Publications (136)820.26 Total impact
- [Show abstract] [Hide abstract] ABSTRACT: Legionella-associated respiratory failure has a high mortality, despite modern ventilation modalities. Extracorporeal membrane oxygenation (ECMO) is used to achieve gas exchange independent of pulmonary function in patients with severe respiratory failure. This was a retrospective review of the management and outcome of patients with Legionella-associated respiratory failure treated with ECMO support in a large ECMO center over the past 10 years. A retrospective review of patients with confirmed Legionella-associated severe respiratory failure managed with ECMO support at a single center. Between 2000 and 2010, 19 patients with severe respiratory failure caused by Legionella were managed with ECMO after failure to respond to conventional intensive care management. Median PaO2/FiO2 ratio was 66 and median pCO2 was 60 torr. Sixteen patients (84%) survived to hospital discharge. Extracorporeal membrane oxygenation should be considered in patients with Legionella-associated respiratory failure, who have failed conventional ventilation.
- [Show abstract] [Hide abstract] ABSTRACT: Objectives: Patients on extracorporeal membrane oxygenation (ECMO) are at risk from thoracic complications such as bleeding or pneumothorax, which may subsequently necessitate thoracic surgical intervention. We aimed to: 1) analyse the indication and nature of thoracic surgical intervention in these patients and 2) analyse the effect of a change in the ECMO circuit from roller pump to centrifugal pump on transfusion requirements pre and post thoracotomy. Methods: We retrospectively reviewed a prospectively collected database of 569 adults put on ECMO between 1995 and 2011. Patients undergoing thoracotomy were identified and outcomes were statistically analysed. Results: Forty thoracotomies were performed in 18 patients [61% male, median age 31 (14-56) years, one bilateral procedure]. The indications for ECMO included: pneumonia 14/18 (78%), trauma 2/18 (11%) and other 2/18 (11%). Median duration on ECMO was 13 (1-257) days and the time to initial thoracotomy was 10 (1-183) days. The indications for thoracotomy were: excessive bleeding post chest drain insertion (11/19, 58%), uncontrolled air leak (9/19, 47%) and pleural effusion (4/19, 21%). The primary operations were 12/19 (63%) evacuation of haemothorax, 3/19 (16%) lung repair, 2/19 (11%) diagnostic lung biopsy and 2/19 (11%) other. Ten patients needed a further 21 thoracotomies (3 lobectomies); average 2 (1-5) per patient. In total, 30/40 (75%) thoracotomies were performed for bleeding complication. The change from roller to centrifugal pump trended towards a reduction in mean transfusion requirements in these patients following thoracotomy (11.5 versus 4 units, p=0.14). The in-hospital mortality was 7/18 (39%) patients. There were no statistically significant predictors of poor outcome. Conclusions: The need for thoracotomy whilst on ECMO is 3.2% in this large series. Intervention may be complicated, thus, either ECMO specialists should have thoracic training or thoracic surgeons should be on-site. Potential mortality is high and, although not statistically significant, a difference in transfusion requirements was observed following the change of circuit.
- [Show abstract] [Hide abstract] ABSTRACT: Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients with severe acute respiratory distress syndrome (ARDS), but its role has remained controversial. ECMO was used to treat patients with ARDS during the 2009 influenza A(H1N1) pandemic. To compare the hospital mortality of patients with H1N1-related ARDS referred, accepted, and transferred for ECMO with matched patients who were not referred for ECMO. A cohort study in which ECMO-referred patients were defined as all patients with H1N1-related ARDS who were referred, accepted, and transferred to 1 of the 4 adult ECMO centers in the United Kingdom during the H1N1 pandemic in winter 2009-2010. The ECMO-referred patients and the non-ECMO-referred patients were matched using data from a concurrent, longitudinal cohort study (Swine Flu Triage study) of critically ill patients with suspected or confirmed H1N1. Detailed demographic, physiological, and comorbidity data were used in 3 different matching techniques (individual matching, propensity score matching, and GenMatch matching). Survival to hospital discharge analyzed according to the intention-to-treat principle. Of 80 ECMO-referred patients, 69 received ECMO (86.3%) and 22 died (27.5%) prior to discharge from the hospital. From a pool of 1756 patients, there were 59 matched pairs of ECMO-referred patients and non-ECMO-referred patients identified using individual matching, 75 matched pairs identified using propensity score matching, and 75 matched pairs identified using GenMatch matching. The hospital mortality rate was 23.7% for ECMO-referred patients vs 52.5% for non-ECMO-referred patients (relative risk [RR], 0.45 [95% CI, 0.26-0.79]; P = .006) when individual matching was used; 24.0% vs 46.7%, respectively (RR, 0.51 [95% CI, 0.31-0.81]; P = .008) when propensity score matching was used; and 24.0% vs 50.7%, respectively (RR, 0.47 [95% CI, 0.31-0.72]; P = .001) when GenMatch matching was used. The results were robust to sensitivity analyses, including amending the inclusion criteria and restricting the location where the non-ECMO-referred patients were treated. For patients with H1N1-related ARDS, referral and transfer to an ECMO center was associated with lower hospital mortality compared with matched non-ECMO-referred patients.
- [Show abstract] [Hide abstract] ABSTRACT: Extracorporeal membrane oxygenation (ECMO) is a modified form of cardiopulmonary bypass that allows short-term support for potentially reversible severe acute respiratory and/or cardiac failure in critically ill adults and children. There is increasing interest in veno-venous (VV) ECMO for severe acute respiratory failure in adults. The National Institute for Health and Clinical Excellence has recently updated its interventional procedure guidance, which summarises available data on efficacy and safety of this procedure and provides guidance for clinicians wishing to undertake VV ECMO. The authors summarise and reflect on the guidelines and discuss some recent developments in technology and clinical practice of VV ECMO.
- [Show abstract] [Hide abstract] ABSTRACT: We present the case of a near fatal aspiration of a foreign body requiring extracorporeal membrane oxygenation (ECMO) support. The use of ECMO to support treatment for a foreign body in the distal trachea is rare and there are only two cases reported in the literature. A 13-year-old male presented with a three-weeks' history of a cough and swinging fevers. Subsequent investigation revealed a foreign body causing collapse of the right middle and lower lobe with abscess formation. On attempted bronchoscopic removal, copious amounts of pus were aspirated, soiling both lungs. The patient became severely hypoxic and hypotensive. He was unstable on ventilation and inotropes and ECMO was used to stabilise him and facilitate removal of the foreign body and infected lung. He made excellent recovery and suffered no neurological sequalae. This is the first reported use of ECMO support for an acute presentation of a chronic problem. If the patient is too unstable for bronchoscopy, ECMO can be used to temporarily stabilise the patient allowing safe removal of the object. If the patient is acutely unwell and septic, ECMO should be more readily considered.
- [Show abstract] [Hide abstract] ABSTRACT: Since April 2009, the novel pandemic A/H1N1 influenza virus began causing illness in the UK. While causing mild flu-like symptoms in the majority of cases, the virus has been also identified as the cause of an outbreak of febrile respiratory infection.34 confirmed cases of pandemic H1N1 in pregnant women were admitted to the maternity unit in Leicester. Leicester Glenfield Hospital is the ‘front door’ for access to adult extracorporeal membrane oxygenation (ECMO) in the UK. In consequence, our experiences reflect the severe end of the clinical spectrum.The authors summarised cases of infection with pandemic H1N1 virus in pregnant women in Leicester between April and December 2009.Pregnant women represent approximately 1% of the general population of the UK. Three of the 11 patients (18.2%) admitted to the intensive care unit at Leicester Royal Infirmary, with the confirmed 2009 H1N1 influenza were pregnant women. Of the 53 patients referred for ECMO, 18 (34%) were pregnant or recently delivered. When compared to the non-pregnant cohort, perinatal women are at risk of severe respiratory failure.Adult respiratory distress syndrome requiring respiratory support is a documented complicated of the H1N1 influenza virus. ECMO support when conventional ventillatory methods have failed, improves the respiratory function. Pregnant or recently delivered women were over represented in the groups admitted for respiratory support, and experience a more complicated recovery.These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-flu drugs and encourage the vaccination programme in pregnant women.
- [Show abstract] [Hide abstract] ABSTRACT: Panton-Valentine leukocidin expressing Staphylococcus aureus pneumonia, an infection that affects predominantly young people, has a mortality rate of > 70% despite aggressive conventional management. Little information is available on the management of patients with Panton-Valentine leukocidin expressing S. aureus pneumonia with extracorporeal membrane oxygenation support. As a large extracorporeal membrane oxygenation center, we reviewed our experience and outcomes with Panton-Valentine Leukocidin expressing S. aureus pneumonia. Locally held register of all extracorporeal membrane oxygenation patients at Glenfield Hospital. Retrospective study including all patients with sputum-positive Panton-Valentine leukocidin expressing S. aureus pneumonia managed with extracorporeal membrane oxygenation support at a single extracorporeal membrane oxygenation center. On review of our database held from September 1989 until date, there were four patients with sputum-confirmed Panton-Valentine leukocidin expressing S. aureus pneumonia managed with extracorporeal membrane oxygenation. Refractory hypoxemia and/or uncompensated hypercapnia despite optimal conventional management were the indications for extracorporeal membrane oxygenation. After varying periods on extracorporeal membrane oxygenation with appropriate antibiotic and ancillary care, all four patients were discharged home. Panton-Valentine leukocidin expressing S. aureus pneumonia can cause severe, necrotizing pneumonia associated with acute respiratory distress syndrome, which can be particularly challenging to manage. Extracorporeal membrane oxygenation support permits low pressure lung ventilation, avoiding barotrauma to lungs made friable by Panton-Valentine leukocidin expressing S. aureus infection. Although this is a small number of patients, the results are encouraging.
- [Show abstract] [Hide abstract] ABSTRACT: Objectives: To determine the comparative effectiveness and cost-effectiveness of conventional ventilatory support versus extracorporeal membrane oxygenation (ECMO) for severe adult respiratory failure. Design: A multicentre, randomised controlled trial with two arms. Setting: The ECM centre at Glenfield Hospital, Leicester, and approved conventional treatment centres and referring hospitals throughout the UK. Participants: Patients aged 18-65 years with severe, but potentially reversible, respiratory failure, defined as a Murray lung injury score >= 3.0, or uncompensated hypercapnoea with a pH <7.20 despite optimal conventional treatment. Interventions: Participants were randomised to conventional management (CM) or to consideration of ECMO. Main outcome measures: The primary outcome measure was death or severe disability at 6 months. Secondary outcomes included a range of hospital indices: duration of ventilation, use of high frequency/oscillation/jet ventilation, use of nitric oxide, prone positioning, use of steroids, length of intensive care unit stay, and length of hospital stay and (for ECMO patients only) mode (venovenous/veno-arterial), duration of ECMO, blood flow and sweep flow. Results: A total of 180 patients (90 in each arm) were randomised from 68 centres. Three patients in 10.75 for the ECM group compared with 7.31 for the conventional group. Costs to patients and their relatives, including out of pocket and time costs, were higher for patients allocated to ECMO. Conclusions: Compared with CM, transferring adult patients with severe but potentially reversible respiratory failure to a single centre specialising in the treatment of severe respiratory failure for consideration of ECM significantly increased survival without severe disability. Use of ECM in this way is likely to be costeffective when compared with other technologies currently competing for health resources.
- [Show abstract] [Hide abstract] ABSTRACT: Introduction The incidence of parapneumonic effusion in children has been rising in the UK since the mid 1990s (1). There is anecdotal evidence that the number of complicated cases with more severe illness may be increasing. This is frequently due to severe underlying, often necrotic pneumonia, caused by unusual organisms (2), pulmonary abscesses or bronchopleural fistulas. Chest ultrasound does not reliably identify these processes and CT scanning is the investigation of choice. However, there has been little research in the use of chest CT in children with parapneumonic effusion and its use remains controversial. Aims To evaluate the usefulness of chest CT in children with parapneumonic effusion. Methods We retrospectively reviewed the medical notes and imaging of all children admitted between January 2004 and December 2009 with a diagnosis of parapneumonic effusion to the University Hospitals of Leicester NHS Trust. Results A total of 183 children were identified. Of this number, 51 children underwent CT scanning. The main indications for chest CT were as follows: slow/no response to IV antibiotic treatment (25%), failed attempt at chest drainage without urokinase (24%) and acute critical clinical deterioration (16%). Other indications included failure of chest drainage with urokinase, failure of surgical intervention or investigation for other pathology. A range of pathological findings were identified with CT. 38% of the CT scans identified collapse consolidation. Other pathology was also identified that was not apparent on ultrasound scan. 4% identified pulmonary abscess, 4% identified areas of lung necrosis, 4% identified broncho-pleural fistula and 6% identified cavitating pneumonias. Conclusion (1) A chest CT is useful in children with a complicated parapneumonic effusion to detect lung pathology not readily detected with chest ultrasound. (2) A small number of children have a pulmonary abscess complicating the parapneumonic effusion. (3) Further research is needed to establish the role and timing of chest CT scanning in children with infective pleural disease.
- [Show abstract] [Hide abstract] ABSTRACT: Existing evidence indicates that once mature neonates with severe cardio-respiratory failure become eligible for Extra Corporeal Membrane Oxygenation (ECMO) their chances of intact survival are doubled if they actually receive ECMO. However, significant numbers survive with disability. NEST is a multi-centre randomised controlled trial designed to test whether, in neonates requiring ECMO, cooling to 34 degrees C for the first 48 to 72 hours of their ECMO course leads to improved later health status. Infants allocated to the control group will receive ECMO at 37 degrees C throughout their course, which is currently standard practice around the world. Health status of both groups will be assessed formally at 2 years corrected age. All infants recruited to the study will be cared for in one of the four United Kingdom (UK) ECMO centres. Babies who are thought to be eligible will be assessed by the treating clinician who will confirm eligibility, ensure that consent has been obtained and then randomise the baby using a web based system, based at the National Perinatal Epidemiology Unit (NPEU) Clinical Trials Unit. Trial registration.Babies allocated ECMO without cooling will receive ECMO at 37 degrees C +/- 0.2 degrees C. Babies allocated ECMO with cooling will be managed at 34 degrees C +/- 0.2 degrees C for up to 72 hours from the start of their ECMO run. The minimum duration of cooling will be 48 hours. Rewarming (to 37 degrees C) will occur at a rate of no more than 0.5 degrees C per hour. All other aspects of ECMO management will be identical. Primary outcome: Cognitive score from the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III) at age of 2 years (24 - 27 months). For the primary analysis, children will be analysed in the groups to which they are assigned, comparing the outcome of all babies allocated to "ECMO with cooling" with all those allocated to "ECMO" alone, regardless of deviation from the protocol or treatment received. For the primary outcome the analysis will compare the mean scores for each group of surviving babies. The rationale for this choice of primary analysis is to give a fair representation of the average ability of assessable children, accepting the limitation that excluding deaths might impose.The consistency of the effect of cooling on the group of babies recruited to the trial will be explored to see whether cooling is of particular help, or not, to specific subgroups of infants, using the statistical test of interaction. Therefore pre-specified subgroup analyses include: (i) whether the ECMO is veno-arterial or veno-venous; (ii) whether the child's oxygenation index at the time of recruitment is <60 or > or = 60; (iii) initial aEEG pattern shown on the cerebral function monitor, and (iv) primary diagnostic group. Current Controlled Trials ISRCTN72635512.
Article: Coordinated response for ECMO[Show abstract] [Hide abstract] ABSTRACT: The number of patients referred for extracorporeal membrane oxygenation (ECMO) to the Heartlink ECMO Centre in Leicester for respiratory failure due to H1N1 influenza recently increased.1 In the month to 16 December 2010, 29 patients with confirmed H1N1 flu …
- [Show abstract] [Hide abstract] ABSTRACT: Congenital diaphragmatic hernia and oculocutaneous albinism are both rare birth defects that can be diagnosed in the newborn period. However, they have not been previously reported to have occurred together. This report describes a unique case of a male Asian baby with oculocutaneous albinism and a right-sided congenital diaphragmatic hernia.
- [Show abstract] [Hide abstract] ABSTRACT: Recurrent wheezing in children is frequently due to asthma and responds to bronchodilator therapy. We report a case of a 13-year old boy with a 2-year history of presumed asthma not responding to bronchodilator therapy. Bronchoscopy revealed a right main bronchus tumor, which was diagnosed as bronchial schwannoma after resection by sleeve lobectomy. We review the literature on this tumor.
- [Show abstract] [Hide abstract] ABSTRACT: Severe acute respiratory failure in adults causes high mortality despite improvements in ventilation techniques and other treatments (eg, steroids, prone positioning, bronchoscopy, and inhaled nitric oxide). We aimed to delineate the safety, clinical efficacy, and cost-effectiveness of extracorporeal membrane oxygenation (ECMO) compared with conventional ventilation support. In this UK-based multicentre trial, we used an independent central randomisation service to randomly assign 180 adults in a 1:1 ratio to receive continued conventional management or referral to consideration for treatment by ECMO. Eligible patients were aged 18-65 years and had severe (Murray score >3.0 or pH <7.20) but potentially reversible respiratory failure. Exclusion criteria were: high pressure (>30 cm H(2)O of peak inspiratory pressure) or high FiO(2) (>0.8) ventilation for more than 7 days; intracranial bleeding; any other contraindication to limited heparinisation; or any contraindication to continuation of active treatment. The primary outcome was death or severe disability at 6 months after randomisation or before discharge from hospital. Primary analysis was by intention to treat. Only researchers who did the 6-month follow-up were masked to treatment assignment. Data about resource use and economic outcomes (quality-adjusted life-years) were collected. Studies of the key cost generating events were undertaken, and we did analyses of cost-utility at 6 months after randomisation and modelled lifetime cost-utility. This study is registered, number ISRCTN47279827. 766 patients were screened; 180 were enrolled and randomly allocated to consideration for treatment by ECMO (n=90 patients) or to receive conventional management (n=90). 68 (75%) patients actually received ECMO; 63% (57/90) of patients allocated to consideration for treatment by ECMO survived to 6 months without disability compared with 47% (41/87) of those allocated to conventional management (relative risk 0.69; 95% CI 0.05-0.97, p=0.03). Referral to consideration for treatment by ECMO led to a gain of 0.03 quality-adjusted life-years (QALYs) at 6-month follow-up [corrected]. A lifetime model predicted the cost per QALY of ECMO to be pound19 252 (95% CI 7622-59 200) at a discount rate of 3.5%. We recommend transferring of adult patients with severe but potentially reversible respiratory failure, whose Murray score exceeds 3.0 or who have a pH of less than 7.20 on optimum conventional management, to a centre with an ECMO-based management protocol to significantly improve survival without severe disability. This strategy is also likely to be cost effective in settings with similar services to those in the UK. UK NHS Health Technology Assessment, English National Specialist Commissioning Advisory Group, Scottish Department of Health, and Welsh Department of Health.
- [Show abstract] [Hide abstract] ABSTRACT: Aortic root abscess without any involvement of the aortic valve is extremely rare. This report describes an 11-year-old girl with subperiosteal abscess due to a virulent organism called Panton-Valentine leukocidin-secreting staphylococci. Although her initial transthoracic echocardiogram did not show any cardiac abnormality, she subsequently experienced an aortic root abscess communicating with the left ventricle. The aortic valve was unaffected, and no other cardiac abnormality was detected at any stage. The girl made a complete recovery after surgical intervention for her aortic root abscess, which was increasing in size despite antibiotic therapy. Patients with such illnesses require close monitoring with repeated expert echocardiography and timely intervention.
- [Show abstract] [Hide abstract] ABSTRACT: To review the UK neonatal extracorporeal membrane oxygenation (ECMO) service and identify predictors of outcome. Retrospective review of the national cohort. Patients and interventions: 718 neonates received ECMO for respiratory failure between 1993 and 2005. Measurements and results: Diagnoses were: 48.0% meconium aspiration syndrome (97.1% survivors), 15.9% congenital diaphragmatic hernia (CDH; 57.9% survivors), 15.9% sepsis (62.3% survivors), 9.5% persistent pulmonary hypertension (79.4% survivors), 5.6% respiratory distress syndrome (92.5% survivors) and 5.1% congenital lung abnormalities (24.3% survivors). The overall survival rate of 79.7% compared favourably with the worldwide Extracorporeal Life Support Organization (ELSO) Registry. Over the period of review, pre-ECMO use of advanced respiratory therapies increased (p<0.001), but ECMO initiation was not delayed (p = 0.61). The use of veno-venous (VV) ECMO increased (p<0.001) and average run time fell (p = 0.004). Patients treated with VV ECMO had a survival rate of 87.7% compared with 73.4% in the veno-arterial (VA) ECMO group; only 42.4% of those needing conversion from VV to VA ECMO survived. In non-CDH neonates, lower birth weight, lower gestational age, older age at ECMO and higher oxygenation index (OI) were associated with increased risk of death. In CDH neonates, lower birth weight and younger age at ECMO were identified as risk factors for death. The UK neonatal ECMO service achieves good outcomes and with overall survival rate reaching 80% compares favourably with international results. Advanced respiratory therapies are used widely in UK ECMO patients. Identification of higher OI and older age at ECMO as risk factors in non-CDH neonates reinforces the importance of timely referral for ECMO.
- [Show abstract] [Hide abstract] ABSTRACT: Extracorporeal membrane oxygenation has been shown to be effective in term neonates with severe but reversible lung disease within the context of randomized, controlled trials. Extracorporeal membrane oxygenation now has been open to a wider population of infants in the United Kingdom, and other treatments have become available. The population referred for extracorporeal membrane oxygenation, therefore, has changed. The aims of this study were to (1) compare respiratory outcomes of infants who received extracorporeal membrane oxygenation in recent years with those from 10 years ago and (2) determine whether respiratory outcome varied with diagnostic group. All infants who were referred to a single extracorporeal membrane oxygenation center and were <12 months old during a 7-year period were eligible. One year after extracorporeal membrane oxygenation, lung volume, airway conductance, maximum expiratory flow, and indices of tidal breathing were measured. A total of 106 infants (77% of those eligible) were tested, and results were compared with those of 51 infants referred for extracorporeal membrane oxygenation as part of the original United Kingdom extracorporeal membrane oxygenation trial. Lung volume was not different, but there was a strong trend for the infants who were seen in more recent years to have better forced expiratory flow and specific airway conductance. Restricting analysis to the major subgroup (meconium aspiration) confirmed these findings. When divided into diagnostic subgroups, infants who required extracorporeal membrane oxygenation for respiratory distress syndrome or who were >2 weeks old when extracorporeal membrane oxygenation was commenced had a poorer respiratory outcome than others. The respiratory outcome of infants who were treated beyond the tightly regulated criteria of the United Kingdom trial remains good and even shows a trend toward improvement. Certain subgroups require extracorporeal membrane oxygenation for longer and have poorer pulmonary function when followed up.
University Hospitals Of Leicester NHS TrustLeiscester, England, United Kingdom
The Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle-on-Tyne, England, United Kingdom
University of Leicester
Leiscester, England, United Kingdom
- Department of Health Sciences
Great Ormond Street Hospital for Children NHS Foundation Trust
Londinium, England, United Kingdom
- • Department of Infectious Diseases
- • Cardiac Intensive Care Unit (CICU)