The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks
- 1.7k Downloads
In view of the expected 2009 influenza A(H1N1) pandemic, the Italian Health Authorities set up a national referral network of selected intensive care units (ICU) able to provide advanced respiratory care up to extracorporeal membrane oxygenation (ECMO) for patients with acute respiratory distress syndrome (ARDS). We describe the organization and results of the network, known as ECMOnet.
The network consisted of 14 ICUs with ECMO capability and a national call center. The network was set up to centralize all severe patients to the ECMOnet centers assuring safe transfer. An ad hoc committee defined criteria for both patient transfer and ECMO institutions.
Between August 2009 and March 2010, 153 critically ill patients (53% referred from other hospitals) were admitted to the ECMOnet ICU with suspected H1N1. Sixty patients (48 of the referred patients, 49 with confirmed H1N1 diagnosis) received ECMO according to ECMOnet criteria. All referred patients were successfully transferred to the ECMOnet centers; 28 were transferred while on ECMO. Survival to hospital discharge in patients receiving ECMO was 68%. Survival of patients receiving ECMO within 7 days from the onset of mechanical ventilation was 77%. The length of mechanical ventilation prior to ECMO was an independent predictor of mortality.
A network organization based on preemptive patient centralization allowed a high survival rate and provided effective and safe referral of patients with severe H1N1-suspected ARDS.
KeywordsViral infection Extracorporeal membrane oxygenation Preparedness plan ARDS
We thank Minister of Health Prof. Antonio Fazio and the Ministry of Health who funded the entire network organization. We thank Maria Grazia Pompa (Department of Malattie Infettive e Profilassi Internazionale, Ministry of Health, Italy) for providing incidence and mortality data of patients admitted to the Italian ICUs with influenza A(H1N1) during the study period. We thank the Coordination Center of GiViTi for providing data of patients with H1N1 included in GiViTi H1N1 registry. We thank the biostatisticians Teresa Greco and Rosalba Lembo (Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Milan, Italy) for providing support on statistical analysis. We thank G. Tognoni (Consorzio Mario Negri Sud, Santa Maria Imbaro, Italy) for providing support on ethical and legal aspects. We thank the Italian Air Force whose indispensable support allowed long distance patient transfer. We thank all ambulance personnel whose indispensable support allowed interhospital transfer of all patients. We are indebted to all physicians, perfusionists, and nursing staff of the participating units for their priceless cooperation in caring for these complex patients.
- 4.Dominguez-Cherit G, Lapinsky SE, Macias Ae, Pinto R, Espinosa-Perez L, de la Torre A, Poblano-Morales M, Baltazar-Torres JA, Bautista E, Martinez A, Martinez MA, Rivero E, Valdez R, Ruiz-Palacios G, Hernández M, Stewart TE, Fowler RA (2009) Critically ill patients with 2009 influenza A(H1N1) in Mexico. JAMA 302:1880–1887PubMedCrossRefGoogle Scholar
- 5.Kumar A, Zarychansky R, Pinto R, Cook DJ, Marshall J, Lacroix J, Stelfox T, Bagshaw S, Choong K, Lamontagne F, Turgeon AF, Lapinsky S, Ahern SP, Smith O, Siddiqui F, Jouvet P, Khwaja K, McIntyre L, Menon K, Hutchison J, Hornstein D, Joffe A, Lauzier F, Singh J, Karachi T, Wiebe K, Olafson K, Ramsey C, Sharma S, Dodek P, Meade M, Hall R, Fowler RA, Canadian Critical Care Trials Group H1N1 Collaborative (2009) Critically ill patients with 2009 influenza A(H1N1) infection in Canada. JAMA 302:1872–1879PubMedCrossRefGoogle Scholar
- 7.Miller RR III, Markewitz BA, Rolfs RT, Brown SM, Dascomb KK, Grissom CK, Friedrichs MD, Mayer J, Hirshberg EL, Conklin J, Paine R III, Dean NC (2010) Clinical findings and demographic factors associated with ICU admission in Utah due to novel 2009 influenza A(H1N1) infection. Chest 137:752–758PubMedCrossRefGoogle Scholar
- 8.Estenssoro E, Ríos FG, Apezteguía C, Reina R, Neira J, Ceraso DH, Orlandi C, Valentini R, Tiribelli N, Brizuela M, Balasini C, Mare S, Domeniconi G, Ilutovich S, Gómez A, Giuliani J, Barrios C, Valdez P, Registry of the Argentinian Society of Intensive Care SATI (2010) Pandemic 2009 influenza A in Argentina: a study of 337 patients on mechanical ventilation. Am J Respir Crit Care Med 182:41–48PubMedCrossRefGoogle Scholar
- 9.Rello J, Rodríguez A, Ibañez P, Socias L, Cebrian J, Marques A, Guerrero J, Ruiz-Santana S, Marquez E, Del Nogal-Saez F, Alvarez-Lerma F, Martínez S, Ferrer M, Avellanas M, Granada R, Maraví-Poma E, Albert P, Sierra R, Vidaur L, Ortiz P, Prieto del Portillo I, Galván B, León-Gil C, H1N1 SEMICYUC Working Group (2009) Intensive care adult patients with severe respiratory failure caused by influenza A(H1N1)v in Spain. Crit Care 13:R148PubMedCrossRefGoogle Scholar
- 10.Jain S, Kamimoto L, Bramley AM, Schmitz AM, Benoit SR, Louie J, Sugerman DE, Druckenmiller JK, Ritger KA, Chugh R, Jasuja S, Deutscher M, Chen S, Walker JD, Duchin JS, Lett S, Soliva S, Wells EV, Swerdlow D, Uyeki TM, Fiore AE, Olsen SJ, Fry AM, Bridges CB, Finelli L, 2009 Pandemic Influenza A(H1N1) Virus Hospitalizations Investigation Team (2009) Hospitalized patients with 2009 H1N1 influenza in the United States, April–June 2009. N Engl J Med 361:1935–1944PubMedCrossRefGoogle Scholar
- 12.WHO (2011) National influenza pandemic plans. http://www.who.int/csr/disease/influenza/nationalpandemic/en/index.html
- 13.Sprung CL, Zimmerman JL, Christian MD, Joynt GM, Hick JL, Taylor B, Richards GA, Sandrock C, Cohen R, Adini B; European Society of Intensive Care Medicine Task Force for Intensive Care Unit Triage during an Influenza Epidemic or Mass Disaster (2010) Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Intensive Care Med 36:428–443Google Scholar
- 15.Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL, Truesdale A, Clemens F, Cooper N, Firmin RK, Elbourne D, CESAR trial collaboration (2009) Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 374:1351–1363PubMedCrossRefGoogle Scholar
- 18.Extracorporeal Life Support Organization (2010) www.elso.med.umich.edu/H1N1.htm. Accessed 28 May 2010
- 19.Freed DH, Henzler D, White CW, Fowler R, Zarychanski R, Hutchison J, Arora RC, Manji RA, Legare JF, Drews T, Veroukis S, Kesselman M, Guerguerian AM, Kumar A, Canadian Critical Care Trials Group (2010) Extracorporeal lung support for patients who had severe respiratory failure secondary to influenza A(H1N1) 2009 infection in Canada. Can J Anesth 57:240–247PubMedCrossRefGoogle Scholar
- 20.Norfolk SG, Hollingsworth CL, Wolfe CR, Govert JA, Que LG, Cheifetz IM, Hollingsworth JW (2010) Rescue therapy in adult and pediatric patients with pH1N1 influenza infection: a tertiary center intensive care unit experience from April to October 2009. Crit Care Med 38:2103–2107PubMedCrossRefGoogle Scholar
- 21.Roch A, Lepaul-Ercole R, Grisoli D, Bessereau J, Brissy O, Castanier M, Dizier S, Forel JM, Guervilly C, Gariboldi V, Collart F, Michelet P, Perrin G, Charrel R, Papazian L (2010) Extracorporeal membrane oxygenation for severe influenza A(H1N1) acute respiratory distress syndrome: a prospective observational comparative study. Intensive Care Med 36:1899–1905PubMedCrossRefGoogle Scholar