H1N1: The Aftermath Dr Brian Cook Clinical Director, Critical Care, NHS Lothian Chairman, Scottish Intensive Care Society Audit Group

H1N1: How it all started 21st April 2009: USA confirms 2 cases of “Swine Flu” 27th April: First 2 UK cases imported from Mexico 29th April First US death ?159 deaths in Mexico

H1N1: Why all the fuss?? Seasonal Flu: H2N2, H3N2 250-500,000 deaths/yr Sporadic cases: 1997, 2003 onward: H5N1 2009: Rapidly spread H1N1 with fatalities

NHS Initial Responses

Initial Organisational Problems Multiple well meaning sources of guidance Isolation rooms H1N1 Testing frequency/timescale PPE masks Availability Fitting Staff groups

Pandemic Declared by WHO 11/6/09 NHS/Government responses Containment to Treatment Phase Health Boards- Pandemic Planning Groups Multiple specialties Clinicians and managers and external agencies Regular meetings Double intensive care capacity

Predictions: Peak Week (9th November)   Baseline Scenario A Scenario B Scenario C GP Consultations 50,063 +5,500 +7,650 +23,400 Emergency Admissions 1,480 +234 +2,050 +3,400 ITU Cases 69 +30 +400 +840 Deaths 145 +170 +250 +2,100 Beds 2071 +212 +1,914 +3,262

ICU Planning: Double Bed Capacity Assumptions Non-essential surgery stopped Spread into theatre recovery areas Non-ICUAnaesthetists freed up Rob staff from theatres/recovery Rob anaesthetic machines

ICU Planning Staff: Training in ICU and others Equipment: PPE Conventional Ventilators Oscillators Haemofilters At risk groups Children in adult ICU’s ? Pregnant women – obstetric responses in ICU’s Triaged ICU admission/withdrawal???

Triaged ICU Christian M et al. CMAJ 2006 Taylor B et al. JICS 2006

Triaged ICU Prioritisation for Critical Care Admission based on SOFA score and Clinical Opinion   Michael D. Christian et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ • November 21, 2006 • 175(11) | 1377- 1381

ICU Planning: Scotland Scottish Critical Care Delivery Group ICU Clinicians Collation of Escalation Plans Collective responses and mutual support Equipment Capacity management Triage responses Scottish Intensive Care Society Audit Group Bed numbers: Temporary and Established Rapid dissemination network to all ICU’s Research liaison: SwIFT

SwiFT inclusion criteria All patients (adult or paediatric) who were either: H1N1 swine influenza (suspected or confirmed) patients referred and assessed as requiring critical care; or non-H1N1 patients referred and assessed as requiring critical care (under usual/ non-pandemic circumstances) but not admitted to a critical care unit in your hospital.

SwiFT recruitment by week – Scotland

33.3 ICU cases per million population ANZICS 28.7 per million (June to Aug 09) www.sicsag.scot.nhs.uk The ANZIC Influenza Investigators NEJM 2009; 361

SwiFT case flow - Scotland Total cases Initial assessment During critical care Final H1N1 124 Confirmed 30 + Confirmed 30 = Confirmed 60 Suspected 94 Suspected 12 Non-H1N1 Tested Negative 52

H1N1 Patients in ICU Clinical Presentations

Reported presentation Missing Missing Missing Intercurrent Viral Viral Viral Intercurrent Intercurrent Airflow Airflow Airflow Bacterial Bacterial Bacterial

Age Mean 42 54 57

Body composition (BMI) % obese 33 10 14 Body composition (BMI) missing for 4 patients (3.2%)

Pregnancy Currently Missing Missing Not Not Not

ECMO A pregnant woman with swine flu is getting the "best possible treatment“ after being flown to Sweden, according to the Scottish health secretary. Nicola Sturgeon said she had had a very rare reaction to the H1N1 virus. Sharon Pentleton, 26, who is critically ill, was taken to Crosshouse Hospital, in Kilmarnock, last week, where she had been put on a ventilator. She was transferred to Stockholm on Thursday because no beds were available in the UK for the procedure she needed.

ECMO: The CESAR Trial Lancet 2009; 374:1351-63 Online publication Sept 09 Study July 01- Aug 06 180 patients randomised Transfer to Glenfield for consideration for ECMO V Best Conventional Management at Referral Centre (no protocol)

ECMO: The CESAR Trial Lancet 2009; 374:1351-63 Composite outcome death or severe disability at 6 months: ECMO 37% Conventional Treatment 53% p=0.03

ECMO: The CESAR Trial Lancet 2009; 374:1351-63 Group Differences and Confounders 90 “ECMO” patients 5 died pre or in transit 17 did not have ECMO ECMO group significantly more likely to have: Low volume low pressure ventilation strategy Longer time with LPLV strategy Steroids MARS Incomplete follow up 3 control patients

Set Up New ECMO Centre(s)?? “…there is insufficient evidence to provide a recommendation for extracorporeal membrane oxygenation use among patients with respiratory failure resulting from influenza. However, clinicians should consider extracorporeal membrane oxygenation within the context of other salvage therapies for acute respiratory failure.” (Crit Care Med 2010; 38:1398 –1404 “…clinicians at hospitals that do not have an ECMO program, it would be advisable to establish institutional guidelines to identify ECMO-eligible patients in a timely manner and to establish a relationship with an ECMO capable institution to facilitate safe interhospital transport”

http://www.scotland.gov.uk/Publications/2010/04/16151905/0

ECMO for H1N1 in Scotland May 09-Mar 10 ICU Total H1N1 136 Referred for ECMO 21 (15%) Accepted for ECMO 17 Died prior to ECMO 4 Got ECMO 12 Died on ECMO 0 Survived ICU 13 (62%) Survived Hospital 13

ECMO Centres Treating Scottish Patients with H1N1 May 09-Mar 10 Referrals Accepted Glenfield 15 9 Aberdeen 6 6 Karolinska 1 1 Other 1 1

ECMO Centres Treating Scottish Patients with H1N1 May 09-Mar 10 Accepted Got ECMO Survived ICU Hospital Glenfield 9 6 7 7 Aberdeen 6 5 5 5 Karolinska 1 1 1 1 Other 1 0 0 0

H1N1 Workload ANZICS 64% IPPV Median = 7days www.sicsag.scot.nhs.uk

Duration of critical care Median 8.8 1.0 3.9

Organ support: adv. respiratory No Yes

Organ support: renal No Yes

H1N1 Outcome 4 patients still in hospital ANZICS hospital mortality 17% but 16% still in hospital

Survival status at end of critical care Dead Dead Dead Alive Alive Alive

ICU/Critical Care Profile Equipment/Resources H1N1 Aftermath “UK response to H1N1 pandemic was highly satisfactory, independent review says” BMJ 2010;340:c3569 The review, by Deirdrie Hine, a former chief medical officer for Wales, says that preparations, including stockpiling drugs and plans to buy up to 132 million doses of vaccine, were "soundly based in terms of value for money, reflecting the inherently low cost of vaccination in relation to the value of lives saved….. changes need to be made to ensure that critical care services can cope with a more severe pandemic should it occur. “ ICU/Critical Care Profile Equipment/Resources Future disasters and pandemics

Thank you www.sicsag.nhs.scot.uk