Could be a pretty brutal flu season

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It wasn't even a particularly nasty bug in Australia, it was just a hippy granola-crunching utopia come true with effectively nobody vaccinated (since the vaccine didn't work).

On the other hand, rapid influenza tests were also just rolled out in many regional centres so I wonder if this epidemic might also represent an increase in the detection rate vs the infection rate. Hard to tell.

Subjectively, it felt pretty brutal. My hospital had a fair few ECMO retrievals.
 
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Lots of proning and paralysis. I think there are too many people who end up on ECMO with all its complications whom we don’t treat aggressively per ARDS net early. In my fellowship we would keep these ALI pts on bipap at times or intubate without paying attention to TV , paralysis or proning. Instead of all these manoevures we would call our CTICU guys and then pt would go on ECMO and one time had a thromboembolic stroke along with a lot of vent associated lung injury some of which would be irreversible.
Now I work in a midsize community hospital and while we have proning/paralysis we have to transfer to the mothership for ECMO. And it’s hard to tx to the mothership. Now I am very cautious / aggressive with pts who I sense have ALI and may become ARDS. I almost never use bipap or high flow but tube early and am aggressive with the roc in 1st 48 hrs. Heavy sedation / paralysis / don’t let any ventilator synchrony in 1st 48 hrs. Our nurses prone on pillows but I move to that quickly if pAFi02 < 100 persistently. Severe lung injury occurs early and you have to be aggressive with low TV at that time.
Result : I have’nt had to tx anyone for ECMO to the mothership for nearly 2 years.
 
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Nephro critical care said:
Lots of proning and paralysis. I think there are too many people who end up on ECMO with all its complications whom we don’t treat aggressively per ARDS net early. In my fellowship we would keep these ALI pts on bipap at times or intubate without paying attention to TV , paralysis or proning. Instead of all these manoevures we would call our CTICU guys and then pt would go on ECMO and one time had a thromboembolic stroke along with a lot of vent associated lung injury some of which would be irreversible.
Now I work in a midsize community hospital and while we have proning/paralysis we have to transfer to the mothership for ECMO. And it’s hard to tx to the mothership. Now I am very cautious / aggressive with pts who I sense have ALI and may become ARDS. I almost never use bipap or high flow but tube early and am aggressive with the roc in 1st 48 hrs. Heavy sedation / paralysis / don’t let any ventilator synchrony in 1st 48 hrs. Our nurses prone on pillows but I move to that quickly if pAFi02 < 100 persistently. Severe lung injury occurs early and you have to be aggressive with low TV at that time.
Result : I have’nt had to tx anyone for ECMO to the mothership for nearly 2 years.
Click to expand...

Ehhh...VV ECMO is pretty benign. If you’re seeing CVA, it means your on VA so by definition you’re dealing with a sicker patient population/more than simply ARDS.
 
TimesNewRoman said:
Ehhh...VV ECMO is pretty benign. If you’re seeing CVA, it means your on VA so by definition you’re dealing with a sicker patient population/more than simply ARDS.
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This event happened 3-4 years ago so I don’t remember the exact circumstances. But I feel I could have done a better job with paralysis / low TV / proning in this case. The patient was pretty dyschronous with vent in 1st 48 hrs. I was just a first year fellow at that time.
I do not remember if and how she got on VA ecmo.
 
TimesNewRoman said:
Ehhh...VV ECMO is pretty benign. If you’re seeing CVA, it means your on VA so by definition you’re dealing with a sicker patient population/more than simply ARDS.
Click to expand...

You can still get CVA with VV ecmo running all the heparin you need gif the circuit. And unless you get some weird associated cardiomyopathy VA ecmo is never the right answer in bad flu ARDS. In fact the cardiac output will work cross purposes with the VA if all that is wrong is the lungs.
 
jdh71 said:
You can still get CVA with VV ecmo running all the heparin you need gif the circuit. And unless you get some weird associated cardiomyopathy VA ecmo is never the right answer in bad flu ARDS. In fact the cardiac output will work cross purposes with the VA if all that is wrong is the lungs.
Click to expand...

Sure, if you have a PFO or are just plain unlucky, but you can’t blame VV for thromboembolic strokes on a routine basis.
 
jdh71 said:
You can blame VV for the kind of CVA that is a brain bleed . . .

How much experience do you have with ECMO?
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Sure. But no more than anyone else you anticoagulaye, and you canalways run them off anticoagulation if you’re horribly concerned. And I have much more experience than I’d like.
 
jdh71 said:
You can blame VV for the kind of CVA that is a brain bleed . . .

How much experience do you have with ECMO?
Click to expand...

Plus, the above comment referred explicitly to thromboembolic strokes.
 
TimesNewRoman said:
Sure. But no more than anyone else you anticoagulaye, and you canalways run them off anticoagulation if you’re horribly concerned. And I have much more experience than I’d like.
Click to expand...

You would be incorrect about CVA risk.

And running a vulnerable patient relying on the oxygenation provided by your circuit off of heparin is . . . Interesting.
 
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jdh71 said:
You would be incorrect about CVA risk.

And running a vulnerable patient relying on the oxygenation provided by your circuit off of heparin is . . . Interesting.
Click to expand...

Plenty of people do it from time to time. The cannulas are (all?) heparin bonded now a days anyways.
 
jdh71 said:
You would be incorrect about CVA risk.

And running a vulnerable patient relying on the oxygenation provided by your circuit off of heparin is . . . Interesting.
Click to expand...

There are even people using VA ecmo for trauma (a couple case series, etc) where I can’t imagine people are running a circuit with a normal goal PTT.

It’s not as crazy as you think it is. I’ve run VA off anticoag for short periods of time depending on the scenario.
 
TimesNewRoman said:
There are even people using VA ecmo for trauma (a couple case series, etc) where I can’t imagine people are running a circuit with a normal goal PTT.

It’s not as crazy as you think it is. I’ve run VA off anticoag for short periods of time depending on the scenario.
Click to expand...

Sometimes you do what you think you have to do. Those outlier situations while interesting and informative are not indicative of standard practice.
 
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