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

Nurses COVID

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I ask this question because twice this week that I am reading of critical swine flu patients having to be transferred to other facilities for treatment with ECMO. I am wondering how many critical cases would require this extreme level of care.

I would not think that many would but, if many people come down with this flu this fall, that would likely increase the number of critical cases, some of which may need this procedure. I am curious about what our capacity is to do this in the US. Surely only the biggest hospitals would be able to treat these cases.

The UK is having quite a strong outbreak of swine flu right now, and it is summer there. Australia, on the other hand, is in the middle of their winter flu season. It is hard to make comparisons between the two different places. At any rate, here is the first report that I came across:

http://www.dailymail.co.uk/news/article-1201825/First-picture-pregnant-woman-rushed-Sweden-swine-flu-virus-threatens-overwhelm-intensive-care-wards.html;jsessionid=C985E455C9FE4EC6E64190D88CC04A4E

This article describes the transfer of a Scottish woman to a four bed ECMO unit in Sweden. The Swedes came and got her by private jet. Strangely enough, this was the link for a different article on the same case a day ago, but has since been replaced by this latest article. I have no faith that it won't be replaced by yet another topic very soon so I will paste the pertinent info.

www.dailymail.co.uk said:

Ms Pentleton is monitored 24-hours a day by an array of equipment and a team of specialists.

She arrived on Thursday evening after Swedish doctors chartered a private jet to fly the two hours to Scotland to pick her up.

Crister Classon, a spokesman for the hospital, said: 'We are happy to help Britain or any other country if they run out of beds.

'It is a normal procedure to help other countries when they need it.

'We have only four beds and we currently have two swine flu patients in them, so there there are presently only two spare beds.'

It is thought a second British patient may be transferred to the unit.

The hospital's Dr Palle Palmer explained that the ECMO machine - similar to a heart and lung machine - was used to 'buy time' for patients. He said people could be kept on the machine for up to two months, but added that most patients did not need ECMO treatment for that long. He said: 'Normally it takes about two weeks, that's the normal treatment. But it is possible to run it for longer.

The Glenfield Hospital in Leicester, where doctors had hoped to treat Miss Pentleton, has the first designated ECMO unit for adults in the UK. But because it was full - with two of its five machines already being used by swine flu patients- medics turned to Stockholm.

ECMO treatment has only recently been accepted into mainstream NHS practice, being regarded as experimental in adults until the completion of a trial six months ago. Seriously sick children have been successfully treated for some time.

Best chance: Scottish health secretary Nicola Sturgeon said it was vital Miss Pentleton was transferred to Sweden

Consultant cardio-thoracic surgeon Mr Richard Firmin director of the ECMO unit in Leicester, said an average of 100 patients a year are treated there and beds could be expanded to 10 if absolutely necessary.

Patients are attached to an ECMO machine while their lungs recover from a variety of conditions, including viral infections and trauma. It involves circulating the patient's blood outside the body and adding oxygen to it artificially, Mr Firmin said 'The circuit is basically an external lung. Anybody who ends up with ECMO is somebody who is at the very severest end of lung failure.'

Patients may need treatment for two to eight weeks, at a cost of £55,000 to £105,000 per patient. Professor David Menon, an intensive care specialist at Cambridge University, said a small minority of swine flu victims who need intensive care have suffered a direct viral attack on their lungs, rather than a secondary infection. The condition called pneumonitis involves destruction of lung tissue.

Specializes in Too many to list.
This is how my hospital does it... We do have enough perfusionists available to continue a regular OR schedule, but they are frazzled after a few days of this.

I would imagine that all will be very stressed after a fall and winter full of these types of cases if they decide to use ECMO. I wonder if decisions will be made on how costly and labor intensive it is to use this mode of tx as most do not seem to survive.

Hospitals in some southern hemisphere countries have already been cancelling elective surgeries because of the numbers of flu victims being admitted as critical care cases.

Can the pediatric hospitals take adult cases? Many will be teens and young adults...My hospital offers ECMO, but only for neonates.

Hopefully this won't be a HUGE issue. But I agree it has great potential stress the system a bit. According to one report out of Australia, "2% of hospitalized patients and 6% of ICU (H1N1) flu patients go on to ECMO". The CDC is projecting a large number of total cases this fall in the US. And it is unclear as to whether we will have an effective vaccine...and if we do...how much and who will get it?

It is still uncertain what the overall survival rates are for these patients. Experts in Europe are saying 60% should survive. The data so far from Australia seems to be a little lower than that. The current experience in the States in the last 6-8 weeks is somewhere around that. It will be interesting to see what is reported from the ELSO database. Those who present with community acquired MRSA are not doing that well. But one thing that seems to be certain is that if you get sick enough to "qualify for ECMO" with an H1N1 related pneumonia, you're not likely to make it through without ECMO. So I'd say 40%-60% chance of survival vs. almost certain death might be worth whatever the cost. (In general ECMO costs much less than an organ transplant which is generally accepted in our society as a worthwhile expense.)

Maybe all the preparation in anticipation will make it all go smoother than it otherwise would.

We'll see...

Specializes in CTICU.

There is some confusing info being posted.

1. You have to compare apples with apples. Percutaneous ECMO in several units in Australia is instituted by intensivists and used very early in the case, and they have excellent results (esp. The Alfred). In any case, the early and frequent institution of ECMO could give you skewed numbers.

2. Centrimag pumps are a very expensive way to run ECMO. Centrimag pumps cost around $8500-12000 dollars. Jostra or Biomedicus pumps only cost several hundred dollars. The Centrimag consoles are not cheap, and are also quite expensive to rent from Thoratec, because they are usually used for VADs. Biomedicus machines are a lot cheaper and widely available.

3. Not all big ECMO centres are listed on that ELSO website. In particular, UPMC in Pittsburgh is not listed and they do A LOT of VADs and ECMO. In addition, Children's Hospital of Pittsburgh also uses both ECMO and VADs for peds cases.

4. The limitation is really not the machines or equipment. It's the hospital CTICU/ICU beds, and the specialized staff to run the systems. There's no point sending 1 or 2 staff to outlying hospitals to run the ECMO, because you also need the capability to get back to the OR, change out circuits/oxygenators, etc etc. You need to be in a big center.

5. You do not need a surgeon to institute ECMO, unless it's centrally cannulated. Peripheral ECMO cannulae are reasonably easy (similar to an IABP) and quick to insert, and mean that support can be quickly initiated.

6. Another possible way to ramp up the ECMO capacity US-wide would be to adopt a model similar to The Alfred. ECMO is instituted either in OR or ICU, and managed by intensivists in ICU. The perfusionists handle in OR, but once in ICU, ECMO-trained RNs manage it. They have a formal ECMO course which is offered 1-2 times a year, and given by nurses, doctors and perfusionists. There is really no need to have a perfusionist bedside if you have trained ICU RNs - in an emergency, you need to be able to clamp the circuit. Routinely, you need to alter the sweep gas according to ABGs and supervise the circuit. We run Centrimags as VADs with no oxygenator and there's noone sitting bedside - we've even ambulated patients with Centrimag VADs! A lot of the insistence on 24/7 perfusionists with ECMO is the perfusionists creating job security, I think!

The answer to the thread is that we don't know. The percentage of H1N1 patients that end up requiring ECMO would be relatively minimal, so the impact is hard to estimate.

I'd say 40%-60% chance of survival vs. almost certain death might be worth whatever the cost. (In general ECMO costs much less than an organ transplant which is generally accepted in our society as a worthwhile expense.)

Transplantation generally has a much better survival than 40-60%, though!!

Specializes in CTICU.

Here's the info for the Alfred ECMO clinical service and course:

http://alfredecmo.com.au/ECMO%20UNIT.html

Specializes in Too many to list.

http://alfredecmo.com.au/ECMO%20UNIT.html

This says almost 60% survive to discharge. That is more than I would have thought.

I wonder if there will be any change in case survival with H1N1.

To date (December 2008) the Alfred has performed 170 adult ECMO interventions with 129 occurring since 2003, an average of more than 20 per annum. Since the first use of ECMO in 1990, 65.9% of ECMO interventions have been associated with a successful wean from ECMO and 49.7% have survived to hospital discharge. Outcomes have improved since 2003 with this cohort of patients achieving a successful wean form ECMO 72% of the time and hospital discharge in 56.8%. Of the 42 patients that received ECMO support prior to 2003, only 28.6% survived to hospital discharge.

Specializes in CTICU.

If you take a look at their data though, the results for respiratory failure are worse, around 50%. Their good results in cardiac patients pushes the overall survival up. Also, as mentioned, they institute ECMO very early and do tend to get better results than those that just implant crash-and-burn patients - you can see the improvement in their results since 2003 when they started the percutaneous ECMO service.

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

Specializes in Too many to list.

http://www.andalusiastarnews.com/news/2009/aug/17/opp-boy-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.

...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)

Specializes in NICU, PICU, PCVICU and peds oncology.

“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.

Specializes in CTICU.

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.

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.

http://www.andalusiastarnews.com/news/2009/aug/17/opp-boy-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.
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