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

Disasters   (60,227 Views 144 Comments)
by indigo girl indigo girl (New Member) New Member

indigo girl works as a visiting nurse.

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indigo girl works as a visiting nurse.

28,132 Visitors; 5,172 Posts

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http://www.dailyrecord.co.uk/news/scottish-news/2009/08/13/scottish-swine-flu-patient-who-was-transferred-to-sweden-returns-to-uk-86908-21594312/

A PREGNANT swine flu patient transferred to Sweden for specialist treatment has returned to the UK, it was confirmed today.

Sharon Pentleton, 26, was flown from Scotland to Stockholm because no beds were available in the UK for the rare procedure she required.

Ms Pentleton, from North Ayrshire, had been receiving treatment in the intensive care unit at Crosshouse Hospital in Kilmarnock due to an extreme reaction to the H1N1 virus.

A spokeswoman for Karolinska University Hospital said today that the patient had left their care and returned to the UK.

NHS Ayrshire and Arran recommended that she received a highly-specialised procedure known as extracorporeal membrane oxygenation (Ecmo) for her symptoms of adult respiratory distress syndrome.

The Ecmo treatment involves circulating the ill person's blood outside the body and adding oxygen to it artificially.

It is a relatively new technique which is used when a patient's lungs are functioning very poorly even with ventilation and high levels of oxygen.

The UK has a national Ecmo unit in Leicester but all five beds were being used at the end of July when Ms Pentleton had to be transferred.

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indigo girl works as a visiting nurse.

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http://www.floridatoday.com/article/20090816/BREAKINGNEWS/90816006/1086/rss07

After fighting for her life the past month, Tiphani Corley has lost her battle against swine flu.

The 19-year-old Rockledge High School graduate died late Saturday night at Shands Hospital in Gainesville. Doctors were using a lung bypass machine and ventilator to keep her alive.

"Her stats just went down. Her organs started shutting down," said Palm Bay resident Denise Klenotich, a family friend. "She went pretty fast."

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NotReady4PrimeTime is a RN and works as a RN, CNCCP(C).

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I wonder just which of her "stats" went down? Sorry, I couldn't resist.

 

Anyone who has any experience with ECMO will tell you that it isn't the miracle everyone thinks it is. It's literally the last ditch. There is nowhere to go from there. And as I think I already said, V-V (veno-venous) ECMO for pulmonary rest is usually a long process and is not nearly as successful as V-A (veno-arterial) ECMO for cardiac rest... and that has a fairly high mortality rate. This story only confirms what has been predicted - the young and healthy will succumb in greater numbers than the old and less firm, at least initially.

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WalkieTalkie works as a RN.

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I think that adult ECMO will not be widely used for the treatment of flu as the benefits of treatment are limited to a very select patient population. I think my hospital has 4 Centri Mag units that we use for adult ECMO... the most I've seen on our floor at once was 2. Any more than that would completely overwhelm us, the perfusionists, and our cardiothoracic surgeons as well. The resources needed to run ECMO such as blood and blood products would quickly dwindle. The survival rate for ECMO, in general, is not great.

I could see it being used in an otherwise healthy adult with sudden and severe pulmonary compromise after other treatments aren't successful, but I really think the usage will be limited.

My hospital has 650+ beds, 12 of which are the CVICU. There are only a few of us qualified to run adult ECMO (limited to the CVICU). We mostly use A-V ECMO because we are a transplant center. V-V ECMO has only been used a couple of times recently... one patient lived, the other died.

Edited by WalkieTalkie

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Unfortunately the info janfrn gave on ECMO is only partially accurate. For too many places ECMO is a last ditch effort and when that occurs the results are usually very poor. However, when appropriately implemented, ECMO can be an excellent mode of support and the outcomes can be very good depending on the patient population supported. If you are getting a worse outcome with V-V ECMO than you are with V-A (especially for cardiac rest) then something is very wrong. An organization called ELSO collects data on ECMO patients and there is clearly better survival rates for V-V patients then for cardiac V-A.

 

I agree that ECMO should not be considered a first line support mode. ECMO is a support mode and not a treatment. If you wait too long to implement the support, then the damage done will not be reversible. Waiting until it is "last ditch effort" is likely to be too late. I noticed from the picture that janfrn posted, the equipment shown there uses pump technology that is nearly 20 years old. There are much newer devices on the market that have improved blood handling characteristics. Not sure if that has anything to do with the reported poor outcomes or not.

 

ECMO capacity is defintiely limited for all the reasons janfrn stated. It can be very resource intensive and is not a light undertaking by the institution. In the US, we should have the capacity to care for up to 200-300 patients at a time if spread evenly across the country. There are not enough places that provide Adult support though. And rarely do the cases end up being spread out evenly. I know there are processes underway in the ECMO community though to deal with potential pandemic of H1N1 ECMO patients this fall.

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indigo girl works as a visiting nurse.

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ECMO capacity is defintiely limited for all the reasons janfrn stated. It can be very resource intensive and is not a light undertaking by the institution. In the US, we should have the capacity to care for up to 200-300 patients at a time if spread evenly across the country. There are not enough places that provide Adult support though. And rarely do the cases end up being spread out evenly. I know there are processes underway in the ECMO community though to deal with potential pandemic of H1N1 ECMO patients this fall.

That is interesting. They are trying to plan ahead for a potential need?

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Based on the information we are getting from Europe and Australia there is thought that we may see an increase in H1N1 on ECMO. I know of/have received reports on 15 patients in 6 different states on ECMO in the last 6 weeks. Prior to April/May there were no reports in the U.S. of ECMO H1N1 patients. So there are discussions within the ECMO Community to try to be a little proactive and try to be ready. We'll see...

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oramar works as a returned nurse.

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Unfortunately the info janfrn gave on ECMO is only partially accurate. For too many places ECMO is a last ditch effort and when that occurs the results are usually very poor. However, when appropriately implemented, ECMO can be an excellent mode of support and the outcomes can be very good depending on the patient population supported. If you are getting a worse outcome with V-V ECMO than you are with V-A (especially for cardiac rest) then something is very wrong. An organization called ELSO collects data on ECMO patients and there is clearly better survival rates for V-V patients then for cardiac V-A.

 

I agree that ECMO should not be considered a first line support mode. ECMO is a support mode and not a treatment. If you wait too long to implement the support, then the damage done will not be reversible. Waiting until it is "last ditch effort" is likely to be too late. I noticed from the picture that janfrn posted, the equipment shown there uses pump technology that is nearly 20 years old. There are much newer devices on the market that have improved blood handling characteristics. Not sure if that has anything to do with the reported poor outcomes or not.

 

ECMO capacity is defintiely limited for all the reasons janfrn stated. It can be very resource intensive and is not a light undertaking by the institution. In the US, we should have the capacity to care for up to 200-300 patients at a time if spread evenly across the country. There are not enough places that provide Adult support though. And rarely do the cases end up being spread out evenly. I know there are processes underway in the ECMO community though to deal with potential pandemic of H1N1 ECMO patients this fall.

I wonder if UPMC or WPAGH in Pittsburgh have this capacity?

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NotReady4PrimeTime is a RN and works as a RN, CNCCP(C).

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ECMORN, the photo I posted is several years old. We have upgraded our equipment since then and are using new technology. I think one of the reasons our outcomes for V-V are not as good is that we tend to get these kids late in the process of their illness... our catchment area covers 1.26 million square kilometers (783,000 square miles) of, for the most part, sparsely populated country and includes a large indigenous population. (It's the largest territory covered by any hospital in Canada.) We'd be more proactive if we could. I think I mentioned our severe asthmatic who has had ECMO twice who is maybe, finally, learning that his asthma isn't a joke. Another reason for our less-successful V-V runs could be the somewhat more vague indicators that ECMO should be considered. With our cardiac kiddies, we have fairly clear-cut indicators and electively cannulate them more often.

We're definitely expanding our capacity, at least in the human resources area. Our PICU is running an ECMO training course at the beginning of October; we usually train 8-10 new providers each course. Our team is fairly evenly distributed between our RNs and RRTs but since the team leader is an RRT, there's a little favoritism in the selection process. Ultimately that isn't an issue... unless you're one of the RNs who wasn't selected. :crying2:

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I have to disagree with oramar here...at least partially...

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.

There are nearly 100 ECMO programs in the United States that report to ELSO (Extracorporeal Life Support Organization) which is a relatively small number compared to all the hospitals in the U.S. However it is a rather large number compared to the rest of the world. The 10 largest ECMO programs in the US have the ability to support anywhere from 3-8 patients at one time. The other 85-90 or so can usually support at least 2 at one time. It is very specialized...but the biggest problem will be that the overwhelming majority of ECMO centers are ONLY pediatric and neonate. So the Adults will have very limited support at experienced centers.

But...there are a significant number (still trying to identify exactly how many) of Adult hospitals that are supporting ECMO patients by using their perfusionists and a "non-traditional" (in many cases) ECMO system to provide this much needed support often on somewhat of an emergent or last ditch effort basis. Problem with this is that the OR has to shut down for cardiac surgeries because the perfusionists are sitting at an ECMO pump 24/7.

There are also a couple of independent agencies that are trying to beef up ECMO System rental capability as well as ECMO Specialist staffing contracts to help support the hospitals that don't have established ECMO programs. You can google ECMO staffing/ECMO equipment/ECMO Specialists etc. and find a couple of different groups at least offering some type of help.

I know there are also groups trying to partner with manufacturers to make sure that there are plenty of ECMO systems available in the U.S. this fall.

So will we be ready?...probably not as ready as we would like to be...but it won't be as bad as it could be.

As for who is doing ECMO...at least those who report to ELSO can be found on the ELSO web site. www.elso.med.umich.edu (I am not associated with the U of M...just happen to know this info is available on this site)

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NotReady4PrimeTime is a RN and works as a RN, CNCCP(C).

18 Likes; 16 Articles; 70,995 Visitors; 7,334 Posts

But...there are a significant number (still trying to identify exactly how many) of Adult hospitals that are supporting ECMO patients by using their perfusionists and a "non-traditional" (in many cases) ECMO system to provide this much needed support often on somewhat of an emergent or last ditch effort basis. Problem with this is that the OR has to shut down for cardiac surgeries because the perfusionists are sitting at an ECMO pump 24/7.

ELSO is now tracking H1N1 statistics on their website. Our hospital is on four of their five lists of providers, all except the adult pulmonary. My guess is that the adult side will utilize the expertise of the children's side to enable capacity there.

Every once in awhile we transport children on ECMO for great distances (800 miles) after a surgeon there has cannulated and their adult perfusionist has run the pump. Our transport team nurses have all been trained so they can limit the number of personnel having to travel. All but one of the kids we've transported has survived. But what I really wanted to comment on here is the "non-traditional) angle. In 2007, the Winnipeg Children's Hospital cut an oxygenator into a CRRT circuit and saved a neonate's life. My friend who works there called it "FakeMO". http://www.hsc.mb.ca/press_release22.doc

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WalkieTalkie works as a RN.

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But...there are a significant number (still trying to identify exactly how many) of Adult hospitals that are supporting ECMO patients by using their perfusionists and a "non-traditional" (in many cases) ECMO system to provide this much needed support often on somewhat of an emergent or last ditch effort basis. Problem with this is that the OR has to shut down for cardiac surgeries because the perfusionists are sitting at an ECMO pump 24/7.

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.

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