Intensive Care Medicine

, 37:1447 | Cite as

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

  • Nicolò PatronitiEmail author
  • Alberto Zangrillo
  • Federico Pappalardo
  • Adriano Peris
  • Giovanni Cianchi
  • Antonio Braschi
  • Giorgio A. Iotti
  • Antonio Arcadipane
  • Giovanna Panarello
  • V. Marco Ranieri
  • Pierpaolo Terragni
  • Massimo Antonelli
  • Luciano Gattinoni
  • Fabrizio Oleari
  • Antonio Pesenti



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.


Viral 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.

Supplementary material

134_2011_2301_MOESM1_ESM.doc (175 kb)
Supplementary material 1 (DOC 175 kb)


  1. 1.
    Fowler RA, Lapinsky SE, Hallett D, Detsky AS, Sibbald WJ, Slutsky AS, Stewart TE, Toronto SARS Critical Care Group (2003) Critically ill patients with severe acute respiratory syndrome. JAMA 290:367–373PubMedCrossRefGoogle Scholar
  2. 2.
    Lew TW, Kwek TK, Tai D, Earnest A, Loo S, Singh K, Kwan KM, Chan Y, Yim CF, Bek SL, Kor AC, Yap WS, Chelliah YR, Lai YC, Goh SK (2003) Acute respiratory distress syndrome in critically ill patients with severe acute respiratory syndrome. JAMA 290:374–380PubMedCrossRefGoogle Scholar
  3. 3.
    Li FC, Choi BC, Sly T, Pak AW (2008) Finding the real case-fatality rate of H5N1 avian influenza. J Epidemiol Community Health 62:555–559PubMedCrossRefGoogle Scholar
  4. 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. 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
  6. 6.
    The ANZIC Influenza Investigators (2009) Critical care services and 2009 H1N1 influenza in Australia and New Zealand. N Engl J Med 361:1925–1934CrossRefGoogle Scholar
  7. 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. 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. 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. 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
  11. 11.
    Lapinsky SE (2010) Epidemic viral pneumonia. Curr Opin Infect Dis 23:139–144PubMedCrossRefGoogle Scholar
  12. 12.
  13. 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
  14. 14.
    The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators (2009) Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA 302:1888–1895CrossRefGoogle Scholar
  15. 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
  16. 16.
    Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R (1994) The American-European consensus conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824PubMedGoogle Scholar
  17. 17.
    Singh JM, MacDonald RD (2009) Pro/con debate: do the benefits of regionalized critical care delivery outweigh the risks of interfacility patient transport? Crit Care 13:219PubMedCrossRefGoogle Scholar
  18. 18.
    Extracorporeal Life Support Organization (2010) Accessed 28 May 2010
  19. 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. 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. 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
  22. 22.
    Davies A, Jones D, Gattas D (2010) Extracorporeal membrane oxygenation for ARDS due to 2009 influenza A(H1N1). JAMA 303:942CrossRefGoogle Scholar
  23. 23.
    Mitchell MD, Mikkelsen ME, Umscheid CA, Lee I, Fuchs BD, Halpern SD (2010) A systematic review to inform institutional decisions about the use of extracorporeal membrane oxygenation during the H1N1 influenza pandemic. Crit Care Med 38:1398–1404PubMedCrossRefGoogle Scholar
  24. 24.
    Park PK, Dalton HJ, Bartlett RH (2010) Point: efficacy of extracorporeal membrane oxygenation in 2009 influenza A(H1N1): sufficient evidence? Chest 138:776–778PubMedCrossRefGoogle Scholar
  25. 25.
    Morris AH, Hirshberg E, Miller RR 3rd, Statler KD, Hite RD (2010) Counterpoint: efficacy of extracorporeal membrane oxygenation in 2009 influenza A(H1N1): sufficient evidence? Chest 138:778–781PubMedCrossRefGoogle Scholar
  26. 26.
    Hubmayr RD, Farmer JC (2010) Should we “rescue” patients with 2009 influenza A(H1N1) and lung injury from conventional mechanical ventilation? Chest 137:745–747PubMedCrossRefGoogle Scholar
  27. 27.
    Dalton HJ, MacLaren G (2010) Extracorporeal membrane oxygenation in pandemic flu: insufficient evidence or worth the effort? Crit Care Med 38:1484–1485PubMedCrossRefGoogle Scholar
  28. 28.
    Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL (2009) Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med 35:2105–2114PubMedCrossRefGoogle Scholar

Copyright information

© Copyright jointly held by Springer and ESICM 2011

Authors and Affiliations

  • Nicolò Patroniti
    • 1
    • 2
    Email author
  • Alberto Zangrillo
    • 3
  • Federico Pappalardo
    • 3
  • Adriano Peris
    • 4
  • Giovanni Cianchi
    • 4
  • Antonio Braschi
    • 5
  • Giorgio A. Iotti
    • 6
  • Antonio Arcadipane
    • 7
  • Giovanna Panarello
    • 7
  • V. Marco Ranieri
    • 8
  • Pierpaolo Terragni
    • 8
  • Massimo Antonelli
    • 9
  • Luciano Gattinoni
    • 10
  • Fabrizio Oleari
    • 11
  • Antonio Pesenti
    • 1
  1. 1.Department of Experimental MedicineUniversity of Milan-BicoccaMonzaItaly
  2. 2.Department of Perioperative Medicine and Intensive CareSan Gerardo HospitalMonzaItaly
  3. 3.Dipartimento di Anestesia Cardiaca e Terapia IntensivaUniversità Vita-Salute San RaffaeleMilanItaly
  4. 4.Anestesia e Rianimazione di Emergenza, Dipartimento DAI e Medicina e Chirurgia Generale e d’UrgenzaAzienda Ospedaliero Universitaria CareggiFlorenceItaly
  5. 5.Dipartimento di Scienze Chirurgiche Rianimatorie-Riabilitative e dei Trapianti d’Organo, Sezione di Anestesia Rianimazione e Terapia Antalgica, Anestesia e Rianimazione I Dipartimento di Emergenza UrgenzaUniversità degli Studi di Pavia, IRCCS Policlinico San MatteoPaviaItaly
  6. 6.Anestesia e Rianimazione IIFondazione IRCCS Policlinico San MatteoPaviaItaly
  7. 7.Terapia IntensivaIstituto Mediterraneo per i Trapianti e Terapie ad alta SpecializzazionePalermoItaly
  8. 8.Dipartimento di Anestesiologia e Medicina degli Stati CriticiUniversità di TorinoTurinItaly
  9. 9.Dipartimento di Terapia Intensiva e AnestesiologiaUniversità Cattolica del Sacro CuoreRomeItaly
  10. 10.Dipartimento di Anestesiologia, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Maggiore PoliclinicoUniversità degli Studi di MilanoMilanItaly
  11. 11.Dipartimento della Prevenzione e ComunicazioneMinistero della SaluteRomeItaly

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