Pandemic flu: the final frontier

Dr Ratna MakkerConsultant Anaesthetist and Clinical Tutor_

Hemel Hempstead General Hospital

10th May 2007

St Albans Sports Club

GP Connect meeting

First Anaesthetist : sometimes first and last stop!

• "And the Lord God caused a deep sleep to fall upon Adam, and he slept"Genesis 2.21

Ghoul

UK Influenza contingency Plan

• Menon et al (2005) Flusurge.

• 8 week epidemic and 25% attack rate.

• Impact of neuraminidase inhibitors.

• Upgraded all level 2 beds to level 3

Findings

• >35000 weekly admissions to hosp >5000 daily admissions

• Total mortality >36000• >200% critical care bed

capacity

• Despite antiviral therapy and bed upgrades impact would result in unsustainable occupancy/ resources overwhelmed.

History of flu

• Hippocrates: 412 BC • At Perinthus (North

Greece)• Italian for influence• Also called grippe

Copenhagen 1952 Polio epidemic

• Copenhagen: left many patients paralyzed and medical students were allocated to ventilate these patients continuously by hand (due to shortages of tank ventilators).

Pessimist

• Globalisation• Catastrophic terrorism• Trained staff: absent 25%• Absences 8 days• ICU beds postcode lottery:

asynchronous with need.• Problems: staff and equipment• Space and cost• Number of victims, duration,• O2• Rent additional ventilators• Stockpile (USA Strategic

National Stockpile)• Children

Great Thinkers

• Trigger factor recognition

• Cancel elective list (dismayed Divisional Director and managers)

• Library of equipment and early mobilisation

• Log non critical care resources

Lateral Thinker

• Cancel elective lists• Use recovery and

operating theatres to ventilate

• Use Recovery nurses and ODPs

• Log negative impact• Post pandemic period

Even more laterally

• Can’t apply figures to all situations

• Pop of 100,000 and 150,000 in St Albans.

• Week 5 >900% rise in bed occupancy!

• 54 pts, 23 ventilated• 35% attack rate 84

pts, 36 ventilated

MMC and MTAS urgent meeting….s

Solutions

I C U admission

• Old, confused, hypotensive, tachypnoec, with uraemia.

• CURB 3-5: • pO2 <8 Kpa (fIo2>0.6)• Rising Pco2• Severe acidosis pH<7.26• Septic shock

So what will we do?

• Close schools• Wear masks• Quarantine• No large gatherings• Make tough decisions• World may change

forever!

Issues

• A] Micro: Equipment• Personnel• Space• B] Meso: co-

ordination• C] Macro: DOH

Micro:Equipment HHGH SACH

• 3 theatres +3 Anaesthetic rooms= 6 ventilators• A&E resus= 1 oxylog /4 bays• ITU= PB, 5+2, 1 oxylog= 8 ventilators• Recovery: 4 bays and 1 ventilator• SACH: 5 theatres and 5 anaesthetic rooms: 10

ventilators• ??BUPA Harpenden: 3 theatres and 3

anaesthetic rooms = 5 ventilators• Potentially 30 ventilators/ 36 patient bays

Micro: Personnel

• ITU nurses• Recovery nurses• Theatre scrub nurses• SCPs• ODPs• Anaesthetists : 13

trainees/ NCCG and 9 FT consultants

• Medical students, Unemployed doctors or official bag squEezers (OBE)

Micro: Space

• ITU• Theatres• Recovery• A&E• Acute medical ward

Micro: Cost

• No idea

Meso Issues

• Liase with Watford General Hospital

• L&D Hospital• East and North Herts• Cambridge• EBS • etc

Macro:

• No idea but contingent upon effective coordination

Questions

Acknowledgements/ Bibliography

• Diane, Library, HHGH• Dr James Ferguson• Google• Thorax Jan 2007• Anaesthesia 2005• BMC Health• Nurses Sci Q• Biosecurity, Bioterrorism 2006• Journal of Critical Care Sep 2003• Journal of Intensive care 2003• Critical Care Nursing clinics of North America 2007