H1N1: The Aftermath

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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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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
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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
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NHS Initial Responses
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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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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 ICUs ?
• Pregnant women obstetric responses in ICUs
• 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 care during 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 ICUs
• 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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SwiFT recruitment by week Scotland
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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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SwiFT case flow - Scotland
Total cases
Initial assessment
During critical care
Final


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H1N1 Patients in ICU Clinical Presentations
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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 42 54 57
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Body composition (BMI)
obese 33 10 14
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

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ECMO The CESAR TrialLancet 2009 3741351-63

• 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 3741351-63
Composite outcome death or severe disability at 6
months ECMO 37 Conventional
Treatment 53 p0.03
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ECMO The CESAR TrialLancet 2009
3741351-63Group 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 381398 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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http//www.scotland.gov.uk/Publications/2010/04/16
151905/0
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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
ANZICS 64 IPPV Median 7days
www.sicsag.scot.nhs.uk
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Duration of critical care
Median 8.8 1.0 3.9
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Organ support adv. respiratory
Yes
No
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Organ support renal
Yes
No
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H1N1 Outcome

• 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
Dead
Dead
Dead
Alive
Alive
Alive
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H1N1 Aftermath
UK response to H1N1 pandemic was highly
satisfactory, independent review says BMJ
2010340c3569 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.

• ICU/Critical Care Profile
• Equipment/Resources
• Future disasters and pandemics

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Thank you
www.sicsag.nhs.scot.uk