Présentation PowerPoint

Pediatric ECMO and aerial transportation on commercial flights:
Experience of an underserved area: the Mayotte Island
Dr François Lion
Anesthesiology, Cardio-Surgery Intensive Care Unit
CHU Fort de France Martinique
Dr Renaud Blondé
Adult and Pediatric Intensive Care Unit
Mayotte Hospital Center
Mamoudzou
Mayotte Hospital Center ICU Team
Sunday 22th November 2015
1- Geographic context
2- Sanitary Evacuation process (EVASAN) from Mayotte to
Réunion Island by UMAC (ECMO mobile units)
3- The EVASAN of children with ECMO we could realize
4- The EVASAN of children with ECMO we did not realize
5- Conclusion and prospects
1- Geographic context
750 NM = 1400 km
from adult cardiac surgery department to Mayotte:
2 hours of flight
10800 km from Reunion to Paris pediatric
Cardiac Surgery and ICU centers:
11 hours of flight
A Comorian island
1- Geographic context
Republic of the Comoro Islands:
3 Islands: Grande Comore, Anjouan, Mohéli
750 000 inhabitants
56% of population under 20 ans
« Eva-kwassa »
Mayotte
Approximately 300 000 inhabitants
50% illegal immigrants
50% children < 15 (no medical follow up)
90% under poverty line
1 French Hospital
1 Airport
1- Geographic context
2- EVASAN process
- Inaccessible by helicopter
- No military plane affected to sanitary mission in the region
- Only one commercial flight a day.
Air Austral commercial monopoly
- Once a week detour and stopover to Moroni (+ 3 heures)
- Round trip impossible in the day
- Planes over-booked
- High cost, non affiliated patients
- Limited means for UMAC: 3 surgeons, 4 perfusionists…
The team must not stay more than 24 hours outside Reunion Island:
The return trip must be guaranteed
Boeing 737
2- EVASAN process
UMAC-OI team: 5 people:
1 perfusionist, 1 cardiac surgeon, 1 intensivist,
SAMU (prehospital medical service) doctor and nurse
Trip back: Stretcher occupies 10 places
10 people for manutention
+ air cargo, electric converters,
batteries, O2…
Décision du transfert d’un patient sous ECMO
La décision du transfert doit être une décision collégiale entre :
- Les chirurgiens cardiaques du CHD
- Les anesthésistes-réanimateurs du Bloc cardiaque
- Les réanimateurs du service réanimation
- Les médecins du SAMU
- Le service receveur
Cette décision doit prendre en compte :
- L’état clinique du patient
- Le moment optimal du transfert en fonction du type d’assistance dont il bénéficie
- Les contraintes matériels de transport : vecteur aérien, matériel, oxygène
I I - b - Procédure EVASAN aéroportée :
- Contact initial des médecins du service demandeur au service receveur pour la
demande de transfert
- Contacter l’astreinte UMAC (Bip 111 ou chirurgien cardiaque de garde)
- Une fois l’accord de transfert donné : staff pluridisciplinaire en salle SAMU
(Anesthésistes réanimateurs cardiaques, chirurgiens cardiaques, réanimateurs, cardiologues,
urgentistes, médecin référent, équipe biomédicale, équipe paramédicale de transfert) pour
déterminer des modalités d’organisation logistique et de la date optimale de départ
- Désignation des accompagnateurs, établir les ordres de mission
- Contacter sécurité sociale (qui est le payeur avec accord faxé)
- Organisation logistique de l’évacuation sanitaire par le SAMU
· Contact compagnie aérienne (principalement Air Austral, Air France refusant à cette
date) demande accord médical
· Réservations civière + places (En tout 15 places avec 2 places devant la civière)
o Demander un accès sur la porte centrale
o Prévoir 10 personnes pour manipuler
o S’assurer de l’alimentation pour le convertisseur
· Liste du matériel (cf liste prédéfinie perfusionnistes, SMUR et remplir la check liste)
· Liste des produits sanguins à emporter (papiers spécifiques de l’EFS)
· S’assurer que le patient a des canules longues (installation dans l’avion)
· Envoyer à la PAF une copie de la pièce d’identité du patient et les contacter.
· Mise à disposition de kits Oxygène aviation par SAMU ou location kits sur Air France
· Organisation du pré-acheminement CHD-Aéroport 3 véhicules
o L’UMH patient
o Ambulance gros volume : Equipe Chir et matériel médical
· Et du post-acheminement Aéroport-hôpital receveur même logistique.
· Prévoir les escortes motards systématiques, pour ce faire contacter les Ambulances
LMC qui gérera avec le centre de commandement à Paris.
· Prévoir un staff avant le départ en salle de staff de Réanimation avec tous les acteurs
et le Biomédical
· Prévoir un départ au moins 3 h avant l’heure de décollage
2- EVASAN process
1 ambulance transportation to the harbour
1 maritime transportation to « Petite Terre »: « La barge »
2- EVASAN process
2- EVASAN process
1 transportation from harbour to airport
Check in, customs…
95°F…
Boarding
2- EVASAN process
2 hours flight over the high planes of Madagascar
2- EVASAN process
Disembarkation
2- EVASAN process
2- EVASAN process
1 ambulance transportation to CHU (CTV surgery and ECMO center)
Total lenght of procedure:
10 hours
2- EVASAN process
Mean time from call to implantation is 48 hours (24- 55 hours) since 2010
Not including patients dead (or MOF constituted) while waiting UMAC team arrival
Jan 2014: Mayotte Intensive Care Unit bought Cardiohelp and got trained to be able to initiate
ECMO on-site in case of emergency without waiting the UMAC team.
3- The EVASAN of children with ECMO we could realize
Age/ weight
14 years/ 55 kg
8 years/ 29 kg
4 years/ 14 kg
Indication
Severe ARDS
Severe ARDS
Severe ARDS
Context/comorbidity
Severe TBI/HDH/haemophilia A
Lyell syndrome
Acute chest syndrome/sickle
cell disease
Length ventilation before
implementation
ECCO2-R: 132 h/ ECMO: 168 h
672 hours
20 hours
Time between call and implementation
55 hours
24 hours
NA
Implementation local team or UMAC
team
ECCO2-R pumpless: local team
then ECMO/UMAC
UMAC
Local
Bypass technique
ECCO2-R AV puis ECMO VV femjug
ECMO VV jug-fem
ECMO VV jug-fem
Length ECMO in Mayotte
ECCO2-R: 45h + ECMO 20 h
24 hours
38 hours
Total length of ECMO
10 days
23 days
29 days
Complications of ECMO
hemorrhage
hemorrhage
Hémorrhage and hemothorax
Demand for blood
4 RCU 2 FPU 3 PCU
5 RCU 2 FPU
4 RCU 1 FPU 1 PCU
Total length of mechanical ventilation
23 days (tracheostomy)
62 days
39 days
Outcome
Recovery ad integrum
Extubated, bypass removed with
success, then deceaded/septic shock
Recovery ad integrum
TBI: traumatic brain injury. HDH extradural haematoma. ECMO extracorporeal membrane oxygenation. UMAC ECMO mobile team
ECCO2-R AV extracorporeal CO2 removal arterio-venous pumpless RCU red cell unit. FPU frozen plasma unit. PCU platelet concentrate unit
VV: veno-venous. Fem-jug: femoro-jugular. Jug-fem: jugulo-femoral.
4- The EVASAN of children with ECMO we did not realize
1 ECMO without EVASAN…
Age/ weight
5 years/ 20 kg
Indication
Severe ARDS
Context/comorbidity
Tropical polymyositis, SAMS-LPV
Length ventilation before
implementation
408 hours
Time between call and implementation
NA
Implementation local team or UMAC
team
local
Bypass technique
ECMO VV jug-fem
Length ECMO in Mayotte
21 days
Total length of ECMO
21 days
Complications of ECMO
atelectasy
Demand for blood
2 RCU
Total length of mechanical ventilation
44 days
Outcome
Recovery ad integrum
MSSA methicillin sensitive staphylococcus aureus; LPV leucocidin panton valentine. NA non applicable. RCU red cell unit.
Jug-fem jugulo-femoral.
1 ECMO totally leaded on place:
Denied in adult and pediatric ICU
at CHU Reunion Island
4- The EVASAN of children with ECMO we did not realize
1 EVASAN without ECMO…
16 year-old boy 40 kg
Mitral stenosis: mitral plasty 7 year-old
Redux annuloplasty in 2005 9 year-old
Expelled to Comores in 2006 (aged 10)
Eva-kwassa
Refractory cardiogenic shock:
Global systolic deficiency, severe mitral stenosis
Mean gradient 22 mmHg pulmonary hypertension 115 mmHg
We tried emergency Evasan without ECMO
2 cardiac arrests while Evasan process…
Wrong decision…
Neither ECMO nor EVASAN
4- The EVASAN of children with ECMO we did not realize
6 month-old little girl, admitted for
respiratory distress…
Pediatric ECMO in Mayotte from 2010 to 2015
5- Conclusion et perspectives
5 pediatric ECMO:
- No pediatric ECLS
- 3 Evasan
- 1 locally leaded
- 1 died before Evasan
- 1 implementation by UMAC team and 4 by local team (18 month period)
Mean age 6,5 years old (3- 14 years)
Total days ECMO resulted: 84 days
3 Evasan with ECMO on air travel: 4500 km of flight on commercial flights
Survival 60%
Year 2014:
3 UMAC Mayotte/total 9 UMAC in Indian Ocean (CHU Reunion UMAC activity)
2 UMAC pediatric
Mayotte: 33 % total UMAC-OI activity
And 100% UMAC pediatric activity upon 3 years
5- Conclusion and prospects
1- Feasability
5- Conclusion et prospects
2- Specific difficulties
More complex and heavy logistics, longer response time
Many complex issues: social, economic, politics, cultural, religious context……….
3- ECLS for CHD in neonates?
1- First mastering the technique on CHU La Reunion
2- Then use the operationnal pathway already existing for adults and children
Or develop longer evasan pathway > 10 000 km directly towards ultra-specialized centers in Paris?
Thank you very much for attention
Special thanks to:
-
Renaud Blondé
Philippe Durasnel
All the Mayotte Intensive Care Unit’s team
Philippe Mauriat
Hugues Lucron