H1N1 and ECMO Concerns for Perfusion: More Considerations

Although it is important to collect all of the inventory data available I am going to throw out the idea, that it may be equally important to have some form/attempt at planning in preparation of an H1N1 pandemic. As perfusionists, we bring not only to the table our skilled abilities in ECMO specialists, but also our expertise in the field (well the majority of you moreso than myself, as a new graduate, but nonetheless..) and as such, to participate in the brainstorming of issues surrounding the provision of ECMO to a large number of people is something I would think we are somewhat responsible for. I may be wrong and there are others which are already taking this all into account. But as a society, I feel that it still may be fun and informative and somewhat necessary to think about some of these things. Here are some things that came to mind:

1. Adequate Blood Products:

a) The ability of Canadian Blood Services to keep up with the demands of 2-8% (quoted from Perflist posting) of hospitalized H1N1 patients being on ECMO?
b) ECMO is resource intensive. Should an estimated hospital cost per potential ECMO case be determined to eitheri) request appropriate funding or ii) address adequacy of proposed government funding?
b) Will there be enough blood for other services, i.e. ortho? How will that be prioritized?

2. Indications for H1N1 Requiring ECMO:

a) In order to aid in the prioritization and best utilization of limited ECMO products, staffing over an underdetermined period of time, precise indications for the use of ECMO in H1N1 patients should be outlined.
This would require a committee of surgeons, anesthetists, intensivists, nurses, and perfusionists. ECMO is a method of support and not a treatment. Specific guidelines do need to be set in order that the most severely ill subset of patients with novel influenza A virus (H1N1) be treated with the most advanced methods of care. How do we identify those which are high risk and may require ECMO?

i. The Center for Disease Control and Prevention (CDC) had an article posted on the use of ECMO on novel A H1N1 patients. This article and other cases need to be evaluated and indications for ECMO outlined.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0710a1.htm

ii. Is there a role for ICEBP (International Consortium for Evidence Based Perfusion).
On the ICEBP website it says “The ICEBP has chosen to focus its efforts on systematically reviewing the literature pertinent to our profession.” Is there already evidence based literature being collected and reviewed on this topic that we may be privy to?
- I believe Dwayne Jones is the liason between the ICEBP and the CSCP. Is there such project?

b) Should a committee at the National level be formed to address preparation issues, has this already been formed?

i. In a posting by one American nurse on http://allnurses.com/pandemic-flu-forum/ecmo-will-we-410682-page2.html they suggest that in their estimation 200-300 ECMO services will be able to be provided at any given time spread across the USA in the case of an H1N1 flu pandemic.

ii. Can we or will we be expected to provide a similar number to the Canadian/Ontario government? This would be necessary in order to evaluate required funding.

3. Reporting:

a) In order to monitor, at a provincial level, the number of ECMO services being provided for H1N1 should there not be a registry of some sort?
a) Allows for better resource management (have resources where they need to be).

b) Anticipate rate at which resources are being used, to make projections as to how long provincial inventory will last?

c) Should an international registry such as ELSO (Extracorporeal Life Support Organization) be our medium for reporting? So that we are participating at all levels in helping to monitor, track and project health, economic, etc., effects of H1N1. See link below: http://www.elso.med.umich.edu/Default.htm

d) Should we be reporting inter-hospital ECMO product transfers? In order to monitor effectiveness of the OHPIP on OSCP site?

4. Centralization of ECMO Services:

a) Possible centralization of ECMO services to specific hospital sites in Ontario was mentioned by Patrick Weighell as a notion floating about, as a method of dealing the an overwhelming need for resources, skill, ICU/CVISU/CSU staff etc.

- Again would have to deal with the transfer of products and the liability thereof potentially.

- Would there be an assembly of those perfusionists more familiar and proficient in ECMO services, transport, and management at these centers? How would these perfusionists be covered if their services were required at another hospital? How long would that process take in the respective HR departments, especially with additional or extra staff not at work?