause a HUGE stress on perfusion staff if the US gets hit as hard as Australia with H1N1.
Wondering what everyone on here has seen? In general, are you seeing more or less H1N1 ICU patients now compared to late spring/early fall??

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

Originally Posted by nursetina03

We have had about 5 H1N1 pt's on ECMO this year, most last month. Now we have no one on ECMO (weird), but I'm assuming the next 'wave' will come.

This is the only part of your post that I can speak to. I'll let the ECMO nurses answer the rest.

I have been reading that a third wave is expected in January. Now, considering that we definitely have a vaccine (shortfall which means that there will continue to be many susceptible hosts for this novel virus), this is likely.

I am afraid that your services will continue to be in demand.

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

An update on our 2 ECMO patients:

20-year-old male is doing better. Decannulated on Monday. Now on 30% FiO2 by vent. Will probably need a trach unless they can get him off in the next couple of days. He's making purposeful movements but not following commands yet (was on paralytics and a lot of benzo sedation throughout ECMO course). He's still needing some sedation for vent dyssynchrony, so I think he will probably wake up once he's either trached or extubated.

Old heart tx patient also decannulated on Monday. He's now on 40% FiO2 and 10 of PEEP, and I was unable to wean it. He already had ESRD and he's been on SLED and continues to be on SLED, and needs pressor support. During ECMO, the patient's cannulas cavitated so badly with positioning that staff were unable to turn the patient during therapy... he's got a huge decub now I'd say his chances of making it out of the hospital are very slim.

We currently have 4 H1N1 confirmed and 1 suspicious (awaiting PCR) on vents on our 12 bed CVICU. All other ICU beds are full and the brass are allowing overtime and actually putting some of the less sick ICU patients in the PACU while this is going on. We have about 50 adult ICU beds, not including places that can take "overflow" vents such as Burn.

Now I have flu-like symptoms, so I won't know what's going on until next week.

On a side-note, I probably didn't get my illness from the hospital where I wear proper PPE. I think I got it from one of the various Halloween parties I attended over the weekend as it had been six days since I was last at work and developed symptoms.

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

Well, I've just returned from our war zone. Current count: 16 bed unit, 6 confirmed H1N1, 3 suspected, 2 on ECMO/CRRT, 2 on HFOV and 1 (s/p heart transplant) on high-flow nasal cannula, 1 still intubated but off isolation now after treatment with oseltamivir and 1 ECMO death. The oldest is the no-longer-isolated at 16 years, the youngest is 4 months. The younger of our ECMOs is unlikely to survive as there's an MRSA sepsis/vasculitis superimposed. My patient today is 3, on HFOV and requiring continuous neuromuscular blockade. Also has a really nasty extravasation injury that will probably need grafting.

We also have an infant on ECMO for cardiovascular reasons who has been on for 8 weeks, also s/p heart transplant (great example of what not to do). Our adult unit has 1 flu ECMO and 1 CV ECMO. We're sharing backup circuits now and there's a rumor afoot that our mothballed former CVICU will be opened as a combined adult/peds pandemic ECMO unit on the weekend. I hope they don't plan to cancel my vacation that's coming up the 12th to the 23rd!!

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

Thanks for the reports. I wish the vaccine was more readily available. I have 2 friends in Canada and both of them have children home from college with the flu.

Re: ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?

It's started up in earnest for us too - currently have 3 adults on ECMO for H1N1, and just got another readmitted (was pregnant but crashed and had emergency C-section).

I am getting my shot on Monday if they don't run out.