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

2. 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

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

5. NHS Initial Responses

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

7. 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

10. 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

13. 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

14. 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???

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

16. 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) |

17. 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

18. 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.

19. SwiFT recruitment by week – Scotland

20. 33.3 ICU cases per million population
ANZICS 28.7 per million (June to Aug 09)
The ANZIC Influenza Investigators NEJM 2009; 361

21. 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

22. H1N1 Patients in ICU Clinical Presentations

23. Reported presentation
Missing
Missing
Missing
Intercurrent
Viral
Viral
Viral
Intercurrent
Intercurrent
Airflow
Airflow
Airflow
Bacterial
Bacterial
Bacterial

24. Age
Mean

25. Body composition (BMI)
% obese
Body composition (BMI) missing for 4 patients (3.2%)

26. Pregnancy
Currently
Missing
Missing
Not
Not
Not

27. 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.

28. 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)

29. 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

30. 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

31. 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”

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

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

36. ECMO Centres Treating Scottish Patients with H1N1 May 09-Mar 10
Accepted Got ECMO Survived
ICU Hospital
Glenfield
Aberdeen
Karolinska
Other

38. H1N1 Workload
ANZICS
64%
IPPV
Median =
7days

39. Duration of critical care
Median

40. Organ support: adv. respiratoryNo
Yes

41. Organ support: renal No
Yes

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

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

44. 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

45. Thank you