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H1N1: The Aftermath. Dr Brian Cook Clinical Director, Critical Care, NHS Lothian Chairman, Scottish Intensive Care Society Audit Group. H1N1: How it all started. 21 st April 2009: USA confirms 2 cases of “Swine Flu” 27 th April: First 2 UK cases imported from Mexico 29 th April

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H1n1 the aftermath l.jpg

H1N1: The Aftermath

Dr Brian Cook

Clinical Director, Critical Care, NHS Lothian

Chairman, Scottish Intensive Care Society Audit Group


H1n1 how it all started l.jpg
H1N1: How it all started

21st April 2009:

USA confirms 2 cases of “Swine Flu”

27th April:

First 2 UK cases imported from Mexico

29th April

First US death

?159 deaths in Mexico


H1n1 why all the fuss l.jpg
H1N1: Why all the fuss??

Seasonal Flu: H2N2, H3N2

250-500,000 deaths/yr

Sporadic cases:

1997, 2003 onward: H5N1

2009: Rapidly spread H1N1 with fatalities



Initial organisational problems l.jpg
Initial Organisational Problems

  • Multiple well meaning sources of guidance

  • Isolation rooms

  • H1N1 Testing frequency/timescale

  • PPE masks

    • Availability

    • Fitting

    • Staff groups


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Pandemic Declared by WHO 11/6/09

  • NHS/Government responses

  • Containment to Treatment Phase

  • Health Boards- Pandemic Planning Groups

    • Multiple specialties

    • Clinicians and managers and external agencies

    • Regular meetings

  • Double intensive care capacity


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Baseline

Scenario A

Scenario B

Scenario C

GP Consultations

50,063

+5,500

+7,650

+23,400

Emergency Admissions

1,480

+234

+2,050

+3,400

ITU Cases

69

+30

+400

+840

Deaths

145

+170

+250

+2,100

Beds

2071

+212

+1,914

+3,262

Predictions: Peak Week (9th November)


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ICU Planning: Double Bed Capacity

  • Assumptions

    • Non-essential surgery stopped

    • Spread into theatre recovery areas

    • Non-ICUAnaesthetists freed up

    • Rob staff from theatres/recovery

    • Rob anaesthetic machines


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ICU Planning

  • Staff: Training in ICU and others

  • Equipment:

    • PPE

    • Conventional Ventilators

    • Oscillators

    • Haemofilters

  • At risk groups

    • Children in adult ICU’s ?

    • Pregnant women – obstetric responses in ICU’s

  • Triaged ICU admission/withdrawal???


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Triaged ICU

Christian M et al. CMAJ 2006

Taylor B et al. JICS 2006


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Triaged ICU

  • Prioritisation for Critical Care Admission based on SOFA score and Clinical Opinion

  • Michael D. Christian et al. Development of a triage protocol for critical careduring an influenza pandemic. CMAJ • November 21, 2006 • 175(11) | 1377- 1381


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ICU Planning: Scotland

  • Scottish Critical Care Delivery Group

    • ICU Clinicians

    • Collation of Escalation Plans

    • Collective responses and mutual support

      • Equipment

      • Capacity management

      • Triage responses

  • Scottish Intensive Care Society Audit Group

    • Bed numbers: Temporary and Established

    • Rapid dissemination network to all ICU’s

    • Research liaison: SwIFT


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SwiFT inclusion criteria

  • All patients (adult or paediatric) who were either:

    • H1N1 swine influenza (suspected or confirmed) patients referred and assessed as requiring critical care; or

    • non-H1N1 patients referred and assessed as requiring critical care (under usual/ non-pandemic circumstances) but not admitted to a critical care unit in your hospital.



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33.3 ICU cases per million population

ANZICS 28.7 per million (June to Aug 09)

www.sicsag.scot.nhs.uk

The ANZIC Influenza Investigators NEJM 2009; 361


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Confirmed

Suspected

H1N1

Non-H1N1

Suspected

Tested Negative

Confirmed

Confirmed

30

30

12

60

94

0

124

52

SwiFT case flow - Scotland

Total cases

Initial assessment

During critical care

Final

+

=



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Reported presentation

Missing

Missing

Intercurrent

Missing

Viral

Viral

Viral

Intercurrent

Intercurrent

Airflow

Airflow

Airflow

Bacterial

Bacterial

Bacterial


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Age

Mean 425457


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Body composition (BMI)

% obese331014

Body composition (BMI) missing for 4 patients (3.2%)


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Pregnancy

Currently

Missing

Missing

Not

Not

Not


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ECMO

A pregnant woman with

swine flu is getting the

"best possible treatment“

after being flown to

Sweden, according to the

Scottish health secretary.

Nicola Sturgeon said she had

had a very rare reaction to the

H1N1 virus.

Sharon Pentleton, 26, who is

critically ill, was taken to

Crosshouse Hospital, in

Kilmarnock, last week, where

she had been put on a

ventilator.

She was transferred to

Stockholm on Thursday

because no beds were

available in the UK for the

procedure she needed.


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ECMO: The CESAR TrialLancet 2009; 374:1351-63

  • Online publication Sept 09

  • Study July 01- Aug 06

  • 180 patients randomised

  • Transfer to Glenfield for consideration for ECMO

    V

  • Best Conventional Management at Referral Centre

    (no protocol)


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ECMO: The CESAR TrialLancet 2009; 374:1351-63

Composite outcome death or severe disability at 6 months:

ECMO 37%

Conventional Treatment 53% p=0.03


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ECMO: The CESAR TrialLancet 2009; 374:1351-63Group Differences and Confounders

  • 90 “ECMO” patients

    • 5 died pre or in transit

    • 17 did not have ECMO

  • ECMO group significantly more likely to have:

    • Low volume low pressure ventilation strategy

    • Longer time with LPLV strategy

    • Steroids

    • MARS

  • Incomplete follow up 3 control patients


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Set Up New ECMO Centre(s)??

“…there is insufficient evidence to provide a recommendation for

extracorporeal membrane oxygenation use among patients with

respiratory failure resulting from influenza. However, clinicians

should consider extracorporeal membrane oxygenation within the

context of other salvage therapies for acute respiratory failure.”

(Crit Care Med 2010; 38:1398 –1404

“…clinicians at hospitals that do not have an ECMO program, it would

be advisable to establish institutional guidelines to identify

ECMO-eligible patients in a timely manner and to establish a

relationship with an ECMO capable institution to facilitate safe

interhospital transport”



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ECMO for H1N1 in Scotland May 09-Mar 10

  • ICU Total H1N1 136

  • Referred for ECMO 21 (15%)

  • Accepted for ECMO 17

  • Died prior to ECMO 4

  • Got ECMO 12

  • Died on ECMO 0

  • Survived ICU 13 (62%)

  • Survived Hospital 13


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ECMO Centres Treating Scottish Patients with H1N1 May 09-Mar 10

Referrals Accepted

Glenfield 15 9

Aberdeen 6 6

Karolinska 1 1

Other 1 1


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ECMO Centres Treating Scottish Patients with H1N1 May 09-Mar 10

Accepted Got ECMO Survived

ICU Hospital

Glenfield 9 6 7 7

Aberdeen 6 5 5 5

Karolinska 1 1 1 1

Other 1 0 0 0


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H1N1 Workload 10

ANZICS

64%

IPPV

Median =

7days

www.sicsag.scot.nhs.uk


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Duration of critical care 10

Median 8.81.03.9




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H1N1 Outcome 10

  • 4 patients still in hospital

  • ANZICS hospital mortality 17% but 16% still in hospital


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Survival status at end of critical care 10

Dead

Dead

Dead

Alive

Alive

Alive


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H1N1 Aftermath 10

“UK response to H1N1 pandemic was highly satisfactory, independent review says”

BMJ 2010;340:c3569

The review, by Deirdrie Hine, a former chief medical officerfor Wales, says that preparations, including stockpiling drugsand plans to buy up to 132 million doses of vaccine, were "soundlybased in terms of value for money, reflecting the inherentlylow cost of vaccination in relation to the value of lives saved….. changes need to be madeto ensure that critical care services can cope with a more severepandemic should it occur.“

  • ICU/Critical Care Profile

  • Equipment/Resources

  • Future disasters and pandemics


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Thank you 10

www.sicsag.nhs.scot.uk


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