Elsevier

Journal of Critical Care

Volume 27, Issue 5, October 2012, Pages 454-463
Journal of Critical Care

Infection/Respiratory
Portable miniaturized extracorporeal membrane oxygenation systems for H1N1-related severe acute respiratory distress syndrome: A case series

https://doi.org/10.1016/j.jcrc.2012.01.008Get rights and content

Abstract

Background

Technological advances improved the practice of “modern” extracorporeal membrane oxygenation (ECMO). In the present report, we describe the experience of a referral ECMO center using portable miniaturized ECMO systems for H1N1-related severe acute respiratory distress syndrome (ARDS).

Methods

An observational study of all patients with H1N1-associated ARDS treated with ECMO in Hospital S. João (Porto, Portugal) between November 2009 and April 2011 was performed. Extracorporeal membrane oxygenation support was established using either ELS or Cardiohelp systems (Maquet-Cardiopulmonary-AG, Hirrlingen, Germany).

Results

Ten adult patients with severe ARDS secondary to H1N1 infection (Pao2/fraction of inspired oxygen, 69 mm Hg [56-84]; Murray score, 3.5 [3.5-3.8]) were included, and 60% survived to hospital discharge. Five patients were uneventfully transferred on ECMO from referring hospitals to our center by ambulance. Six patients were treated during the first postpandemic influenza season. All patients were treated with oseltamivir, and 1 received in addition zanamivir. Four patients received corticosteroids. Nosocomial infection was the most common complication (40%). Of the 4 deaths, 2 were caused by hemorrhagic shock; 1, by irreversible multiple organ failure; and 1, by refractory septic shock.

Conclusion

In our experience, ECMO support was a valuable therapeutic option for H1N1-related severe ARDS. The use of portable miniaturized systems allowed urgent rescue of patients from referring hospitals and safe interhospital and intrahospital transport during ECMO support.

Introduction

Since the first outbreak of a respiratory illness caused by a novel swine-origin influenza A (H1N1) virus in Mexico during late March 2009 [1], several reports were published regarding the fact that it can sometimes lead to rapidly progressive acute respiratory distress syndrome (ARDS), with mortality rates ranging from 17% to 46% [2], [3], [4]. In some severe cases, ARDS “rescue therapies” were used in face of progressive refractory respiratory failure. Initial experience with extracorporeal membrane oxygenation (ECMO) for severe ARDS secondary to H1N1 infection during the pandemic was gathered in the 2009 southern hemisphere winter [5]. Extracorporeal membrane oxygenation was also used for respiratory support in H1N1 infection in North American and European ECMO centers during the 2009 northern hemisphere winter [6], [7], [8], [9], [10]. The favorable outcomes and low adverse event rates fostered the use of ECMO by other critical care centers.

Several technological advances significantly improved the practice of “modern” ECMO. Polymethylpentene oxygenators and centrifugal pumps show higher biocompatibility and durability compared with older silicon membrane oxygenators and roller pumps [11], [12]. This allows lower blood product consumption as well as reduced circuit component exchange, enhancing the safety profile of modern ECMO support [13]. Moreover, these technological advances were accompanied by a simplification of the circuitry as well as by the recent development of portable miniaturized systems. These novel systems expanded the use of emergent ECMO support as well as interhospital and intrahospital transportation of patients while on ECMO [14], [15], [16].

Despite these recent advances, there is no significant experience with the use of portable miniaturized systems in the management of patients with H1N1 infection. In the present article, we describe the experience of a referral ECMO center using portable miniaturized ECMO systems for H1N1-related severe ARDS.

Section snippets

Materials and methods

An observational study of patients with H1N1-related ARDS treated with ECMO in Hospital S. João (Porto, Portugal), an 1100-bed tertiary university hospital, was performed. The Hospital S. João ECMO Center is the sole ECMO referral center for the north of Portugal, a region with approximately 4 million inhabitants. It has a case volume of 20 to 30 patients per year, being an Extracorporeal Life Support Organization (ELSO) member. Specific ECMO data were prospectively collected from a dedicated

Characteristics of patients with H1N1 requiring ECMO

During the H1N1 pandemic and the first postpandemic influenza season, 283 patients were directly admitted to Hospital S. João with confirmed H1N1 infection (Fig. 1; Table 1, Table 2). Of note, a significant number of cases were admitted to Hospital S. João independently of disease severity, within the national contingency strategy of case isolation in the beginning of the pandemic phase. Of these, 51 patients were admitted to ICU for severe respiratory failure, of which 6 were referred for

Discussion

In our experience, ECMO support was a valuable therapeutic option for H1N1-related severe ARDS. The use of portable miniaturized systems allowed urgent rescue of patients from referring hospitals and safe interhospital and intrahospital transport during ECMO support.

Four types of respiratory presentations were described in patients with H1N1 infection requiring ICU admission: (1) viral pneumonitis, (2) secondary bacterial pneumonia, (3) exacerbations of asthma or chronic obstructive pulmonary

Acknowledgments

The authors are grateful to all the medical and nursing staffing from the Department of Intensive Care Medicine of Hospital de S. João and from the Intensive Care Unit of the Department of Infectious Diseases of Hospital de S. João. The authors also want to thank Hospital de Santo António (Porto), Centro Hospitalar de Coimbra (Hospital Geral de Coimbra - Covões), Centro Hospitalar Trás-os-Montes e Alto Douro (unidade hospitalar de Vila Real), Centro Hospitalar do Nordeste (unidade hospitalar de

References (39)

  • A. Davies et al.

    Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome

    JAMA

    (2009)
  • D.A. Turner et al.

    Extracorporeal membrane oxygenation for severe refractory respiratory failure secondary to 2009 H1N1 influenza A

    Respir Care

    (2011)
  • N. Patroniti et al.

    The Italian ECMO network experience during the 2009 influenza A (H1N1) pandemic: preparation for severe respiratory emergency outbreaks

    Intensive Care Med

    (2011)
  • B. Holzgraefe et al.

    Extracorporeal membrane oxygenation for pandemic H1N1 2009 respiratory failure

    Minerva Anestesiol

    (2010)
  • A. Roch et al.

    Extracorporeal membrane oxygenation for severe influenza A (H1N1) acute respiratory distress syndrome: a prospective observational comparative study

    Intensive Care Med

    (2010)
  • M.A. Noah et al.

    Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A (H1N1)

    JAMA

    (2011)
  • E. Khoshbin et al.

    Poly-methyl pentene oxygenators have improved gas exchange capability and reduced transfusion requirements in adult extracorporeal membrane oxygenation

    ASAIO J

    (2005)
  • B.E. Steinbrueckner et al.

    Centrifugal and roller pumps—are there differences in coagulation and fibrinolysis during and after cardiopulmonary bypass?

    Heart Vessels

    (1995)
  • A. Haneya et al.

    Comparison of two different minimized extracorporeal circulation systems: hematological effects after coronary surgery

    ASAIO J

    (2009)
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