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MEDICAL GRANDROUNDS

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  1. MEDICAL GRANDROUNDS October 22, 2009 Ledesma Hall Leonid Zamora MD

  2. OBJECTIVES • To present a case of a young female who developed complicated pneumonia secondary to Influenza A(H1N1) Virus Infection • To discuss the latest updates on the Virus.

  3. General Data • AMG • 23 years old • Female • Single • Filipino • a student from DLSU • Lives in Paranaque • Known Diabetic

  4. Chief Complaint • DYSPNEA

  5. HISTORY OF PRESENT ILLNESS • 5 DAYS PTA • non-productive cough • body malaise • high grade fever (Tmax 40.5C) • Consult at RITM • throat swab done • voluntary isolation at home

  6. HISTORY OF PRESENT ILLNESS • 2 DAYS PTA • persistence of the above symptoms • self-medicated with Cefuroxime 500mg 2x a day • No consult

  7. HISTORY OF PRESENT ILLNESS • Few hours PTA • increasing frequency and severity of cough • Dyspnea • No chest pains, orthopnea, paroxysmal nocturnal dyspnea • Throat swab done in RITM  POSITIVE • ER consult ADMISSION

  8. Review of Systems • No headache • No loss of consciousness • No blurring of vision • No nausea, vomiting • No dysuria, hematuria • No diarrhea/constipation • No bleeding • No polyuria, polydipsia, polyphagia

  9. Past Medical History • Diabetes since 2007 – on Metformin 500mg TID and Rosiglitazone 4mg OD • Hypertensive since 2008 - no maintenance medications (HBP 150/90 – UBP 130/80) • (+) PCOS x 5 months on Norethisterone (Primolut) and Medroxyprogesterone acetate (Provera) • No previous hospitalizations or surgeries • No known allergies.

  10. Family History • Diabetes and Hypertension  both parents • (+) Asthma  maternal side (cousins) • No Asthma • No Cancer

  11. Personal and Social History • Non smoker • Occasional alcoholic beverage drinker • No recent Travel outside Metro Manila • Student of DLSU – was recently closed due to reported cases of positive Inluenza A(H1N1)

  12. Physical Examination • Conscious, coherent, in respiratory distress • BP 110/70 HR 115 reg RR 30 Temp 39 C Ht 162.5cm Wt 109kg BMI 41.3 • Warm moist skin. No active dermatosis. • Pink palpebral conjunctivae, anicteric sclerae, moist buccal mucosa, nonhyperemic posterior pharyngeal wall, tonsils not enlarged, (+) alar flaring. • Supple neck, no cervical lymphadenopathies, (+) neck vein distention, no carotid bruit.

  13. Physical Examination • Symmetrical chest expansion, no lagging, (+) tight air entry, (+) wheezes, bilateral. • Adynamic precordium, AB at 5th Left intercostal space, Mid clavicular line, tachycardic, regular rhythm, no murmurs, no gallop rhythm. • Flabby abdomen, normoactive bowel sounds, non-tender, no masses, no organomegaly. No abdominal bruit. • Full and equal pulses. No cyanosis. No edema.

  14. Salient Features • 23 years old, Female • a student from DLSU • Diabetic • Obese • Dyspnea • Increasing severity of cough • Fever • POSITIVE for A(H1N1) • in respiratory distress. • BP 110/70 HR 115 reg RR 30 Temp 39C • (+) alar flaring • (+) neck vein distention • (+) tight air entry • (+) wheezes, bilateral.

  15. ADMITTING IMPRESSION Severe Sepsis secondary to Community Acquired Pneumonia secondary to Influenza A(H1N1) Diabetes Mellitus, Type 2, Non-insulin requiring Obese Class III Hypertension Stage 1 Polycystic Ovarian Syndrome

  16. COURSE IN THE WARD • At the ER • In respiratory distress • VS • BP 110/70 • HR 115 reg • RR 30 • Temp 39 C • O2 sat 82% at room air • NPO • CBC, CXR, ECG, ABGs • Hooked to Pulse Oximeter • MVM 0.5 • PNSS 1L x 100ml/hr • Rx: • Fenoterol + Ipratropium (Berodual) nebulization q4h, • Oseltamivir 75mg tab q12h, • Budesonide 500mcg BID nebulization, • Hydrocortisone 100mg q8h • Paracetamol 300mg q4h

  17. CXR (July 6, 2009) hazy infiltrates in the upper lobe likely due to pneumonia, infiltrates in the right paracardiac and left lower lobe

  18. Sinus Tachycardia NSSTTWC 12 – L ECG

  19. Arterial Blood Gases

  20. Complete Blood Count

  21. COURSE IN THE WARD • At the ER • In respiratory distress • VS • BP 110/70 • HR 115 reg • RR 30 • Temp 39 C • O2 sat 82% • Imp: Acute Respiratory Distress Syndrome • Infectious Disease Referral • Sputum GS/CS • Spec 16 • Started with • Piperacillin-Tazobactam 4.5g IV q8h • Levofloxacin 500mg IV q24h • Pulmonology and Endocrinology Referral

  22. ACUTE RESPIRATORY DISTRESS SYNDROME • Acute onset of Respiratory Failure • Diffuse Bilateral infiltrates on Chest radiograph • Absence of left atrial hypertension (PCWP < 18 mmHg or no clinical evidence of increased left atrial pressure) • Hypoxemia, PaO2/FiO2 < 200

  23. COURSE IN THE WARD • At the ER • In respiratory distress • VS • BP 110/70 • HR 115 reg • RR 30 • Temp 39 C • O2 sat 84% at MVM 0.5 • BIPAP not available • Pulmonology • DDIMER • Start • Enoxaparin 60mg SQ BID • Do ABGs q1h • Standby intubation

  24. Arterial Blood Gases

  25. COURSE IN THE WARD • At the ER • In respiratory distress • VS • BP 110/70 • HR 115 reg • RR 32-34 • O2 sats 83-84% on MVM • Shift MVM to inline neb at 0.6 FiO2

  26. COURSE IN THE WARD • 1st Hospital Day • At the ER • In respiratory distress • O2 sat 75% on in line neb at 0.6 FiO2 • Intubate • MV settings • AC • FiO2 100 • Vt 330 • RR 20 • PEEP 10 • CXR post intubation • ABGs 30 min post • Transfer to MICU • Reintubated

  27. CXR Increase infiltrates in the right lung. ET tube in place

  28. Arterial Blood Gases 30 mins post Intubation

  29. COURSE IN THE WARD • 1st Hospital Day • MICU • Fever Tmax 39C • O2 sat 83% at FiO2 1.0 • Infectious Disease • Discontinue Levofloxacin • Start • Moxifloxacin 400mg IV q24h • Blood CS x 2 sites • SPEC M • Refer to Nephrology for co management • Increase Vt to 500

  30. COURSE IN THE WARD • 1st Hospital Day • MICU • Fever Tmax 39.8C • BP 95/47 • HR 114 • Nephrology • Start IV Ig 50g + 500 ml sterile H2O • 1st Hour – 63.5 ml/hr • 2nd Hour – 127 ml/hr • 3rd Hour – 190 ml/hr • 4th Hour – 254 ml/hr until consumed • Pentoxifylline drip 300mg x 8h x 6 doses

  31. Pentoxifylline in severe sepsis: a double-blind, randomized placebo-controlled study KH Staubach, J Schröder, P Zabel and F StüberDept. of Surgery, Medical University of Lübeck and Kiel, ForschungszentrumBorstel Critical Care 1998, 2(Suppl 1):P017doi:10.1186/cc147

  32. 51 patients • MOF-score  lower in POF treated patients • PaO2/FioO2-ratio was significantly improved in POF treated patients • Pressure-adjusted heart rate (HR×CVP/MAP) was significantly improved from day 6 to day 10 (P < 0.05)

  33. Polyclonal Intravenous Immunoglobulin for the Treatment of Severe Sepsis and Septic Shock in Critically Ill Adults: A Systematic Review and Meta-analysis Conclusion: Demonstrates an overall reduction in mortality with the use of IVIg for the adjunctive treatment of severe sepsis and septic shock in adults Critical Care Medicine: Kevin B. Laupland, MD, MSc; Andrew W. Kirkpatrick, MD; Anthony Delaney, MBBS, MSc. Published: 01/14/2008

  34. COURSE IN THE WARD • 1st Hospital Day • MICU • Fever Tmax 39.8C • BP 95/47 • HR 114 • CVP 20 • Nephrology • Start • Dopamine 400mg/100ml PNSS at 3mcg/kg/min • Dobutamine 500mg/1ooml PNSS at 10mcg/kg/min • Voluven 6% 500ml x 25oml/hr • Hydrocortisone 50mg IV q8h • Furosemide 120mg IV now

  35. COURSE IN THE WARD • 1st Hospital Day • MICU • Albumin 3 • Nephrology • Plasma Cortisol • CBC, CXR portable , DDIMER, CRP, Spec 16, Urinalysis, ABGs, Urine CS • Foley Catheter inserted • Start • Esomeprazole 40mg IVOD • Human Albumin 25% 100ml x 1 hr

  36. Arterial Blood Gases

  37. COURSE IN THE WARD • 1st Hospital Day • MICU • VS • O2 sats 83% • BP 123/64 • Mech Vent Settings • AC • FiO2 1.0 • Vt 400 • RR 34 • PEEP 20 • Pulmonology • Shift Berodual to Terbutaline nebulization q8h • Acetylcysteine neb 600mg

  38. COURSE IN THE WARD • 2nd Hospital Day • Febrile Tmax 38.2 • BP 114/60 • Dobu 5mcg, Dopa 3mcg • HR 139 • O2 sats 92% • Impression: • r/o Pneumocystis Carinii Pneumonia • CVP 22.5 • Infectious Disease • Start • Cotrimoxazole 400/80mg IV q8h • Sputum for PCP – IF • Nephrology • Furosemide 20mg IV q6h • Mannitol 50mg IV drip 30min after furosemide dose

  39. COURSE IN THE WARD • 2ND Hospital Day • As treatment for fibroproliferative phase of ARDS • Pulmonology • Start • Methylprednisolone 4mg/kg q8h • Decrease FiO2 to 0.85  0.75

  40. Methylprednisolone Infusion in Early Severe ARDS*Results of a Randomized Controlled Trial CONCLUSIONS: Methylprednisolone-induced down-regulation of systemic inflammation was associated with significant improvement in pulmonary and extrapulmonary organ dysfunction and reduction in duration of mechanical ventilation and ICU length of stay AU Meduri GU; Golden E; Freire AX; Taylor E; Zaman M; Carson SJ; Gibson M; Umberger R SO Chest. 2007 Apr;131(4):954-63

  41. COURSE IN THE WARD • 3RD Hospital Day • HR 120s, RR 30s, dyspnea • O2sats 95% at FiO2 0.75 • Na 151 • ECG  sinus tachycardia • Hold Terbutaline • Increase FiO2 to 1.0 • Nephrology • Shift IVF to 1/2NSS x 40ml/hr • Dec Furosemide 20mg q8h • Dec Mannitol 50mg to q8h • Give 2nd dose of IV Ig

  42. COURSE IN THE WARD • 4th Hospital Day • 7th Hospital Day • 8th Hospital day • VS • BP 120/70 • Afebrile • O2sats 96% • Keep decreasing FiO2 below 1.0 to keep O2 sats above 90% • Weaning from Mech vent started • Patient was transferred out of MICU • Pip-Tazo Discontinued • Methylprednisolone tapering started

  43. COURSE IN THE WARD • 14TH Hospital Day • VS • BP 120/70 • O2 sats 92% • On T-piece FiO2 0.35 • RSB 18.87 • 15th Hospital Day • ABGs pO2 – 75.7 (115) • At MVM 0.5 • Patient was extubated • Shifted to MVM 0.5 • Hooked to BIPAP • IPAP 15 • EPAP 5 • SIDEFLOW 70

  44. COURSE IN THE WARD • 17TH Hospital Day • ABGs pO2 – 85.6 on BIPAP • 21st Hospital Day • CBC (07/27/09) • WBC – 23.65 (14.4) • Urine CS E.Coli • Sensitive to Cefuroxime • Imp: Hospital Acquired UTI • BIPAP shifted to O2 at 3LPM • Start Cefuroxime 500mg BID • Foley cath removed

  45. COURSE IN THE WARD • 28TH Hospital Day • 31st Hospital Day • HRCT done • MGH

  46. Clinical Course of ARDS • Exudative Phase (Day 1-7) • Proliferative Phase (Day 7-21) • Fibrotic Phase

  47. FINAL DIAGNOSIS • Severe Complicated Pneumonia H1N1 infection with Acute Respiratory Distress Syndrome • Diabetes Mellitus, Type 2, Non insulin Requiring • Obese Class III • Hypertension Stage I • Polycystic Ovarian Syndrome

  48. Influenza A (H1N1)

  49. Influenza is usually a respiratory infection Transmission Regular person-to-person transmission Primarily throughcontact with respiratory droplets Transmission from objects (fomites) possible National Center for Disease Prevention and Control, DOH

  50. Key Characteristics Communicability Viral shedding can begin 1 day before symptom onset Peak shedding first 3 days of illness Correlates with temperature Subsides usually by 5-7th day in adults Infants, children and the immuno-compromised may shed the virus longer National Center for Disease Prevention and Control, DOH