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

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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 Strangely enough, this was the link for a different article on the same case a day ago, but has since been replaced by this latest article.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.

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Specializes in Too many to list.

Western Australia

http://www.news.com.au/perthnow/story/0,21598,25834300-2761,00.html

www.news.com.au said:

The Sunday Times can reveal that a lack of oxygenator machines at Sir Charles Gairdner Hospital forced intensive-care patients with the life-threatening virus to be moved to Royal Perth Hospital. A pregnant woman in a critical condition was the first patient transferred on Friday.

The life-saving machines, known as ``extracorporeal membrane oxygenators'', ``clean'' the patients' blood outside the body, replacing vital oxygen. They have proven critical in keeping seriously ill swine- flu victims alive in the eastern states.

SCGH has only one machine and RPH has three. The SCGH machine is usually needed by doctors conducting open-heart surgery.

Latest figures reveal five WA swine-flu patients are in intensive-care units. There have been 1473 confirmed cases of the virus in the state.

Health Department co-ordinator Andy Robertson admitted there was a shortage of ECMO machines in WA. He said they were principally kept at RPH because staff there were better trained to use them.

Dr Robertson said the State Government had ordered more machines and hoped to get them within the next month.

``Princess Margaret Hospital already has one on order and we're hoping to get probably two or three more,'' he said.

Dr Robertson said transferring the pregnant swine-flu victim at SCGH would ensure she was looked after. ``While we don't like to transfer patients from SCGH to RPH, it is the best step for that patient,'' he said. ``She will get the best care at RPH because they have the equipment and (can) utilise it.''

An intensive-care specialist at SCGH said the management of patients had been chaotic and the lack of equipment was shocking. It was clear a month ago the state needed more ECMO machines.

``They are necessary to get oxygen into the lungs of swine-flu victims,'' he said. ``There are not enough in WA and it is putting patients at risk.''

The ICU specialist said doctors at SCGH were concerned about transferring critically ill patients. ``We don't like to transfer ICU patients because they can deteriorate,'' he said. ``Some doctors think ECMO machines should be moved between hospitals, not the patients.''

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Specializes in CTICU.

I know my major university-based hospital in the US has had a plan for this for several years and has expanded its ECMO program. Luckily the drivers are not that expensive, and the new pumps used are only around $200 USD.

It's not realistic to think that multiple local/smaller hospitals could get ECMO capabilities, just because of the training and expertise required to not kill people while on ECMO. I think it will remain with people being transferred in to major centers - I know that's where I'd want to go if I needed ECMO.

It is rare to crash onto ECMO for respiratory purposes - there's usually sufficient time to see a downward trend and get the patient somewhere capable of instituting it.

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ghillbert said:
I know my major university-based hospital in the US has had a plan for this for several years and has expanded its ECMO program. Luckily the drivers are not that expensive, and the new pumps used are only around $200 USD.

It's not realistic to think that multiple local/smaller hospitals could get ECMO capabilities, just because of the training and expertise required to not kill people while on ECMO. I think it will remain with people being transferred in to major centers - I know that's where I'd want to go if I needed ECMO.

It is rare to crash onto ECMO for respiratory purposes - there's usually sufficient time to see a downward trend and get the patient somewhere capable of instituting it.

It certainly makes sense to only do this where staff are expert in maintaining these patients.

So, what's a driver anyway? You said that they were not that expensive. This is part of the machine, right?

How many beds for ECMO are available at your facility? I take it that you are in a major population area. I wonder what the capacity is nationwide.

I wonder if some of the fatal cases that have already died in the US would have survived if they had been transferred. A useless speculation, I know because we know nothing about the details, but how would the docs decide who would be a good candidate for this type of treatment?

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The short answer to the question that heads this thread is "NO". The long answer is that is a very specialized medical procedure that will be offered at only a small number of very high tech facilities. During this summer's herald event it is feasible to transfer people across state lines for this treatment. However, when this thing peaks this winter the big medical centers will have all their machines tied up with locals and when people from out of state call the answer will be "NO". So their you have the long and short of it.

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Specializes in Too many to list.

Sydney, Australia

http://www.news.com.au/couriermail/story/0,23739,25886675-3102,00.html

A CRITICALLY ill 16-year-old girl with suspected swine flu has been airlifted from Townsville to Sydney to access life-saving medical equipment.

Deputy Premier Paul Lucas told Parliament today that Queensland's Chief Health Officer Jeannette Young made the decision to transfer the teenager to St Vincent's Hospital last night following advice from intensive care specialists.

He said the patient required treatment with a heart-lung bypass machine, not traditionally used in intensive care for patients with the flu.

The extracorporeal membrane oxygenation, or ECMO, machines are usually used when someone is having open-heart surgery to take over the role of the heart and lungs.

However, in recent weeks the machines have proved useful in treating younger patients critically ill with swine flu. They oxygenate the blood of patients whose heart or lungs are no longer functioning adequately.

Mr Lucas said six ECMO machines are available in Queensland - three at The Prince Charles Hospital in Brisbane, two at the Princess Alexandra and one at the Mater Children's.

Five were in use yesterday, when the 16-year-old girl required treatment.

"I am advised the doctors considered the best option for the patient was to transfer her to Sydney ... which would leave some capacity in Brisbane should another patient require ECMO in the coming days," Mr Lucas said.

Two more ECMO machines have been ordered for Queensland and are due to arrive early next week.

(hat tip flutrackers/jeremy)

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Gainsville, Florida

http://www.floridatoday.com/article/20090806/BREAKINGNEWS/90806008/1086/Family+plans+event+for+gravely+ill+flu+patient

This sounds very, very expensive. I wonder how many of these patients we can treat in the US with ECMO at one time. How available is the equipment and the staff to run it?

We may be finding out very soon.

www.floridatoday.com said:

A 19-year-old Rockledge woman diagnosed with swine flu continues to fight for survival as family members plan a fundraiser this weekend to help with mounting medical costs.

Tiphani Corley also faces the potential for organ failure, prompting doctors use a lung bypass machine to keep her alive, relatives said.

“I pray everyone will pray for Tiphani,” said Brenda Farrish, her aunt.

“Pray for a miracle.”

The Rockledge High School graduate is in critical condition at Shands Hospital at the University of Florida in Gainesville. Corley’s mother, a lab tech at a local hospital, remains by her bedside while her father has taken on two jobs to support the family.

A fundraiser will be held at the County Line Saloon, 4650 West New Haven Ave., at 7 p.m. Friday.

The family has also set up a Facebook page asking the community for support and prayers.

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http://www.elso.med.umich.edu/CenterByCategory.asp

This is a list of facilities that is provided by ELSO, the Extracorporeal Life Support Organzation. Per their website, "The primary mission of the Organization is to maintain a registry of, at least, use of extracorporeal membrane oxygenation in active ELSO centers."

I tried to get an idea of whether all hospitals that offer the treatment belong to this organization or not, but frankly I'm still sick, so not firing on all cylinders. Gives a general idea of availability, though.

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Specializes in NICU, PICU, PCVICU and peds oncology.

My unit has the most active pediatric ECLS program in Canada. Our ECMO specialists are RNs or RTs with specialized training. We have an ECLS transport program and have successfully transported a number of children already on ECLS from other hospitals in western Canada. It's a huge commitment to have an ECLS program not just because of the cost of equipment and not least the need for extra manpower, huge volumes of blood products, continual laboratory testing, and ongoing training for staff. ECLS is a high-risk modality that may cause hemorrhage into any organ system, thromboses, overwhelming sepsis, irreparable vascular damage and any number of other complications including death. V-V ECMO, the method used to treat respiratory failure and is usually of long duration, has only mediocre outcomes, although we have had one youngster who's been ECMO'd twice for status asthmaticus who remains alive today. Our duration of treatment for respiratory failure has ranged from days to 12 weeks, the average being about 2-3 weeks. Babies and toddlers with intercurrent RSV and adenovirus typically do not survive. We've had no H1N1 cases requiring ECLS yet.

Capacity? We've had as many as four kids on at a time, although that isn't typical. Our hospital has half a dozen drivers (the pump that circulates the blood outside the body) shared between adults and children. We always have a circuit primed with Plasmalyte so it can be ready to go in the time it takes the surgeon to place the cannulae. When we have a patient on, we have a back-up circuit primed in case of failure. This winter will be very challenging on so many fronts.

The photo is our unit with three ECMO patients visible.

EcmoPatients.jpg
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Specializes in Too many to list.

Thank you both for all of your information.

Can the same type of machines be used for both kids and adults, or are some specifically adapted for the size of the patient?

I take it that the patient must come to the machine and the support staff.

From the picture, it looks like the patients are not in isolation. Or are there machines in isolation rooms? Is that going to be a problem?

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Specializes in NICU, PICU, PCVICU and peds oncology.

The driver is one-size-fits-all. The size of the circuit is adjusted to the size of the patient. While it is possible to take the technology to the patient, it would mean sending the specialist team (temporarily including a surgeon to perform the cannulation) to the patient too. It makes the most sense to transfer the patient to the technology.

We have six rooms that are large enough to accommodate the bed, the driver (seen in the right foreground of my photo), all the equipment and supplies, the two computer terminals needed for charting and the two or three personnel needed to care for the patient. (Doesn't leave much room for moving around, usually means climbing over or moving things continually.) Four of them are pressurized rooms.

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South Hampton, UK

http://www.dailyecho.co.uk/news/4536361./

Transferred for special equipment, most likely means ECMO before she died. According to the link provided by DeepFried RN, the hospital she was sent to does provide it.

http://www.elso.med.umich.edu/CenterByCategory.asp

www.elso.med.umich.ed said:

Madelynne Butcher, 18, dies after contracting H1N1 virus

12:30pm Saturday 8th August 2009

Madelynne, of Sholing, Southampton , showed no signs of illness when she headed off on holiday to Tenerife with a friend in June to celebrate finishing her exams.

However, when she returned she was sick and short of breath and her mother took her to see a doctor and then to Southampton General Hospital where she was later sedated.

After two weeks she was transferred to Glenfield Hospital in Leicester to be treated with specialist equipment.

Her mum and dad Alan went to visit her in Leicester on Thursday morning and were told when they arrived that their daughter had died.

The exact cause of her death has yet to be established but Madelynne had been diagnosed as having swine flu by Southampton doctors and had been prescribed the drug Tamiflu.

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