Critically Ill Patients With H1N1 Influenza A Undergoing Extracorporeal Membrane Oxygenation

Abstract

The most common cause of death due to the H1N1 subtype of influenza A virus (swine flu) in the 2009 to 2010 epidemic was severe acute respiratory failure that persisted despite advanced mechanical ventilation strategies. Extracorporeal membrane oxygenation (ECMO) was used as a salvage therapy for patients refractory to traditional treatment. At Legacy Emanuel Hospital, Portland, Oregon, the epidemic resulted in a critical care staffing crisis. Among the 15 patients with H1N1 influenza A treated with ECMO, 4 patients received the therapy simultaneously. The role of ECMO in supporting patients with severe respiratory failure due to H1N1 influenza is described, followed by discussions of the nursing care challenges for each body system. Variations from standards of care, operational considerations regarding staff workload, institutional burden, and emotional wear and tear of the therapy on patients, patients’ family members, and the entire health care team are also addressed. Areas for improvement for providing care of the critically ill patient requiring ECMO are highlighted in the conclusion.

Transferring Patients With Refractory Hypoxemia to a Regional Extracorporeal Membrane Oxygenation Center

“…A central venous pressure of 9 to 12 mm Hg and pulmonary capillary wedge pressure of 13 to 20 mm Hg may be targeted. 36 Of note, the mixed venous oxygen saturation (S VO 2 ) is falsely elevated in the setting of V-V ECMO, because the distal pulmonary artery receives blood that has just returned from the circuit oxygenator. In addition, acquiring acceptable cardiac output thermodilution curves can be a challenge because of the proximity of the ECMO drainage and return catheters to the site in the right atrium where injectate is infused.…”

“…In addition, acquiring acceptable cardiac output thermodilution curves can be a challenge because of the proximity of the ECMO drainage and return catheters to the site in the right atrium where injectate is infused. 36 If hemodynamic status cannot be optimized with fluid management, heart rate controlling medications, or vasoactive and inotropic infusions, conversion to venoarterial ECMO may be considered. 36 , 38 …”

“…They also may provide emotional support for the health care team, as withdrawing care after such an intense hospital course may result in moral distress. 36 The ethical issues surrounding prolonged ECMO therapy are just beginning to emerge, as many patients now survive their initial illness to become dependent on extracorporeal support. 48 …”

“…6 , 38 Supporting Hemodynamic Status Frequently, a patient's hemodynamic status improves after initiation of V-V ECMO therapy, which is likely because once the circuit takes over oxygenation, hypoxia-induced pulmonary arterial hypertension resolves, thus relieving the workload on the myocardium. 36 Patients may benefit from hemodynamic monitoring via a PAC to optimize fluid status, cardiac output, and myocardial workload. A central venous pressure of 9 to 12 mm Hg and pulmonary capillary wedge pressure of 13 to 20 mm Hg may be targeted.…”

“…If the patient is unable to receive heparin, as in the case of heparin-induced thrombocytopenia, bivalrudin or argatoban may be considered. [36][37][38] Regardless of which anticoagulant agent is used, careful assessment for both inappropriate clotting and clinical bleeding is required. The entire circuit is assessed for the development of fibrin deposits or blood clots that could impede flow or pose life-threatening risk to the patient should they dislodge.…”