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H1N1: The Aftermath Dr Brian Cook Clinical Director, Critical Care, NHS Lothian Chairman, Scottish Intensive Care Society Audit Group.

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Presentation on theme: "H1N1: The Aftermath Dr Brian Cook Clinical Director, Critical Care, NHS Lothian Chairman, Scottish Intensive Care Society Audit Group."— Presentation transcript:

1 H1N1: The Aftermath Dr Brian Cook Clinical Director, Critical Care, NHS Lothian Chairman, Scottish Intensive Care Society Audit Group

2 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 First US death ?159 deaths in Mexico

3 H1N1: Why all the fuss?? Seasonal Flu: H2N2, H3N ,000 deaths/yr Sporadic cases: 1997, 2003 onward: H5N1 2009: Rapidly spread H1N1 with fatalities

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5 NHS Initial Responses

6 Initial Organisational Problems Multiple well meaning sources of guidance Isolation rooms H1N1 Testing frequency/timescale PPE masks –Availability –Fitting –Staff groups

7 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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10 BaselineScenario AScenario B Scenario C GP Consultations 50,063+5,500+7,650+23,400 Emergency Admissions 1, ,050+3,400 ITU Cases Deaths ,100 Beds ,914+3,262 Predictions:Peak Week (9 th November)

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13 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

14 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???

15 Triaged ICU Christian M et al. CMAJ 2006 Taylor B et al. JICS 2006

16 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 care during an influenza pandemic. CMAJ November 21, (11) |

17 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

18 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.

19 SwiFT recruitment by week – Scotland

20 The ANZIC Influenza Investigators NEJM 2009; ICU cases per million population ANZICS 28.7 per million (June to Aug 09)

21 SwiFT case flow - Scotland H1N1 124 Confirmed 30 Non-H1N1 0 0 Suspected 94 Tested Negative 52 Suspected 12 Confirmed 30 Confirmed 60 Total casesInitial assessmentDuring critical careFinal +=

22 H1N1 Patients in ICU Clinical Presentations

23 Reported presentation Viral Bacterial Airflow Intercurrent Missing Viral Bacterial Airflow Intercurrent Missing Viral Bacterial Airflow Intercurrent Missing

24 Age Mean

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

26 Pregnancy Currently Not Missing Not

27 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.

28 ECMO: The CESAR Trial Lancet 2009; 374: Online publication Sept 09 Study July 01- Aug patients randomised Transfer to Glenfield for consideration for ECMO V Best Conventional Management at Referral Centre (no protocol)

29 ECMO: The CESAR Trial Lancet 2009; 374: Composite outcome death or severe disability at 6 months: ECMO 37% Conventional Treatment53%p=0.03

30 ECMO: The CESAR Trial Lancet 2009; 374: Group 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

31 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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34 ECMO for H1N1 in Scotland May 09-Mar 10 ICU Total H1N1136 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

35 ECMO Centres Treating Scottish Patients with H1N1 May 09-Mar 10 ReferralsAccepted Glenfield159 Aberdeen66 Karolinska11 Other11

36 ECMO Centres Treating Scottish Patients with H1N1 May 09-Mar 10 AcceptedGot ECMOSurvived ICUHospital Glenfield9677 Aberdeen6555 Karolinska1111 Other1000

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38 H1N1 Workload ANZICS 64% IPPV Median = 7days

39 Duration of critical care Median

40 Organ support: adv. respiratory YesNo

41 Organ support: renal YesNo

42 H1N1 Outcome 4 patients still in hospital ANZICS hospital mortality 17% but 16% still in hospital

43 Survival status at end of critical care Dead Alive

44 H1N1 Aftermath ICU/Critical Care Profile Equipment/Resources Future disasters and pandemics “UK response to H1N1 pandemic was highly satisfactory, independent review says” BMJ 2010;340:c3569 The review, by Deirdrie Hine, a former chief medical officer for Wales, says that preparations, including stockpiling drugs and plans to buy up to 132 million doses of vaccine, were "soundly based in terms of value for money, reflecting the inherently low cost of vaccination in relation to the value of lives saved….. changes need to be made to ensure that critical care services can cope with a more severe pandemic should it occur. “

45 Thank you


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