【体外膜肺ECMO课件】-H1N1-The-Aftermath

H1N1:TheAftermathDrBrianCookClinicalDirector,CriticalCare,NHSLothianChairman,ScottishIntensiveCareSocietyAuditGroupH1N1:Howitallstarted21stApril2009:USAconfirms2casesof“SwineFlu”27thApril:First2UKcasesimportedfromMexico29thAprilFirstUSdeath?159deathsinMexicoH1N1:Whyallthefuss??SeasonalFlu:H2N2,H3N2250-500,000deaths/yrSporadiccases:1997,2003onward:H5N12009:RapidlyspreadH1N1withfatalitiesInitialOrganisationalProblemsMultiplewellmeaningsourcesofguidanceIsolationroomsH1N1Testingfrequency/timescalePPEmasksAvailabilityFittingStaffgroupsPandemicDeclaredbyWHO11/6/09NHS/GovernmentresponsesContainmenttoTreatmentPhaseHealthBoards-PandemicPlanningGroupsMultiplespecialtiesCliniciansandmanagersandexternalagenciesRegularmeetingsDoubleintensivecarecapacity

BaselineScenarioAScenarioBScenarioCGPConsultations50,063+5,500+7,650+23,400EmergencyAdmissions1,480+234+2,050+3,400ITUCases69+30+400+840Deaths145+170+250+2,100Beds2071+212+1,914+3,262Predictions: PeakWeek(9thNovember)

ICUPlanning:DoubleBedCapacityAssumptionsNon-essentialsurgerystoppedSpreadintotheatrerecoveryareasNon-ICUAnaesthetistsfreedupRobstafffromtheatres/recoveryRobanaestheticmachinesICUPlanningStaff:TraininginICUandothersEquipment:PPEConventionalVentilatorsOscillatorsHaemofiltersAtriskgroupsChildreninadultICU’s ?Pregnantwomen–obstetricresponsesinICU’sTriagedICUadmission/withdrawal???TriagedICUChristianMetal.CMAJ2006TaylorBetal.JICS2006TriagedICUPrioritisationforCriticalCareAdmissionbasedonSOFAscoreandClinicalOpinion

MichaelD.Christianetal.Developmentofatriageprotocolforcriticalcare

duringaninfluenzapandemic.CMAJ•November21,2006•175(11)|1377-1381ICUPlanning:ScotlandScottishCriticalCareDeliveryGroupICUCliniciansCollationofEscalationPlansCollectiveresponsesandmutualsupportEquipmentCapacitymanagementTriageresponsesScottishIntensiveCareSocietyAuditGroupBednumbers:TemporaryandEstablishedRapiddisseminationnetworktoallICU’sResearchliaison:SwIFTSwiFTinclusioncriteriaAllpatients(adultorpaediatric)whowereeither:H1N1swineinfluenza(suspectedorconfirmed)patientsreferredandassessedasrequiringcriticalcare;ornon-H1N1patientsreferredandassessedasrequiringcriticalcare(underusual/non-pandemiccircumstances)butnotadmittedtoacriticalcareunitinyourhospital.SwiFTrecruitmentbyweek–ScotlandTheANZICInfluenzaInvestigatorsNEJM2009;361

33.3ICUcasespermillionpopulationANZICS28.7permillion(JunetoAug09)www.sicsag.scot.nhs.ukSwiFTcaseflow-ScotlandH1N1124Confirmed30Non-H1N10Suspected94TestedNegative52Suspected12Confirmed30Confirmed60TotalcasesInitialassessmentDuringcriticalcareFinal+=H1N1PatientsinICUClinicalPresentationsReportedpresentationViralBacterialAirflowIntercurrentMissingViralBacterialAirflowIntercurrentMissingViralBacterialAirflowIntercurrentMissingAgeMean 42

54

57Bodycomposition(BMI)Bodycomposition(BMI)missingfor4patients(3.2%)%obese

33

10

14PregnancyCurrentlyNotMissingMissingNotNotECMOApregnantwomanwithswinefluisgettingthe"bestpossibletreatment“afterbeingflowntoSweden,accordingtotheScottishhealthsecretary.

NicolaSturgeonsaidshehadhadaveryrarereactiontotheH1N1virus.SharonPentleton,26,whoiscriticallyill,wastakentoCrosshouseHospital,inKilmarnock,lastweek,whereshehadbeenputonaventilator.ShewastransferredtoStockholmonThursdaybecausenobedswereavailableintheUKfortheproceduresheneeded.ECMO:TheCESARTrial

Lancet2009;374:1351-63

OnlinepublicationSept09StudyJuly01-Aug06180patientsrandomisedTransfertoGlenfieldforconsiderationforECMOVBestConventionalManagementatReferralCentre(noprotocol)ECMO:TheCESARTrial

Lancet2009;374:1351-63Compositeoutcomedeathorseveredisabilityat6months:ECMO 37%ConventionalTreatment 53% p=0.03ECMO:TheCESARTrial

Lancet2009;374:1351-63

GroupDifferencesandConfounders90“ECMO”patients5diedpreorintransit17didnothaveECMOECMOgroupsignificantlymorelikelytohave:LowvolumelowpressureventilationstrategyLongertimewithLPLVstrategySteroidsMARSIncompletefollowup3controlpatientsSetUpNewECMOCentre(s)??“…thereisinsufficientevidencetoprovidearecommendationforextracorporealmembraneoxygenationuseamongpatientswithrespiratoryfailureresultingfrominfluenza.However,cliniciansshouldconsiderextracorporealmembraneoxygenationwithinthecontextofothersalvagetherapiesforacuterespiratoryfailure.”(CritCareMed2010;38:1398–1404“…cliniciansathospitalsthatdonothaveanECMOprogram,itwouldbeadvisabletoestablishinstitutionalguidelinestoidentifyECMO-eligiblepatientsinatimelymannerandtoestablisharelationshipwithanECMOcapableinstitutiontofacilitatesafeinterhospitaltransport”.uk/Publications/2010/04/16151905/0ECMOforH1N1inScotlandMay09-Mar10ICUTotalH1N1 136ReferredforECMO 21 (15%)AcceptedforECMO 17DiedpriortoECMO 4GotECMO 12DiedonECMO 0SurvivedICU 13 (62%)SurvivedHospital 13ECMOCentresTreatingScottishPatientswithH1N1May09-Mar10 Referrals AcceptedGlenfield 15 9Aberdeen 6 6Karolinska 1 1Other 1 1ECMOCentresTreatingScottishPatientswithH1N1May09-Mar10

Accepted GotECMO Survived ICU HospitalGlenfield 9 6 7 7Aberdeen 6 5 5 5Karolinska 1 1 1 1Other 1 0 0 0H1N1Workloadwww.sicsag.scot.nhs.uk

ANZICS64%IPPVMedian=7daysDurationofcriticalcareMedian8.8

1.0

3.9Organsupport:adv.respiratoryYesNoOrgansupport:renalYesNoH1N1Outcome4patientsstillinhospitalANZICShospitalmortality17%but16%stillinhospitalSurvivalstatusatendofcriticalcareDeadDeadDeadAliveA