Critical Care: Role of MV, ECMO, and other critical infrastructure

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1 Critical Care: Role of MV, ECMO, and other critical infrastructure Christian Sandrock, MD, MPH UC Davis School of Medicine

2 The Next 30 Minutes Why the ICU? Why are some critical care issues, particularly MV, an issue? What are our options? Solutions for high demand critical issues

3 Demand Multiple potential causes of large numbers of pt with resp failure FIRE CBRN Infection

4 Matching form to function Disaster ER Disaster ICU

5 ER ICU OR

6

7 15 min intervals Lancet 2006; 368:

8 Lancet 2006; 368:

9 Time Pt in ICU/OR Pt in ER

10 H1N1 in ICU- Canada 215 patients (168 confirmed) Mean age 32.3, 30% children 67.3 % female 25.6% aboriginal Canadians 4 days symptoms to ICU 81% received MV, 95% neuroaminidase Mean time on ventilator:12 days Kumar A et al JAMA 2009;302(17):epub

11 H1N1 in ICU- Canada Rescue therapies Paralysis: 28% ino: 13.7% HFOV: 11% ECMO: 4.3% Prone: 3% Overall ICU Mortality at 90 days: 17.3% Kumar A et al JAMA 2009;302(17):epub

12 ECMO in H1N1 May play a role in select patients 68 patients (2.8 per million) Peep 18 Po2/FiO2 56 Age 34.4 Mean time 10 days 71% survival Fritenbery et al EID Oct (11): and JAMA 2009;302(17):epub

13 Critical issues of the ICU Conventional Ventilators Non-Conventional Ventilators HFOV, APRV, ECLS Non-Conventional Adjuvant therapy Prone, inos, steroids Supportive equipment Tubing Medical gas

14 H1N1 step 1 Baseline limited surge capacity in ICU How many ventilators are there? Must have an up to date inventory How many ventilators are available right now? Real time data ( Situational Awareness ) Can they play nice in the sandbox?

15 Methods: Stakeholders Ventilator Equipment Pool Home Care Companies Oral Surgery Clinics All Hospitals Ventilator Industry (vendors, distributors and sales) Medical Schools VENTILATOR INVENTORY EMS Region Services OAASC ACP Training RT Schools Sleep Clinics Physicians (practicing anesthesia and respirology outside of hospitals)

16 Mechanical Ventilators H1N1 In H1N1, can provide care for most with ventilator Must be able to provide ARDSnet LTVV ventilation AVOID lung injury However, requires close care with RT High medical gas needs Most Fi in severe cases High tubing turnover

17 Surge PPV Options Manual Ventilators

18 Optimal Surge PPV Minimum vent characteristics to care for patients with ARDS/ airways obstruction across ages is unknown Surge mechanical ventilators should provide significant benefit over manual ventilators Survival % Vent Features Vent Features Until better data available, relying on expert consensus

19 Surge PPV Options Automatic Resuscitators

20 Surge PPV Options EMS Transport Ventilators

21 Surge PPV Options Sophisticated Transport Ventilators

22 Transport Vs Full-feature ICU Vents Availability 1. Assist- Volume control Both 2. FDA approved for peds/adults Both 3. Inspiratory static pressure measurement Both 4. Internal PEEP/ PEEP compensation Both 5. Internal compressor w/ flow max > 80 L/min Both 6. Insp trigger sensitivity Both 7. Oxygen blender Both 8. Battery back-up > 4 hrs for usual settings Both 9. Ease of use ST > FF 10. Flexibility of settings/ functions FF > ST 11. Procurement cost FF>>ST

23 Surge PPV Options Full-feature Ventilators

24 Full Feature Vents $$$$$$$$ Limited portability/transport issues Complex to trouble shoot Require large storage space Ongoing maintenance

25 Non-rescue strategies HFOV, ECMO

26 H1N1 in ICU- Canada Rescue therapies Paralysis: 28% ino: 13.7% HFOV: 11% ECMO: 4.3% Prone: 3% Overall ICU Mortality at 90 days: 17.3% Kumar A et al JAMA 2009;302(17):epub

27 ECMO in H1N1 May play a role in select patients 68 patients (2.8 per million) Peep 18 Po2/FiO2 56 Age 34.4 Mean time 10 days 71% survival Fritenbery et al EID Oct (11): and JAMA 2009;302(17):epub

28 QuickTime and a decompressor are needed to see this picture. HFOV

29 ECMO

30

31 Issues in management Very specialized Staff support required by training Additional difficulty High heparin load Nurising additional 1:2 ratio. Coordination of resources Plan with all on region

32

33 Other equipment

34 O2 ETT Suction Circuit Humidifier

35

36 Canada, Proportion with O2 100% Kumar et al. JAMA Canadian ICU Experience % Patients Requiring Supplemental Oxygen Patients in ICU 80% 60% 40% 20% 22.0% 23.1% 12.5% 9.0% 56.5% 59.6% 26.4% 25.6% 6.4% 1.2% 52.8% 56.1% 0% Hospital Day All Invasive MC Non invasive MV Mask/NC JAMA. 2009;302(17):(doi: /jama )

37 Nathaniel Hupert, MD, MPH Director Preparedness Modeling Unit

38 Consumable Reusable Nathaniel Hupert, MD, MPH Director Preparedness Modeling Unit

39 Some solutions

40 Initial expansion of critical care treatment space during disasters Rubinson, L. et al. Chest 2008;133:32S-50S

41 Critical care expansion during sustained catastrophies will require further expansion of critical care capabilities Rubinson, L. et al. Chest 2008;133:32S-50S

42 Other steps Regional planning for non-conventional therapy Can we share these ECLS resources? Create a crisis care guide or trigger When are we no longer providing care that is consistant? Follow patient safety (documented)

43 Other steps Develop regional triage plan Develop regional triggers Just in time education to reduce patient transfer Telemedicine Ventilator management standard

44 Thank you

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