Extracorporeal Membrane Oxygenation for ARDS Due to 2009 Influenza A(H1N1)

[tetano]

JAMA letter

To the Editor: Dr Davies and colleagues1 reported the use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) during the 2009 influenza A(H1N1) epidemic in Australia and New Zealand. Compared with the previous winter, the incidence of ECMO use was far greater in conjunction with H1N1 infections.

Only 20 patients (32%) were treated with inhaled nitric oxide before initiation of ECMO, although this therapy is considered an effective rescue treatment of refractory hypoxemia in acute lung injury.2 Moreover, it is not reported whether inhaled nitric oxide was continued on ECMO and what concentrations were used. In addition to providing selective pulmonary vasodilation, inhaled nitric oxide may be an effective topical anti-infective agent,3 with activity against the replication of influenza viruses in vitro.4 During the severe acute respiratory syndrome (SARS) epidemic, an antiviral effect on the SARS coronavirus was reported.5 It remains to be determined whether inhaled . . . [Full Text of this Article]

Sven Laudi, MD; Thilo Busch, PhD; Udo Kaisers, MD, PhD
udo.kaisers@medizin.uni-leipzig.de
Department of Anesthesiology and Intensive Care Medicine
University of Leipzig Medical Faculty
Leipzig, Germany

http://jama.ama-assn.org/cgi/content/extract/303/10/941

[kiwibird]

Re: Extracorporeal Membrane Oxygenation for ARDS Due to 2009 Influenza A(H1N1)

Another article with a little more information:

snip...Three children younger than 15 received ECMO. None of the patients was older than 65.

The most common comorbidities were obesity in 50%, asthma in 28%, and diabetes in 15%.

Nearly one in 10 was pregnant.

More than a quarter (28%) were coinfected with a bacterium, most commonly Streptococcus pneumoniae in 10 and Staphylococcus aureus in four.

Before doctors initiated ECMO, about two-thirds (68%) of patients received vasoactive drugs and 24% received renal replacement therapy.

Almost all of the patients (94%) received oseltamivir (Tamiflu) for a median duration of eight days.

The median duration of ECMO was 10 days, and two patients were still receiving the treatment at the end of the study period.

Most patients (81%) received rescue therapies for acute respiratory distress syndrome, including recruitment maneuvers (67%), inhaled nitric oxide (32%), epoprostenol (22%), prone positioning (20%), and high-frequency oscillatory ventilation (5%).

Hemorrhagic complications were common, occurring in 54% of ECMO patients. The most common sources were ECMO cannulation sites (22%), the gastrointestinal tract (10%), and the respiratory tract (10%).

Infective complications occurred in 62% of patients, most commonly in the respiratory tract (44%) and bloodstream (21%).

As of Sept. 7, some 21% of patients who received ECMO had died. Of the survivors, 32 had been discharged from the hospital, 16 were still hospitalized but no longer in the ICU, and six remained in the ICU.

All three children treated with ECMO were still alive, although one was still in the ICU.

Among those who died, contributed causes were listed as intracranial hemorrhage in six, other hemorrhage in four, and intractable respiratory failure in four.

The authors acknowledged that the analysis was subject to the inherent limitations of a case series.

The study was also limited by the inability to report on the possible outcome if ECMO had not been used and on long-term outcomes.

http://www.medpagetoday.com/Infectio...RItheFlu/16381

[kiwibird]

Re: Extracorporeal Membrane Oxygenation for ARDS Due to 2009 Influenza A(H1N1)

HIGH CASE-FATALITY RATE IN MEXICO

Guillermo Dom?nguez-Cherit, MD, from the Instituto Nacional de Ciencias M?dicas y Nutrici?n Salvador Zubir?n, Mexico City, and colleagues conducted a retrospective study of critically ill patients with confirmed, probable, or suspected influenza A (H1N1) in Mexico admitted to one of six hospitals between March 24 and June 1, 2009. Mortality, H1N1-related critical illness, mechanical ventilation, and ICU and hospital lengths of stay were assessed.

Of 899 patients admitted to the hospital, 58 were critically ill. However, four patients died in the emergency department due to increased patient volumes and delayed admission to the ICU. Patients were young (median age, 44.0) and presented with fever; all but one had respiratory complaints such as cough, dyspnea, or wheeze. Altogether, the median number of comorbidities was two, with obesity being the most common (36.2%; mean BMI, 32). Two patients had a history of COPD.

Median time from symptom onset to hospitalization was six days and from hospitalization to ICU, one day. Ventilatory support was provided to 54 patients for severe ARDS and refractory hypoxemia. Sixty-day mortality was 41.4%. ?Most (19) patients died within the first two weeks after becoming critically ill,? the investigators noted. Overall, mortality was associated with:

Higher APACHE II and Sequential Organ Failure Assessment (SOFA) scores
Lower arterial pressure at admission
Evidence of renal and hepatic organ injury
Lower ratio of Pao2 to Fio2
Higher set PEEP at admission to ICU.
No significant differences were seen in tidal volume or ventilation strategies between survivors and nonsurvivors, the study authors noted. Survivors were more likely to have been treated with neuraminidase inhibitors (odds ratio, 8.5).

?It is possible that the 2009 influenza A (H1N1) experience described here is somewhat unique to Mexico and may be related to a variety of factors, including climate, air quality, and altitude in Mexico City,? the investigators speculated, ?or, noting the long duration between illness onset and presentation to the hospital with severe disease, potential differences in timing of access or presentation of the population to acute care compared with other settings.? ...snip

http://www.pulmonaryreviews.com/09dec/C2.html

Further information about other country stats are within this article

[kiwibird]

Re: Extracorporeal Membrane Oxygenation for ARDS Due to 2009 Influenza A(H1N1)

Source: http://jama.ama-assn.org/cgi/content/extract/303/10/942
Extracorporeal Membrane Oxygenation for ARDS Due to 2009 Influenza A(H1N1)?Reply

Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.




In Reply: Dr Laudi and colleagues note that 32% of patients in our series received inhaled nitric oxide before commencing ECMO for 2009 influenza A(H1N1)?related ARDS. As a case series, management of patients followed clinical practice rather than standardized care, and we did not collect data on nitric oxide dosage or use once ECMO was initiated. One of the notable features of the pandemic was the widespread distribution of patients to intensive care units (ICUs) in Australia and New Zealand, with many admissions to community hospitals, few of which are likely to have nitric oxide available. The meta-analysis1 cited by Laudi et al concluded that "nitric oxide is associated with limited improvement in oxygenation in patients with [acute lung injury] or ARDS but confers no mortality benefit and may cause harm." We are unaware of data indicating that nitric oxide is better than other rescue therapies, such as recruitment maneuvers,

full article available here:http://jama.ama-assn.org/cgi/content/full/303/10/942

[JJackson]

Re: Extracorporeal Membrane Oxygenation for ARDS Due to 2009 Influenza A(H1N1)

If you have not already seen it this short (30 min) talk by Dr. Paul Forrest on Australian ECMO/H1N1(2009) is well worth the time.

http://www.sfar2010.com/grippe/grippe.php?grippe=03-2_sfar1&PHPSESSID=996a5f3308b8b319ef0a7b32117bd7b2

I know it has been linked to before here but I could not find the original posting, but hat tip to whoever first found it.