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 Strangely enough, this was the link for a different article on the same case a day ago, but has since been replaced by this latest article.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 Clinical Research, Outpt Women's Health.

That was very moving. I sure hope she heals. What an ordeal.

I note in the link that there was a reference to 13 days as some kind of limit. Is this general, are there any specific guidelines for length of use or is it a Dr.'s discretion on a case by case basis? This is adult ECMO presumably different rules apply in pediatric cases. What becomes limiting? I am sorry I am all Qs & no As.

Specializes in NICU, PICU, PCVICU and peds oncology.

I don't think there are absolute limits in anything we do, are there? Many cases of pulmonary ECLS are of long duration because the lungs take a long time to recover, especially if there have been hemorrhages or necrosis. Judging recovery is also complex, so a patient may be recovered to the point of no longer needing ECLS but have a chest xray that looks AWFUL! One of the assessments used is a daily oxygen challenge. The first round of blood gases are done on current settings (blood is drawn from all cannulae, usually 3 at least in peds, and from the patient) then the oxygen on the ventilator, which is on rest settings, is turned up to 100% for 15 minutes. Another patient arterial gas is then drawn and compared to the previous ones. What suggests recovery is that the patient's pO2 will be dramatically higher on 100% oxygen with no changes made to the ECLS settings. The pO2 may go from 100 on the pre-challenge gas to 300 on the intra-challenge one. Then we know we can start weaning the flows. It's quite possible that it may take weeks to reach that point. So the reference to 13 days may relate to an average of all cases studied?

When I was reading the Facebook notes, I tried to imagine proning an adult on ECLS and my mind refused to go there. I can't imagine the logisitic challenges... well, actually I can and that's why I don't want to think about it. The circuit is made up of 3/8" internal-diameter tubing connected to wire-reinforced cannulae implanted into the right internal jugular and right internal carotid (typically, but femorals have been used, and transthoracic cannulation is often used in cardiac ECLS) with possibly a cannula in one femoral vein if they can't get adequate blood flow from the patient to the pump, a left atrial vent if the heart needs offloading, or a cephalad cannula to drain the head. There are multiple connections with high-velocity, high-pressure blood flowing through them. Barbed connectors are used, the tubing is pushed past at least two barbs and then the connection is zip-tied fr added security. There can be no kinks in the circuit. So proning would be a nightmare. I commend the staff at Chapel Hill for doing it... more than once by the sounds of it!

Specializes in Too many to list.

Braceville Township, Ohio

http://www.vindy.com/news/2009/dec/05/fatal-flu-case-shocks-family/?newswatch

She never dreamed that her husband would die from H1N1.

Walter was transferred to University Hospitals Case Medical Center in Cleveland on Nov. 2. Doctors put Walter on an ECMO machine, which removed Walter’s blood and oxygenated it for him. ECMO stands for extracorporeal membrane oxygenation.

“He didn’t smoke. He was healthy,” she said. “My husband was 44 years old. I didn’t think he had anything to worry about.”

(hat tip pfi/Ree)

Specializes in Too many to list.

When I was reading the Facebook notes, I tried to imagine proning an adult on ECLS and my mind refused to go there. I can't imagine the logisitic challenges... well, actually I can and that's why I don't want to think about it....So proning would be a nightmare. I commend the staff at Chapel Hill for doing it... more than once by the sounds of it!

http://www.startribune.com/photos/?c=y&img=1Killer1206_thumb.png

Is this what they are using? Wow! I cannot imagine this either...

Specializes in Too many to list.

UPDATE on Post #19, the RI teen in North Carolina

http://www.flutrackers.com/forum/showpost.php?p=326943&postcount=10

Would this type of reaction to a change of the ECMO circuit be expected? I get that this is very complicated.

"Today was a difficult day for Lil. Her heart stopped for awhile after they changed her ECMO circuit. They kept giving her CPR and eventually she returned to us. I can't tell you what a miracle it was to see how strong a fighter she is. There were some other setbacks but she is now stable - the numbers are about the same as they were yesterday. But we pray for her to make more progress in the coming days. Keep hoping to see 300 mL on her lung volume."

http://www.facebook.com/group.php?gi....2634561355..1

Specializes in Too many to list.

Elmira, New York

http://www.caringbridge.org/visit/elijahnist/mystory

This is a very sad update about the child in post #118.

http://www.wetmtv.com/news/local/story/Elmira-Boy-Dies-from-Swine-Flu/n3u8pK-MEUCHiMZvRriBQg.cspx

Elijah Nist, the Elmira boy hospitalized with Swine Flu has died. A spokesperson with the Golisano Children's Hospital in Rochester sent out the following statement from the Nist family Tuesday afternoon:

"The Nist family is grateful for the support and countless prayers they've received for Elijah. He passed away this afternoon with his family around him. The family asks for privacy in their time of grief."

8 year old Elijah had been in the hospital since November 7th. He was a third grader at Parley Coburn Elementary School.

(hat tip flutrackers/treyfish)

Specializes in ECMO and CRRT.

Not necessarily. When you change out a circuit, you have to: 1) clamp the pt off of ECMO; 2) cut away the connections to the old cirucut; 3) connect to the new circuit to the pt; 4) unclamp. We can do this in 20-30 seconds. I've heard of places that can do it in 18 seconds. If anything goes wrong during that process, it may take longer. Either way, even 30 seconds without oxygenation can be too much for the most unstable kid, as you know. Also, if the circuit had been clotting and not functioning properly prior to this, the pt may already have been desatting, then clamping took away all o2 support.

Another possibility is that the pt was on VA ECMO with no native cardiac output. Then any amount of time without the 'bypass' support of ECMO would warrant CPR.

A third possibility is that something was wrong with the ECMO prime, and the pt required CPR AFTER connecting to the new circuit. At our instition, when priming for VV ECMO or elective (not emergant) VA ECMO, we electrolyte correct the circuit before hooking it to the pt. If the pt were on VV and connected to a circuit that was primed with 'old' blood, the potassim in the prime blood could have been high enough to cause an arrest. If the pt were on VA, arrest wouldn't matter, you could crank up flow to support the pt.

Hope that wasn't too confusing!!

Specializes in ECMO and CRRT.

Proning helps sometimes and our institution had done it before on adults/large kids. THat's one MORE reason why I'm glad I work NIGHT SHIFT!! I dont' have to be involved in that cluster!!!

Specializes in Too many to list.

Waco, Texas

http://www.kwtx.com/home/headlines/79319592.html

There was “no warning, no asthma cough, just one minute he was playing, the next hour he spiked a fever and vomited. He then had shortness of breath so I gave him a nebulizer treatment of Albuterol and it did not help,” ...

...the boy was taken first to a Waco emergency room and then transferred to Scott & White Hospital in Temple, where initially he responded well to treatment.

But then complications developed, and doctors diagnosed him with life-threatening acute respiratory distress syndrome and said he required a procedure called extracorporeal membrane oxygenation or ECMO, which Scott & White personnel weren’t trained to perform on patients in Nicholas’ age group, the letter said.

...with authorization from the secretary of the Air Force, an Air Force crew flew doctors from Christus Santa Rosa and 3,000 pounds of equipment to Temple, where a 7-and-a-half hour procedure was performed to prepare him for the flight to San Antonio, the letter said.

The Air Force crew and medical personnel later flew Nicholas to San Antonio, where he was taken to Christus Santa Rose and placed on a permanent ECMO machine.

He died there around 12:30 a.m. Monday.

He would have celebrated his 10th birthday on Dec. 30.

(hat tip pfi/monotreme)

http://www.legacy.com/obituaries/wacotrib/obituary.aspx?page=lifestory&pid=137349987

Specializes in Too many to list.

Calgary, Alberta

http://www.vancouverite.com/2009/12/15/alberta-boy-who-was-in-a-coma-from-swine-flu-has-died/

A 16-year-old Calgary boy who had been in a coma after getting a serious infection from Swine Flu has died, his devastated grandmother confirmed Tuesday night.

Michael Gorbous had been on life-support since Nov. 2 when he was admitted to hospital. By the time he was rushed to hospital in an ambulance Michael had severe pneumonia in both lungs and he was placed on an ECMO machine that helped him breathe.

The grade-11 boy never came out of the coma, said his grandmother Fay Gorbous.

"He passed away at 4 a.m., they phoned me after six to tell me," she said in an interview. "The doctors and nurses at that hospital were wonderful, they did everything they possibly could."

Specializes in Too many to list.

RI Teen Dies in North Carolina

That was very moving. I sure hope she heals. What an ordeal.

The young woman from post #119 has died.

She was perfectly healthy until she came down with this flu. Extraordinary efforts were made to save her to no avail.

I am so sorry for her family.

http://abclocal.go.com/wtvd/story?section=news/local&id=7175470

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