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

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by indigo girl indigo girl (New Member) New Member

indigo girl works as a visiting nurse.

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You are reading page 6 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.

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

16 Articles; 71,072 Visitors; 7,339 Posts

Looks like I'll be joining our ECLS team after all. We're gearing up for the potential of six concurrent ECMOs... hmm, what did I say in my previous post? That number six keeps cropping up. Anyway, the training runs October 5-9 and it sounds like we'll also be training a group of people from Calgary too. I wonder how all of this fits into Alberta Health Services' plans to close 350 acute care beds in the next short while?

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indigo girl works as a visiting nurse.

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Good luck, janfrn.

This does not seem to be a good time to be closing acute care beds.

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

16 Articles; 71,072 Visitors; 7,339 Posts

What the news is reporting today is that the 350 acute care beds they plan to close will close over the next three years, as the people waiting SNF/LTC placement are moved into more appropriate beds in the community. And Dr. Duckett has said that "No one will move unless and until the appropriate placement is in place". Given that this province has closed LTC beds and transformed many more into designated assisted living spaces, which are a far cry from long term care beds, it's more likely that these poor people will be moved to an inappropriate level of care and forced to find alternate private care at great expense. The beds closed will not actually disappear from the system but will be kept in reserve for things like H1N1... but the nurses to staff those beds will have left the province, having had their employment terminated or restructured out of existence. It's a catastrophe in the making.

Edited by NotReady4PrimeTime

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indigo girl works as a visiting nurse.

28,143 Visitors; 5,172 Posts

Oklahoma City, Oklahoma

http://www.cbsnews.com/stories/2009/09/18/eveningnews/main5321795.shtml

Hugh Estlinbaum sits for hours encouraging his very sick son.

"We're just floored by how well you're doing. How hard you're fighting," Estlinbaum said. "How hard you're fighting. We can see it, Tony, we can see it."

Above his sedated son Tony - photos of the all-American 10 year old. Tony got the H1N1 virus last Sunday, and began fighting for his life. "You are strong. You are special, and you can do anything," his dad said.

Carolyn Howard's daughter Leteasha is another critically ill H1N1 patient in the intensive care unit of Oklahoma City's Children's Hospital, reports CBS News correspondent Mark Strassmann. Heavily sedated, she's been clinging to life for the last three weeks.

"I rub her hand and tell her I love her," Howard said. "And we're ready for her to come home."

At home, this 10 year old loves to sing and dance. But in Oklahoma, one of America's hardest-hit states by H1N1, Leteasha got sick and never got better. A machine called an ECMO may be her last hope. It oxygenates her blood, acting as her heart and lungs to give her sick body a fighting chance.

Tony and Leteasha's rooms are 40 feet apart at the hospital. But doctors say their chances of recovery are miles apart. Tony's improving slowly, day by day. But Leteasha Howard's family knows, she is not responding.

"What explains why one child is doing well and the other child is not doing well?" Strassmann asked.

"Great question. I wish we knew the answer to it," said Dr. Cameron Mantor. "This is something that's new to us."

Leteasha has weight issues and asthma. Not enough, doctors say, to explain why she's sinking as Tony improves.

Reformatted.

(hat tip flutrackers/shiloh)

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indigo girl works as a visiting nurse.

28,143 Visitors; 5,172 Posts

Northern Ireland

http://www.belfasttelegraph.co.uk/news/local-national/swine-flu-victim-airlifted-to-hospital-in-england-14520370.html

A woman from Northern Ireland suffering from severe complications related to swine flu has been airlifted from Belfast to a specialist unit in Leicester.

The patient, who gave birth 10 days ago in the South Eastern Trust area, needs a procedure known as Extra Corporeal Membrane Oxygenation (ECMO).

It is understood the baby is doing well at home, and being nursed by family members.

Health Minister Michael McGimpsey said the woman required urgent treatment and his thoughts were with her family.

Mr McGimpsey said Leicester had the only "national ECMO unit for adults and provides these specialist services across the UK".

"There are currently plans to double the capacity at the centre to ensure that we are able to respond to any increased demand arising from the swine flu pandemic," he said.

ECMO is a technique of providing both cardiac and respiratory support oxygen to patients.

Breedagh Hughes, a spokeswoman for the Royal College of Midwives, last night told the BBC that pregnant women shouldn't panic as this is a rare condition.

Incidents of swine flu in Northern Ireland are continuing to rise with a 124% increase in the number of people being admitted to hospital. This week, GP consultations increased by 46% and consultations with out-of-hours services were up 43%.

The department said there was also a "significant increase" in the number of antivirals prescribed.

Chief Medical Officer Dr Michael McBride said ECMO is a highly specialised treatment which is indicated for a very small number of people. "It involves taking over the function of the heart and lungs when they are severely damaged, adding oxygen to the blood outside the body," he added.

(hat tip flutrackers/pathfinder)

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indigo girl works as a visiting nurse.

28,143 Visitors; 5,172 Posts

Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome

Summary of Study Findings

We identified all patients who received ECMO for severe ARDS during the 2009 influenza A(H1N1) winter pandemic in Australia and New Zealand. Although there are almost 200 ICUs across these 2 countries, all ECMO was provided at just 15 specialist centers. Within these centers, the burden was substantial, as highlighted by the provision of a large number of total days of ECMO support and the use of ECMO support in approximately one-third of all cases requiring mechanical ventilation at these centers. Affected patients were often young adults, pregnant or postpartum, obese, had severe respiratory failure before ECMO, and received prolonged mechanical ventilation and ECMO support. Children and elderly persons were infrequently treated with ECMO. The majority of patients underwent retrieval to a specialist center for ECMO. Despite the disease severity and the intensity of treatment, the mortality rate was low.

Comparison With Previous Studies

To our knowledge, this is the first multicenter study on the use of ECMO for 2009 influenza A(H1N1)-associated ARDS. Publications from an international ECMO registry12 and from centers experienced in the use of ECMO for ARDS of heterogeneous etiology have reported mortality rates between 30% and 48%.13-15 Although our patients had a mortality rate of 21% (95% CI, 11%-30%), several patients remained in the ICU at the time of reporting.

Several factors may have contributed to the observed mortality rate. First, our patients were young and had ARDS secondary to viral pneumonia, which when managed with ECMO has been associated with higher survival rates than other causes of ARDS.12-14 Second, improvements in ECMO technology (eg, heparin-bonded cannulae, rotary pumps, and small efficient long-lasting oxygenators) and staff training have occurred since previous publications, leading to safer and more effective ECMO application. All of the patients fulfilled the ARDS severity criteria for enrollment in a recently reported randomized controlled trial (the CESAR study16) of ECMO treatment.

Implications for Policy Makers and Clinicians

Our findings have implications for health care planning and the clinical management of patients with 2009 influenza A(H1N1) during the 2009-2010 northern hemisphere winter. Our results indicate that the incidence of ARDS sufficient to warrant consideration of ECMO, based on the criteria used for the CESAR study,16 exceeds 2.6 per million inhabitants. Given the outcomes reported in the CESAR study and in our study, other clinicians may also choose to treat these patients with ECMO. Approximately 15% of our patients were pregnant or postpartum, the largest case series of such patients in the literature.17-18 Most of these patients survived.

Despite the additional disease burden, ECMO capacity was never exceeded; however, information on the resource utilization should facilitate planning in the northern hemisphere. With a similar incidence of ECMO use for 2009 influenza A(H1N1)-associated ARDS, rough estimates are that the United States and the European Union might expect to provide ECMO to approximately 800 and 1300 patients during the 2009-2010 winter, respectively.

Study Strengths and Limitations

Our study is the first to report, to our knowledge, the ECMO experience for 2009 influenza A(H1N1)-related ARDS using a population-based method in 2 developed countries, with well-established and nationally coordinated critical care systems. To our knowledge, this is the complete experience of ECMO in our region during winter. We report important aspects of the epidemiology, disease burden, and resource utilization for ECMO. We confirm previous findings of severe respiratory failure in a subset of patients with 2009 influenza A(H1N1),3 and also demonstrate that most patients survived.

Our study has the inherent limitations of a case series. To improve accuracy, we used systematic methods of data collection, such as a case report form, trained research coordinators, predefined data field definitions, and a prospectively constructed data analysis plan. Although only 78% of patients tested positive for 2009 influenza A(H1N1), the remainder had confirmed influenza A during an outbreak in which the dominant strain of laboratory-confirmed influenza A has been 2009 influenza A(H1N1)19 or had features of a preceding influenzalike illness complicated by pneumonia. In addition, their clinical characteristics were similar to those with confirmed 2009 influenza A(H1N1). As the diagnostic sensitivity of microbiological tests for 2009 influenza A(H1N1) is unknown, many of these patients are likely to have been infected with the virus.

We are unable to report on the possible outcome of our patients if ECMO had not been used, because allocation to receive ECMO was not conducted in the context of a randomized controlled trial. In our study, approximately 30% of patients who were mechanically ventilated with 2009 influenza A(H1N1) were treated with ECMO. This compares to an ECMO treatment rate for patients who were mechanically ventilated with 2009 influenza A(H1N1) of only 10% from all ICUs in 1 Australian state.20 Of the 187 ICUs in Australia and New Zealand, only 15 provided ECMO services; however, these centers were often referred patients with severe respiratory failure despite advanced mechanical ventilatory support through semiformal referral networks.

Of the approximately 4950 patients requiring hospitalization for 2009 influenza A(H1N1) in Australia and New Zealand as of September 7, 2009 (4561 in Australia21 and approximately 400 in New Zealand based on a similar proportion of confirmed cases22), the ICUs at the 15 ECMO centers received 252 patients, 68 of whom received ECMO. Of the 252 patients, 31 died, representing 17% of all 2009 influenza A(H1N1) deaths in Australia21 and New Zealand.22

With the requirement to inform the northern hemisphere for the upcoming winter, we censored our data collection on September 7, 2009. Accordingly, final hospital outcomes were not available for some patients. However, death after weaning from ECMO or following ICU discharge was uncommon. In addition, we are unable to comment on the long-term outcome of our patients, particularly in relation to the degree of pulmonary dysfunction and quality of life. Finally, our estimates of ECMO use may be affected by changes in virulence of the virus or the development and deployment of an effective and safe vaccine.

CONCLUSION

In Australia and New Zealand, during the 2009 influenza A(H1N1) winter pandemic, there was a large increase in the use of ECMO for ARDS in patients compared with the winter of 2008. Despite their illness severity and the prolonged use of life support, most of these patients survived. This information should facilitate health care planning and clinical management for these complex patients during the ongoing pandemic.

The entire free access JAMA study available here: http://jama.ama-assn.org/cgi/content/full/2009.1535

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

16 Articles; 71,072 Visitors; 7,339 Posts

Good information to know; thanks indigo. I just completed my first preceptored pump shift today (not for H1N1 though) and hope we've managed to get ahead of the wave. Our training course included 12 RTs and 9 RNs, 4 PICU fellows, 2 perfusionists from our adult service and 8 guests (physician/nurse/perfusionist) from other cities. It was the largest group they've ever trained all at once. What no one has had the guts to tell us yet is that we're going to be providing most of the ECLS support for the whole province... peds and adult. It could be a very interesting winter.

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indigo girl works as a visiting nurse.

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Good information to know; thanks indigo. I just completed my first preceptored pump shift today (not for H1N1 though) and hope we've managed to get ahead of the wave. Our training course included 12 RTs and 9 RNs, 4 PICU fellows, 2 perfusionists from our adult service and 8 guests (physician/nurse/perfusionist) from other cities. It was the largest group they've ever trained all at once. What no one has had the guts to tell us yet is that we're going to be providing most of the ECLS support for the whole province... peds and adult. It could be a very interesting winter.

Kudos to all of you, janfrn!

I think that you are right, it will be a very interesting winter...I suspect that your advanced training and skills will be put to good use.

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indigo girl works as a visiting nurse.

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Monmouthshire, Wales

http://www.walesonline.co.uk/news/wales-news/2009/10/14/two-more-swine-flu-deaths-in-wales-confirmed-91466-24932335/

...a 21-year-old pregnant woman, from Monmouthshire, died just two weeks after her baby was born by Caesarean section.

She had been transferred to Glenfield Hospital, in Leicester, for ECMO treatment, but she died on October 9.

(hat tip pfi/monotreme)

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indigo girl works as a visiting nurse.

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Collingswood, New Jersey

http://kdka.com/health/karin.mchugh.h1n1.2.1247906.html

She was nine months pregnant, developed flu like symptoms and had trouble breathing. The baby was delivered in an emergency c-section. He was fine and weighed six pounds, 10 ounces. Then McHugh started crashing.

McHugh was flown from a small South Jersey hospital to the Hospital of the University of Pennsylvania. She had one of the worst cases of H1N1 swine flu doctors have seen. Her lungs were incapacitated, no oxygen, no life.

"Karin did die and was resuscitated and brought back, that happened twice in one night," Dr. Halpern said.

She was on a ventilator, drugs, and nothing was working. Karin McHugh's organs were shutting down. In desperation, the HUP team turned to heart lung bypass.

"It undoubtedly saved her life," Dr. Halpern said.

(hat tip oramar!)

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cactus wren works as a icu rn.

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update on the gal from Scotland.

A true miracle of modern, high-tech, medicine:

UK:

Swine flu woman gives birth to boy

(UKPA) - 14 minutes ago

http://www.google.com/hostednews/ukpress/article/ALeqM5hTIesyCDfG1hq3QcI94gZ1S4bgqg

A pregnant woman from North Ayrshire who was flown to Sweden for life-saving treatment after contracting swine flu has had a baby boy.

Sharon Pentleton, 27, feared for the health of her unborn child after she suffered an extreme reaction to the H1N1 virus.

But the baby, weighing 6lb 9oz, was successfully delivered by Caesarean section at an Ayrshire hospital on Wednesday.

According to reports, Ms Pentleton and her new son appear to be fit and well and nurses are happy with how they are doing.

Ms Pentleton was six months pregnant when she went to Crosshouse Hospital in Kilmarnock with severe back pain in July, where she was treated for appendicitis before being diagnosed with swine flu.

When she slipped into a coma, doctors decided she needed a rare treatment known as extracorporeal membrane oxygenation (ECMO), which circulates the patient's blood outside the body and adds oxygen to it artificially.

All of the UK's five ECMO beds, at the Glenfield Hospital in Leicester, were full, so she was flown to University Hospital in Stockholm for the treatment.

Ms Pentleton said she was anxious about giving birth to her son: "They told me there was nothing to worry about with him, because I was worrying about brain damage because everything that I've been through and the medication I've been on.

"But they say there's just a slight chance, they can't tell you 100%, but they say it's very unlikely that he's been damaged in any way - which is a wee miracle."

Ms Pentleton and her family have since launched a campaign to raise money for Scotland's own dedicated adult ECMO unit.

_________________

Nice to read a bit of good news for a change.

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indigo girl works as a visiting nurse.

28,143 Visitors; 5,172 Posts

Why thank you cactus! Long time, no see!

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