Intensivist delivered quaternary severe respiratory failure retrieval service
-
Upload
pbsherren -
Category
Health & Medicine
-
view
759 -
download
3
Transcript of Intensivist delivered quaternary severe respiratory failure retrieval service
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
Critical care is a level of medical support and not a
geographical location…
Critical care is a level of medical support and not a
geographical location
Why not offer ECMO for retrieval patients?
• Consultant intensivist +/- fellow
• Specialist ECMO nurse
• Perfusionist
• Ambulance crew
• NO surgeons
The Team
GSTT Severe Respiratory failure regional referral guideline
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
• 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
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
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
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
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
Comparison of ventilator parameters pre and immediately
post-retrieval, n=59 At referral Immediately
following retrievalP-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*
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
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
Questions?