A session blog from Day 2 of State of the Art, London December 2015. See the full list.
Blogger Ben Attwood
Tim Gould opens the session to explain why we couldn’t have much on Ebola last year – the key players were in the field at the time!
The British military experience in Sierra Leone
Following Ebola outbreak, Andy got the call from his boss asking ‘ I’ve got a special job for you’…!
The Army devised a programme of prevention and recovery in Sierra Leone.
Many healthcare workers (HCWs) were dying of Ebola during the epidemic – 70% mortality of those who contracted the virus.
How do you train for something you’ve never seen before? Simulated patient field training exercise.
Caring for Critically Ill patients with Ebola virus disease (Fowler RA et al AJRCCM 2014) provided some direction for strategy.
A military hangar in York is used as a simulated Ebola treatment centre, with innovations such as gas heaters to simulate 27 degree heat, and fluorescent dye to simulate infective diarrhoea and subsequent decontamination exercise.
Sierra Leone is very poor – not just economic but also hygiene, no health infrastructure. The MOD set up a treatment centre with 80 beds carved out of the jungle, potentially 36 beds to treat HCWs. Patients go into an assessment area, screened for fever, myalgia, vomiting. If suspected positive, get moved to a separate area for testing (PCR). If positive, go into confirmed area and treated. If negative, showered, changed and given money from SL government.
PPE pre-Ebola was very hot, moisture impermeable, goggles, helmets.
New suits for Ebola – lightweight, moisture-permeable, visors, more human looking!
Team comprised ICM specialists, ED, Gastro, Resp and GPs.
Patients are tested with nasal swab samples – they undergoing portable PCR analysis, 1 hour later – result. Prior to this there was a 72 hour lag time to diagnosis.
Fever – 48 hours – D+V – Bleeding / Multi-organ failure. Patients stigmatised if symptomatic so often presented late. The interventions changed over time to reflect increased information about disease.
CVC insertion reduced venepuncture requirement. Few needed blood transfusion despite being oozy. POC malaria. Transfusion lab on-site. iStat for electrolytes prompted aggressive K+ replacement which reduced hypokalaemia induced sudden death.
The unit used a Flexiseal to contain highly infectious diarrhoea – often patient asked for it!
Nutrition was addressed with plumpyNut – a high energy bar, safer and nicer than NG tube.
International HCWs infected were repatriated with 1st class care (e.g. Learjet flight home).
PPE donning highly supervised and exhaustive/exhausting. Andy shows a great time-lapse video of the process (can lose >1kg weight in the process!)
Public Health England and equivalent bodies requested daily surveillance logs.
Is it over? Not quite. DFID have co-ordinated a 16 bed mobile Ebola treatment unit.
- Ebola epidemic presented unique, novel challenge
- Required training for previously unexperienced issues
- Huge amount of learning has been achieved and will be disseminated.
- Caring for Critically Ill patients with Ebola virus disease (Fowler RA et al AJRCCM 2014)
Managing Ebola in a European ICU
The German experience. Dominic works in UMC Hamburg which has a treatment centre for highly contagious infectious disease. Impressive spec: 2 airlocks (1 staff, 1 patient). Positive pressure suits, negative pressure unit. Room which has Point of Care testing (ABG, electrolytes, microscope etc).
Ebola itself: it’s from the Filoviridae family which has 5 distinct phenotypes. Dominic trots through some pathophysiology. Ebola host is Bats, transmitted by smear infections, poor hygiene, rarely through sexual contact.
Dominic outlines Case example of a 35M working at SL with a typical presentation of Ebola. Has MODS (met acidosis, oliguria, hepatic dysfunction).
Is this direct virus effect or secondary to hypovolaemic shock?
Options are available to treat virus:
Brincidofivir (17 tablets, impractical), Zmapp (none available), TKM-Ebola (RNA molecule, approved for ‘emergency use’), Reconvalescens-Sera/Blood (requires serum match).
ICU shock treatment: Volume replacement (large volume shifts, with oedema ++, electrolyte disturbance) prompted CVC placement which is v challenging requiring rigorous training under BSL-4 conditions. Dominic shows video of clinicians in spacesuits circulating around the patient.
In treating patients, there was initially optimism as the numbers got better. However, as has already been talked about in this conference, better numbers do NOT mean better outcomes. Patients after a few days start dropping Hb, rising WCC, suggesting sepsis. Paralytic ileus common. Doing blood cultures not easy (couldn’t get samples to Micro!), so samples are incubated locally, and checked visually for resistance patterns. Results showed Gram negative organisms, which lead to change of antibiotics from ceph to meropenem.
In patients with deteriorating GCS and ileus, unsure how best to manage. In the end they settled for NIV with a gastric tube.
- Challenges: Large volume shifts, electrolyte imbalances, secondary complications
- Solutions: Well-prepared inter-professional and inter-disciplinary team
- Early Central Line Placement
- Close monitoring of electrolytes/vol status
- Flexible concepts for feeding, respiratory support, diagnostics
Planning for future highly contagious disease in a British ICU
Dan runs the Royal Free High level isolation unit.
Quote from the press “With no proven treatment for Ebola, care will be limited to Fairly Basic Supportive Treatment” and they will be treated through a plastic bag.
This is perhaps underplaying the situation!
Royal Free uses a Trexler isolator biocontainment system, with superb specialist nursing care and a MDT approach that provides critical care support but also has access to experimental therapies, some first in man.
He has a 100% success rate in the 4 patients treated with Ebola and with no healthcare worker infected.
Dan takes us through the 4, now famous patients, including the re-admitted patient with reactivated syndrome.
Coppetts Wood was the home of the High Security ID unit for smallpox infection, but never treated a smallpox patient. However they did successfully treat a case of Ebola from a needle-stick injury the Trexler system. There’s also been cases of Lassa fever and Congo fever.
He outlines what happens when you refer a patient to his unit.
A patient arrives in a patient transport isolator (sometimes with press helicopter cover!)
The unit is purpose built for high ID patients, maximum 2 and is a hospital-within-a-hospital. PPE is not used in management as ‘half-suits’ allow interaction with the patient, all contained on the inside. There’s a similar lab to the ones outlined by previous speakers used for point of care testing.
Treatments of EVD – Antivirals, convalescent plasma and Monoclonal antibodies which were all first-in-man were difficult to administer (lots of paperwork as never been used for treatment!)
Staffing is expensive (Dedicated ICU consultant 24/7, 4 nurses per shift, 2x daily MDT meetings. Again, a CVC placed on admission. All ICU resources (ventilator, invasive lines) available including RRT with its own tent!
Finally, how do you prepare for a patient with a highly contagious disease?
Clear, written and rehearsed plan for unexpected ED patient. New guidelines due in the New Year
Safety of staff is paramount
Rapid confirmation of diagnosis
Transfer team will take patient to a designated HLIU
- How do you prepare for a patient with a highly contagious disease?
- Clear, written and rehearsed plan for unexpected ED patient. New guidelines due in the New Year
- Safety of staff is paramount
- Rapid confirmation of diagnosis
- Transfer team will take patient to a designated HLIU
Long term sequalae of Ebola patients? Andy replies it appears that Ebola remains in immunoprivileged sites, not yet reported in the literature.
Is there a contigency plan for more than 2 patients in the UK? Dan says that there is a surge plan but if there were more than 8 patients it would be very challenging to accommodate. More facilities coming on stream.
Tim Gould asks how Dan manages the agitated patient – it’s a very difficult one, the unit has ready-drawn up meds to sedate if required.
Dominic is asked about NIV vs. intubating patient – again the safety of colleagues is paramount and decisions about intubation should only be made if risk of contamination is minimised.