Rescue Mission to Brazil

Marcelo with his wife Tatiana and their daughter Raphaela.

In the last week of January, there was a fatal fire at a night club in Santa Maria, Brazil, a university town of 250,000 people. 230 people died at the scene and many were evacuated to Porto Alegre, the state capital, for treatment of asphyxia, inhalation injury and poisoning by cyanide released from combustion of the insulation. There was only one exit for the 7-800 participants at the disco club. Rescuers flew the injured to Porto Alegre, 300 Km away, where they were distributed to 5 hospitals.

UHN thoracic surgeon Marcelo Cypel, who had completed medical school and residency training in Porto Alegre learned that some of the victims were dying in ICUs because of severe respiratory distress syndrome. When his former surgery colleagues notified the Brazilian Minister of Health of Marcelo’s work in lung failure, and he was asked to help (http://www.surgicalspotlight.ca/Article. aspx?ver=Spring-Summer_2012&f=RespiratoryTreatment). After receiving a telephone call from Minister Alexandre Padilha, Marcelo contacted intensivists at each hospital to assess the problem. Most felt reluctant to use extracorporeal membrane oxygenation (ECMO) because they had experienced such poor results with it previously.

Marcelo flew to Porto Alegre, went to each of the 5 hospitals, assessed all of the victims and called back to Toronto for ICU nurse Lina Karkanawi and perfusion manager Cyril Serrick to join him. In one lung failure patient with significant burns, they debrided the burns every 4 days, running the ECMO circuit off heparin during the operation. “At the same hospital, I was asked to see a patient with a head injury, and severe ARDS. He had poor oxygenation with blood saturation of 75% despite maximal ventilation. After 3 weeks of ECMO, he was decannulated and is recovering well. By the time I got to Sao Paulo airport for my connection flight to Porto Alegre, my cell phone started ringing - there was a death on ECMO. Clearly, they needed more help and equipment. At one hospital, which is a transplant centre, their previous ECMO experience led to 3 deaths, so they were reluctant to use the treatment. We brought experience into place and reassurance that good outcomes can be achieved if the indication is correct and the device is used at the right time. At the main centre in Porto Alegre, the first patient was on high pressure ventilation with single organ lung failure and a CO2 of 110. We inserted the Avalon cannula for veno venous ECMO. I called Novalung and Maquet and those companies sent equipment and people to help. The first patient could not be bronchoscoped because of hypoxia. Once he was on ECMO, we were able to debride his airway bronchoscopically. After 4 days of ECMO and frequent debridement, he was able to be maintained on gentle ventilation and decannulated by day 5. The government support was excellent and assured that there was good integration between the hospitals.”

Marcelo screened 50 patients. Only 3 needed ECMO, others were manageable on the ventilator or too badly burned to be subjected to anti-coagulation. Patients were prioritized on the basis of their primary lung injury with little or no body surface burns. One patient died at an ICU that resisted the institution of ECMO treatment. A young girl in another hospital required 12 days of ECMO. She was decannulated with remote guidance from Marcelo after he returned to Toronto.

“The main points to take away from this experience are:
ECMO is not an impossible or ineffective treatment, contrary to prior belief;

Use ECMO at the right time;
There were no complications related to ECMO itself in these 3 patients

The educational activities related to this mission were very important.”

Representatives of all the hospitals were educated by Lina, Cyril and Marcelo. After he left Porto Alegre, Marcelo did daily Skype conferences in Portuguese with the help of Eddy Fan, an intensive care physician from Toronto General Hospital. “There was a big expansion of knowledge in Brazil. They realized this can be done and patients can be saved with the right indication and strict management protocols we developed at UHN. That is our global impact. After we left Brazil, the teams there used this therapy in 2 additional patients with successful outcomes. We are doing the same for Ontario. ECMO using these techniques will become like dialysis in the future.

“The use of ECMO has increased dramatically in the past 2 years. The experience has demonstrated that the plateau pressure on the ventilator must be kept less than 25 cm to avoid injury. In the absence of ECMO, when patients become more desaturated, the usual practice is to increase the pressure, increase the FIO2, and turn the patient prone-all increasing the injury. ECMO can speed recovery because it avoids injury to the lung, allows us to remove sedation, remove paralysis, put the diaphragm to work, and get the patient up and mobilized in some instances. We have 4 patients in the ICU on ECMO now, some of them are reading, doing physiotherapy and exercising on the treadmill. This practical educational demonstration of the possibility of rescue of severely injured patients directly conflicted with my Brazilian collleagues’prior experience - like ours here in the early 2000's and also during the H1N1 pandemic in 2006 and 2007, when ECMO often was unable to rescue patients with acute lung failure. In contrast, in the last 2 years, the same population had a survival of 80% at our center.

“In the future, we will do more workshops in Brazil. Toronto is well positioned to develop a program approach because of the organized aspect of surgical care in the university. Practice in this field is moving faster than the literature. There is only one randomized trial of ECMO with a significant improvement over standard ventilation, but there have been thousands of patients treated with ECMO in Europe and North America in the last few years. We performed 30 cases last year, 10 in the first 2 months of this year. At present, we have funding only for the use of ECMO in patients awaiting lung transplantation. However we are working to obtain funding to use ECMO as a bridge to recovery in patients with acute lung illness where most of the time the lungs will recover and transplant is not needed.”

M.M.