Authorities must plan for a surge in critical illness caused by swine flu

One major difference between the current influenza pandemic and previous pandemics is the rapid and systematic reporting of data describing the patients affected, how they were treated, and what happened. Observational studies of the first months of the pandemic are already available from Canada, Mexico, and Australasia. All three describe the sickest patients with H1N1 infections—those who had a short illness characterised by fever followed by rapid respiratory failure, refractory hypoxaemia, and often shock and multiorgan failure. These patients were typically young adults or adolescents who were reasonably healthy, although a substantial minority had chronic health problems such as asthma, diabetes, or obesity. All were admitted to intensive care units where they needed prolonged ventilation, vasopressors, and a range of sophisticated supportive treatments.

Mortality for these patients was higher in Mexico (41.4% (24/58) at 60 days; 95% CI 28.9% to 55.0%) than in Canada (17.3% (29/168) at 90 days, 12.0% to 24.0%). The Australasian study reported a mortality of 21% (14/68; 11% to 30%) among people who were sick enough to need extracorporeal membrane oxygenation.

The Mexican study included 58 people treated in six units in April and May. The Canadian study included 168 people treated in 38 units between April and August. Resources were stretched to the limit in both countries despite the modest numbers, says an editorial (doi:10.1001/jama.2009.1539). Planners may need to reconfigure services to make more efficient use of available beds, equipment, and expertise. Failing that, they will have to decide openly and explicitly who will and who will not receive life support.

High inspired oxygen doesn’t prevent wound infections

Debate continues over the value of a high percentage of inspired oxygen during surgery after a trial found that 80% oxygen did not prevent wound infections. The double blind trial was large and fairly conclusive: 131 of 685 (19.1%) patients given 80% oxygen …