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 Strangely enough, this was the link for a different article on the same case a day ago, but has since been replaced by this latest article.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

Well, I went back to work last night... and the patient I had on ECMO is doing about the same.

We also have another v-v ECMO going on an old heart tx patient in his 50s for H1N1. 5 of our 12 beds are occupied with H1N1 patients on vents... and that's just the CVICU.

Specializes in NICU, PICU, PCVICU and peds oncology.

That's not unusual for respiratory ECLS, the course is usually longer than for cardiac reasons. I know our unit is as prepared as we can be. Hopefully the 21 of us who were recently trained will be able to finish our supervised practicum before the surge! And as the beds fill with flu kids,it may end up that we isolate the non-flu patients in the same way we did the last bad RSV outbreak, putting all the flu kids out in the main unit and the non-flus in the iso rooms. Of course once we get to that point, our elective cardiac and neurosurgical cases will be postponed ...

Those two kids I mentioned in my last post have caused quite a flap. All the staff who have had face-to-face contact are on the OH&S hit list and are being monitored for symptoms. That would be a lot of people since one of them has a dressing that's a 3 person job... never the SAME 3 people.

Specializes in Too many to list.

http://news.stv.tv/scotland/north/133508-swine-flu-victims-receive-life-saving-treatment-in-scotland/

A video about the availablity of ECMO in Scotland:

Two swine flu victims have been given life-saving treatment at a hospital in Scotland for the first time, MSPs heard today.

Health Secretary Nicola Sturgeon said the Aberdeen Royal Infirmary was the only Scottish hospital which had adult ECMO machines and staff trained in their use.

Previously, Scotland had ECMO equipment for adults in Aberdeen but no staff trained in their use and Scottish patients needing this treatment were send to Leicester.

(hat tip pfi/pixie)

Specializes in NICU, PICU, PCVICU and peds oncology.

I was speaking with a coworker Monday night about this topic. He moved to Canada from the UK in 2002. He takes a dim view of the capacity for ECMO in Leicester, indicating that their program is not particularly stellar.

What catches my attention is that before these two cases in Aberdeen, the UK had FIVE potential ECMO beds for a population three times that of Canada. We could, on our unit, in a pinch, run five ECMOs and we're only one of seven centres in the country with active ECMO capability.

Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
We got our first patient on ECMO for H1N1 (probable) related ARDS last night. I'll give you guys some background info:

Patient is in his early 20s. No significant PMH except for some slight MR and what mom called "developmental delays." Patient does not have any known chronic medical conditions, and all anatomical structures are normal. Patient presented at outside facility with flu-like symptoms (sore throat, cough, diarrhea, etc) and admitted to said outside facility.

The patient rapidly deteriorated at the outside facility and was life flighted to us, intubated en route, and progressed into ARDS. Patient had started with normal vent settings and then ended up on 100% FiO2 and 20 of PEEP, with sats in the low 80s. ECMO was initiated within a day of him being transferred to us. Patient was cannulated in the room, so I do not believe that he had an extreme period of hypoxemia after normal interventions had failed.

Tamiflu was started immediately upon admission at our hospital (not sure what the other hospital had done). Patient is also being covered on broad spectrum abx, including vanco. So far all blood and sputum cultures are negative. The patient has had two H1N1 neg rapid influenza tests at the previous hospital, and one at ours. The PCR test was not performed due to the likelihood that he has H1N1, and the fact that the turn around time on PCR tests at our facility is a couple of days. It would not change the way we are treating him anyway.

It is interesting to note that the patient had been placed on a propofol drip. I noticed that the patient had been becoming bradycardic during the night. I couldn't think of a good reason for the bradycardia, and I was thinking of possible propofol infusion sydrome, even though the patient had not been on the gtt very long. We did start the patient on some low-dose dopamine, but the heart rate did not really seem to respond to it.

Our hospital does baseline daily CKs, lactic acids, and triglyceride levels to detect early PRIS. Well, guess what? The patient's CK (initially elevated due to probable myocarditis) went from 600-something yesterday, to 1500-something this morning. In addition to that, his triglycerides went from a baseline of 100-something to 588 this morning! Yikes! We couldn't get the propofol shut off quickly enough!

Overall, this patient looks worse this morning than yesterday. His chest x-ray is more whited out, and to top things off, he had a 10 second new-onset seizure right before change of shift. His blood gasses have obviously improved, but other things are going wrong now. His Cr was hovering around 3 this morning. It will be interesting to see if he has progressed at all when I return to work on Tuesday night.

I will keep you updated... oh, and if anyone thinks that I have too much patient information on here, and that I should edit the post, please let me know. I'm just trying to get the word out about what's going on in my unit.

Our perfusionists have been following what's going on in countries like New Zealand, and they state they have been prepping for an onslaught of ARDS patients.

Kudos to Indigo Girl for keeping this thread going!

Did you all paralyze him?

Use Midazolam instead?

Why did they go straight to ECMO without trying him on Jet ventilation first? Was his ARDS that bad? If it were, why wasn't he paralyzed and not just sedated?

\

Specializes in NICU, PICU, PCVICU and peds oncology.

Enough of our ARDS patients are still not adequately ventilated after sedation and paralysis that they need HFOV (we don't use HFJV) or progress to ECMO.

Specializes in CVICU.
Did you all paralyze him?

Use Midazolam instead?

Why did they go straight to ECMO without trying him on Jet ventilation first? Was his ARDS that bad? If it were, why wasn't he paralyzed and not just sedated?

\

Yes, he was immediately switched to Versed. We did paralyze him on Monday (he's still on the paralytics). He is doing a little better today. We are slowly seeing improvements in his Cr.

We rarely use oscillators at my facility.

They did end up running a PCR test and he is confirmed H1N1+

Specializes in NICU, PICU, PCVICU and peds oncology.

We've stepped into the ring as of Thursday. We have a preschooler with pre-existing issues on ECLS but this child has not moved or responded to anything pretty much since admission. CT head shows a large bleed that is visible on more than half the slices and many small infarcted areas, but a perfusion scan doesn't support brain death. There's fulminant DIC in both patient and circuit... not a hopeful picture at all.

So glad this thread is still going! I had to post a note about the physician in Sweden who commented on ECMO patients "feeling pretty good on ECMO". I thought it was funny, too. Then I had the chance to meet up with some representatives of the Karolinska Institute program at the 20th anniversary ELSO conference in Ann Arbor, Michigan. They were presenting on update on analgesia and sedation in ECMO patients. Granted the majority of their adult patients are chemically paralyzed and sedated at the time of cannulation to minimize oxygen demand...but they begin to wean sedation after 24-48 hours and within 2 days the adult patients are fully awake and aware! They argue that ECMO is not inherently painful and paralytics/sedatives are unnecessary after adequate oxygen delivery is established. Pain medication is provided as needed but...

They brought pictures of adult patients on ECMO sitting up in bed eating popsicles, patients waving at the camera, even patients playing cards with their families! They say that the patients feel SO GOOD that it is not uncommon for them to ask to be taken off the machines so they can go home! Can you imagine? My program provides ECMO to primarily neo/pediatric patients, but we have ramped up our adult program in response to H1N1, and we are very much in demand. I don't think it is very practical for young peds cases (how do you explain to a 2 year old not to pull on the cannulas please?) but it is something to consider when working with older patients.

Specializes in Too many to list.

Littlestown, Pennsylvania

http://www.publicopiniononline.com/ci_13710810?source=most_viewed

Kyree, a student in Mrs. Erin Hahn's kindergarten class, died at Penn State Hershey Medical Center after a three-week

battle with swine flu, Shreve said. Kyree was taken to Gettysburg Hospital on Oct. 11 with a fever, was moved to Hershey

on the same day and tested for swine flu soon after, she said.

The boy went into respiratory arrest during his first night in the hospital and while he seemed to improve after several weeks of being connected to a heart-lung machine, he died on Saturday from pneumonia and hemorrhaging in his lungs, Shreve said. Kyree had no pre-existing health conditions, she said.

(hat tip flutrackers/BC)

Specializes in ECMO and CRRT.

We have had about 5 H1N1 pt's on ECMO this year, most last month. Now we have no one on ECMO (weird), but I'm assuming the next 'wave' will come. We'll see. The current issue is that we're a Children's Hospital and many of the super sick H1N1 patients are young adults. In the past, we did adult ECMO (in the PICU), but due to politics (and available PICU beds) we stopped a few years ago. That being said, we had 2 'adults' (early 20's) on last month. The other problem is that we only do 4 pt's simultaneously and we're the only center (other then a small neo center) in the state.

This leads to one of the current debates surrounding this flu, which is whether to transfer the adults to ECMO centers (even if they're children's hospitals), or send the patients to established adult ECMO centers (there aren't many in the US, and only 2-3 that cannulate, then transfer). This delima, combined with promising results of ECMO for H1N1 in Australia, has led many adult instututions to 'try ECMO' in some form or fashion. This scares me. I work at a high volume, well established ECMO center and I can't imagine just configuring a pump and throwing it on a patient, especially those that require long runs (many of our H1N1's have been on several weeks, even over 1 month). Many of these institutions are using perfusionists, which I'd imagine will cause a HUGE stress on perfusion staff if the US gets hit as hard as Australia with H1N1.

Wondering what everyone on here has seen? In general, are you seeing more or less H1N1 ICU patients now compared to late spring/early fall??

Specializes in Too many to list.
We have had about 5 H1N1 pt's on ECMO this year, most last month. Now we have no one on ECMO (weird), but I'm assuming the next 'wave' will come.

This is the only part of your post that I can speak to. I'll let the ECMO nurses answer the rest.

I have been reading that a third wave is expected in January. Now, considering that we definitely have a vaccine (shortfall which means that there will continue to be many susceptible hosts for this novel virus), this is likely.

I am afraid that your services will continue to be in demand.

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