Intensivist delivered quaternary severe respiratory failure retrieval service

  • 649 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
649
On Slideshare
0
From Embeds
0
Number of Embeds
3

Actions

Shares
Downloads
5
Comments
0
Likes
1

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Intensivist delivered quaternary severe respiratory failure retrieval service with mobile extracorporeal membrane oxygenation (ECMO) capabilities Sherren PB, Shepherd SJ, Glover G, Meadows C, Langrish C, Ioannou N, Daly K, Gooby N, Agnew A, Barrett NA Department of Critical Care, Guy’s and St. Thomas’ NHS Foundation trust, London, UK
  • 2. Critical care is a level of medical support and not a geographical location…
  • 3. Critical care is a level of medical support and not a geographical location
  • 4. Why not offer ECMO for retrieval patients?
  • 5. • Consultant intensivist +/- fellow • Specialist ECMO nurse • Perfusionist • Ambulance crew • NO surgeons The Team
  • 6. GSTT Severe Respiratory failure regional referral guideline
  • 7. Severe Respiratory failure network • National Specialist Commissioning Service held a tender process in 2011 to establish five SRF centres • Centralise care for the sickest patients • Individualised high end care • Mobile ECMO capability was a prerequisite • The retrieval service had to conform to national standards of governance and audit
  • 8. • Retrospective observational study of all patients retrieved by the SRF service between 02/2013 and 01/2014 • Details retrieved from SRF database and Philips careview electronic patient record Methods
  • 9. Patient characteristics at referral, n=60 • Age, mean±SD = 44.1±13.6 • Gender, female (%) = 34 (56.7%) • Murray score, median (IQR) = 3.2 (3-3.5) • PaO2/FiO2 ratio, mean±SD = 10.2±4.1 kPa • FiO2, median (IQR) = 1.0 (0.9-1) • Pplat, mean±SD = 32.8±5.7 cmH2O • pH, mean±SD = 7.14±0.16 • PaCO2, mean±SD = 10.5±4.4 kPa
  • 10. Patient characteristics at referral, n=60 • 16.7% were receiving protective lung ventilation • 78.3% were receiving neuromuscular blockers • 13.3% were ventilated in the prone position • 3.3% were on HFOV • 5% were on inhaled nitric oxide • 68.3% were receiving vasopressors/inotropes • 48.3% had an AKI • 18.3% were receiving RRT
  • 11. ECMO initiation • 48 (80%) patients required vv ECMO initiation at the referring centre • All patients that required ECMO were successfully cannulated • Cannulation techniques were: • 41 (85.4%) bifemoral • 5 (10.4%) femoral-jugular • 2 (4.2%) dual-lumen jugular Avalon cannulation • There were no cannulation or ECMO related complications • One patient with multi-organ failure died prior to transfer
  • 12. Transfer • The mean retrieval distance was 59.5 miles (range 2.3-342) • 58 patients were retrieved by road and one by fixed wing aircraft • There were no serious adverse events during retrieval • 18 (30.5%) patients suffered transient minor adverse events (SpO2 <88%, Systolic BP <80 or non-malignant arrhythmia) • Mean±SD lowest SpO2 and SBP were 91±6% and 105±19mmHg respectively • All 47 patients transferred on ECMO received lung protective ventilation • Of the patients transferred on conventional ventilation, 10 (83.3%) were receiving lung protective ventilation
  • 13. Comparison of ventilator parameters pre and immediately post-retrieval, n=59 At referral Immediately following retrieval P-value PaO2/FiO2 ratio mean±SD, kPa 10.2±4.1 26.2±15.5 <0.0001* Ventilator FiO2 median (IQR) 1.0 (0.9-1) 0.4 (0.3-0.7) <0.0001* Pplat mean±SD, cmH2O 32.8±5.8 23.0±5.5 <0.0001* pH mean±SD 7.15±0.16 7.32±0.09 <0.0001* PaCO2 mean±SD, kPa 10.6±4.4 6.4±1.7 <0.0001*
  • 14. Outcomes • The mean±SD number of days on: • ECMO = 12.9±22 • Invasive ventilation = 17.6±20.3 • Critical care = 20.9±20.6 • Survival to critical care discharge was 77% for patients initiated on ECMO and 75% for those retrieved conventionally
  • 15. Conclusion • Despite very high illness severity, patients who fail mechanical ventilation can be safely transferred to a specialist respiratory failure centre • An intensivist delivered mobile ECMO service delivers safe patient retrieval and a high survival rate
  • 16. Questions?