Jump to content

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

Disasters   (60,321 Views 144 Comments)
by indigo girl indigo girl (New Member) New Member

indigo girl works as a visiting nurse.

28,144 Visitors; 5,172 Posts

advertisement

You are reading page 3 of ECMO - Will We Have Sufficient Capacity for the Fall/Winter Flu Season?. If you want to start from the beginning Go to First Page.

indigo girl works as a visiting nurse.

28,144 Visitors; 5,172 Posts

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.

Edited by indigo girl

Share this post


Link to post
Share on other sites

928 Visitors; 6 Posts

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...

Share this post


Link to post
Share on other sites

ghillbert has 20 years experience and works as a ACNP-BC, CCRN.

1 Follower; 40,981 Visitors; 3,636 Posts

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!!

Edited by ghillbert

Share this post


Link to post
Share on other sites

indigo girl works as a visiting nurse.

28,144 Visitors; 5,172 Posts

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.

Share this post


Link to post
Share on other sites

ghillbert has 20 years experience and works as a ACNP-BC, CCRN.

1 Follower; 40,981 Visitors; 3,636 Posts

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.

Share this post


Link to post
Share on other sites
advertisement

oramar works as a returned nurse.

1 Article; 32,317 Visitors; 5,758 Posts

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

Share this post


Link to post
Share on other sites

indigo girl works as a visiting nurse.

28,144 Visitors; 5,172 Posts

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)

Share this post


Link to post
Share on other sites

NotReady4PrimeTime has 23 years experience as a RN and works as a RN, CNCCP(C).

16 Articles; 71,073 Visitors; 7,339 Posts

“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.

Share this post


Link to post
Share on other sites

ghillbert has 20 years experience and works as a ACNP-BC, CCRN.

1 Follower; 40,981 Visitors; 3,636 Posts

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.

Share this post


Link to post
Share on other sites

928 Visitors; 6 Posts

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.

Share this post


Link to post
Share on other sites

oramar works as a returned nurse.

1 Article; 32,317 Visitors; 5,758 Posts

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.

Share this post


Link to post
Share on other sites
×