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

This thread has turned out to be absolutely fascinating. Thanks to all who have been contributing.

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

http://www.andalusiastarnews.com/new...sick-h1n1-flu/

This child from a small town in Alabama was treated in 3 different states. He was transported first to a Pensacola, Florida hospital by helicopter. Then, he was sent by jet to Atlanta, Georgia for ECMO.

Originally Posted by www.andalusiastarnews.com

...doctors at Sacred Heart discovered holes in each of Kolby’s lungs, which made it very difficult for the child to breathe. They quickly called Emory, which sent a jet to pick up Kolby and transported him immediately to Atlanta on July 29.

In Atlanta, doctors connected Kolby to an ECMO (extracorporeal membrane oxygenation) machine, which adds oxygen to a person’s blood and also provides breathable oxygen into the lungs.

“He’s been sedated for close to two weeks,” Dyess said. “The sedation is to keep him from accidentally pulling out any of the tubes on the machine. This machine allows his lungs to rest, so that way his lungs can collapse down and start healing.”

Dyess said that as of Monday, the hole in Kolby’s left lung appeared to be sealing up.

“That is just wonderful news,” he said. “Hopefully, both lungs will heal up and they’ll be able to take him off the ECMO machine and just hook him up to a regular respirator. That’s what we’re hoping for.”

Dyess said doctors are not sure where Kolby may have initially caught the virus. He said it is especially unusual, because Kolby contracted the virus while his 5-year-old brother, Kasey, did not.

“They know this was caused by the H1N1 virus, and luckily he’s far enough along with fighting the virus that the doctors have taken him off the antibiotics,” he said. “They’re really not sure why Kasey didn’t catch it as well — he had a small fever at one time, but other than that he was fine. The doctors at Emory are actually taking some DNA tests from my wife (Sonya) and me, and they’re going to look at the data and see if they can figure out why one child would have problems, and another child wouldn’t.”

(hat tip pfi/homebody)

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

“That is just wonderful news,” he said. “Hopefully, both lungs will heal up and they’ll be able to take him off the ECMO machine and just hook him up to a regular respirator. That’s what we’re hoping for.”

Hmm, I'm not sure how anyone else does ECMO but all of our patients are already "hooked up to a regular ventilator" on rest settings to keep their lungs from collapsing. The patient I cared for yesterday, 7 months old, is on V-V ECMO for complications from cadaveric liver transplantation. His rest settings were APRV, rate of 12, pressures of 18/+6 and 50% FiO2. Unfortunately we weren't able to maintain cephalad flows without frequent neuromuscular blockade; his cannulae are pretty small and he's a really little person. I think we'll manage to wean him to decannulation, but I think ultimately he will still die. Sad.

We discussed the issue of surgical cannulation vs percutaneous in our M&M rounds on Monday; one of our recent patients had a significant delay in cannulation due to inavailability of the surgeon on call (quite complicated series of issues there). The ECLS program director has discussed the matter with all the other stakeholders and they've decided that for non-cardiac ECLS we should be cannulating percutaneously whenever possible to avoid that issue in the future.

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

Jan, it really is astonishing how much more quickly support can be initiated percutaneously. I was used to looonnng cannulations and when we went to perc, it really was as easy and fast as popping in an IABP. Quite incredible.

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

For patients who have significant "airleak" from pulmonary injury, decreasing the vent settings (PEEP/PIP/Rate) can actually be very functional in sealing the leak. If there is no positive pressure in the lung then the "hole" will seal and eventually heal.

If you have a patient that does not have "airleak" / no pneumothorax, then traditionally many programs do as you mention with lung rest settings and a relatively high PEEP to keep the ling "inflated".

Cannulation issues seem to be a problem in many places. Some programs use both cardiac surgeons as well as pediatric/general surgeons for peripheral cannulation. A few even use the ICU Intensivist for peripheral cannulation. As long as there is emergent availability of a sergeon in case the vessel tears etc. that could be functional. There has to be some consideration of the issue of getting too many people involved in cannulation and then not being able to gain or maintain skill and competence to do them well.

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

Originally Posted by indigo girl

http://www.andalusiastarnews.com/new...sick-h1n1-flu/

This child from a small town in Alabama was treated in 3 different states. He was transported first to a Pensacola, Florida hospital by helicopter. Then, he was sent by jet to Atlanta, Georgia for ECMO.


(hat tip pfi/homebody)

Poor little guy, chances are his brother had a mild, mild case, they did say he ran a low grade fever for a short time. For some people that is all that will happen and for others it will end up like the poor little guy.

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

Originally Posted by ghillbert

Jan, it really is astonishing how much more quickly support can be initiated percutaneously. I was used to looonnng cannulations and when we went to perc, it really was as easy and fast as popping in an IABP. Quite incredible.

The biggest challenge for us with perc cannulation will be the size of our patients. We've put babies as small as 2.4 kg on and we've had to cannulate transthoracically a few times as well. One little guy we were considering ECPR for had a previous cardiac repair and when they attempted a surgical right neck cannulation they discovered the vessels were thromboses, so they dissected his left neck and were preparing the cannulae when they achieved ROSC. The other part of that challenge will be the skill of the ICU fellows with line placement. One of our current ones has a dismal track record with placing even single lumen CVCs. Fortunately our intensivists can be on the unit in a very short time from receiving the call, so there is some hope.

All this talk of ECMO is really making me think about applying for the training we have coming in October. I'd almost made the decision to forego it...

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

Yes, you should do it if you have the opportunity. Taking the course (I did the Alfred one back in 2002) really gave me a much better understanding of everything related to it (even though I thought I already knew a lot!). It's very interesting. We certainly didn't let fellows cannulate though, only the attending intensivists. The course there for those who will be cannulating includes animal model training.

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

Sadly it isn't so much a case of my tossing my hat into the ring and being given the training. There's a selection process and although I'm exceedingly qualified I might not be part of the charmed circle. I missed the cut once already (after a personality conflict with the nursing coordinator over a safety issue on the unit).

Anyway, check this story form the Edmonton Journal Breaking News feature:

EDMONTON - Alberta doctors who treat patients with the H1N1 virus may be paid up to $518 an hour under a proposed “physician financial support program” from the province and the Alberta Medical Association...


http://www.edmontonjournal.com/healt...150/story.html

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

http://www.edmontonjournal.com/healt...150/story.html

Originally Posted by www.edmontonjournal.com

Alberta doctors who treat patients with the H1N1 virus may be paid up to $518 an hour under a proposed “physician financial support program” from the province and the Alberta Medical Association.

Physicians who opt to work with patients with H1N1 would be paid $518.45 an hour during night shifts, $403.24 an hour during evenings and weekends and $259.23 an hour during weekday shifts, AMA President Dr. Noel Grisdale told members in a letter.

The proposed pay rates would apply if a state of public health emergency was declared.

The province and the AMA are also considering a program that would provide a guaranteed income for physicians unable to work because of illness as a result of treating pandemic patients.

Let me get this straight.

They are going to pay the doctors this outrageous sum to see, probably only for a few minutes each, patients with swine flu. But, the nurse who will spend 8 to 16 hours with these patients gets only the regular hourly rate.

What is the compensation for the nurse who gets swine flu? You know what they will say?

No way to prove it happened on the job. You could have been infected in the community. That is exactly what they said about that healthy, athletic nurse that died of swine flu in California.

Not only that, you, the nurse get only a surgical mask or procedure mask to protect you from these poor patients who may be coughing, puking and pooping. That's what we are seeing. Oh wait, you get to use a face shield with it.

Who was that nurse from Canada that spoke to the IOM in Washington last week favoring the surgical mask. I remember her saying, well you are going to catch the flu in the community anyway. Thanks a bunch, Bonnie, whoever you are for going to bat for nurses.

And here I was trying to get sleepy enough to go to bed, janfrn...