So I was reading this
article from Australia detailing some very sick patients with H1N1 who were placed on ECMO.
Is anyone else trying this where they are? We had one 13 year old previously healthy girl die on ECMO with flu, but haven't had to resort to it otherwise this year. What about other modalities such as high frequency? I know this stuff is more common in peds, but wondered if it's making its way into the adult world with the pandemic. Do you think we will be more aggressive with ARDS type issues throughout this season?
Thoughts?
Here's a report from
Canada discussing the recent use of salvage therapies.
My $0.02:
At a major hospital (see profile for city), we've had quite a number of children placed on ECMO following H1N1. The rationale being severe respiratory distress. So far, we've followed about 6, 1 of whom passed away, 3 of whom recovered adequate respiratory function to be extubated and 2 of whom are still being monitored on ECMO.
The average duration on ECMO was 4.5 weeks, with ranges from 2 to 7 weeks. The patient who succumbed to his infection was on ECMO for 7 weeks. The cause of death was a combination of DIC and MultiOrgan System failure. His bleeding could not be controlled.
Overall, it seems to work for children requiring addition respiratory support with H1N1. Why some children have such catastrophic disease courses and others have milder remains very much a mystery. There has been no correlation between previous underlying respiratory dysfunction (CF, asthma) and disease severity. To the contrary, some of the children who eventually require ECMO were previously healthy, no PMH of any illness, certainly no respiratory illness or compromise prior. This was the case for the child we lost who was on ECMO x 7 weeks.
Occasionally some of these children progress to acquire a nosocomial MRSA superinfection that exacerbates the primary illness but even that did not seem to predict the severity of their respiratory compromise or disease. Some of these particular H1N1+MRSA PNA children actually did NOT require ECMO.
Is there an underlying genetic factor that underlies susceptibility to particularly malignant courses following H1N1 infection? Seems plausible at this point but can't find anything in the literature. Certainly seems to follow a certain demographic: younger, often previously healthy, often middle class.
Does ECMO independently affect disease course? I doubt it. But will probably need statistical analyses to definitively state (Mann Whitney U, Fischer's Exact) if this is the case.
Bottom line, if a patient has little to no respiratory function and sats keep dropping, ECMO is likely indicated.
Does is alter the disease course? Not likely
What risks may be involved? possible exacerbation of any coagulopathy
What if I decide not to use ECMO? the longer you delay the decision to commence, the more likely your patient is to suffer vital organ damage from poor oxygenation
Drawbacks for provider? Requires rigorous monitoring. Need q6hour thromboelastograms, heparin level monitoring, Antithrombin and platelet level monitoring and patient must be anticoagulated. May require Clinical Pathology consult as part of the team.
How do I know when to stop? When respiratory function improves
