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October 21, 2009

Pandemic Influenza A (H1N1) in Critically Ill Pediatric Patients. Clinician Outreach and Communication Activity (COCA) Conference Call . October 21, 2009. Continuing Education Disclaimer.

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October 21, 2009

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  1. Pandemic Influenza A (H1N1) in Critically Ill Pediatric Patients Clinician Outreach and Communication Activity (COCA) Conference Call October 21, 2009

  2. Continuing Education Disclaimer In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. CDC, our planners, and our presenters wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use.There is no commercial support.

  3. Accrediting Statements CME: The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Centers for Disease Control and Prevention designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity. CNE: The Centers for Disease Control and Prevention is accredited as a provider of Continuing Nursing Education by the American Nurses Credentialing Center's Commission on Accreditation. This activity provides 1 contact hour. CEU: The CDC has been approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET), 8405 Greensboro Drive, Suite 800, McLean, VA 22102. The CDC is authorized by IACET to offer 0.1 CEU's for this program. CECH: The Centers for Disease Control and Prevention is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the CHES to receive 1 Category I contact hour in health education, CDC provider number GA0082.

  4. Initial Presentation – PCP’s Office: 10.30 am - Day 0 • 13 yr old AA previously healthy adolescent male • 4-day history of sore throat, productive cough • Fever, chest pain – 1 day • Rapid screen for Influenza – Positive • Started on Oseltamivir and Azithromycin • Past history of superficial leg abrasion while playing football – 5 days ago • Dr Samir Shah • Dr Rebekah Shappley • Dr K.J.S. Anand • Division of Pediatric Critical Care Medicine • Le Bonheur Children’s Medical Center • Memphis, TN

  5. Presentation – Outside Hospital ED: 10.45 pm - Day 0 • Received 2 doses of Oseltamivir, 1 dose of Azithromycin • Increased chest pain and progressive dyspnea  ED visit • T - 37.5; BP - 101/54; HR – 130; RR – 62; SaO2- 99% on RA • Diminished breath sounds, bilateral rales and rhonchi • CXR: Extensive bilateral infiltrates, reticulonodular pattern • CBC: WBC 0.4; 12%PMDs, 7% bands, 66%L; Platelets – 208 • Plan: Admit & treat pneumonia with Ceftriaxone

  6. Outside Hospital ED: Day 1 • Progressive worsening to hypoxic respiratory failure • HR - 112, RR - 30, SaO2 94%, on 15L O2 via NRB • ABG: pH 7.18/ pCO2 55/ PO2 38/ HCO3 22 / BD -8 • Intubated by ED physician – 100 ml of BRB from ETT • Vt 400, PEEP 510, Rate 20, 100% FiO2;  SaO2 70-80% • Fluid resuscitation for hypotension  Dopamine started • Transport to PICU requested

  7. Pediflite to PICU transfer: Day 1 • 50 ml bright red blood via ETT – Patient BVM with high PEEP, sedated, paralyzed and transferred to PICU at Le Bonheur Children’s Hospital • At PICU admission: 04:45 hrs: HR - 142, SaO2 58% hand ventilated, BP 118/39, poorly palpable pulses • Progressive hypoxic respiratory failure due to ARDS, influenza pneumonitis, possible secondary bacterial infection presenting in septic shock • Contd pulmonary hemorrhage (approx 500 ml BRB) within 2 hrs • Conventional ventilation with high PEEP (15)  HFOV (MAP escalated from 24 to 34)

  8. Day 1 : 05.00 am – 10.00 am • Mechanical ventilation efforts impeded by need for ETT suctioning and limitations of HFOV • SaO2 improved briefly with BVM ventilation 86-90% • Hypotension despite fluid resuscitation, escalation of inotropes, vasopressin, blood / FFP transfusion(s); milrinone? • ECHO: Ejection fraction 35%; Fractional Shortening 13% • CBC – 0.4 WBC, Platlets 115 • INR - 1.73 , aPTT - 37.1, D dimer - 18.19, Fibrinogen – 387 • Lactic Acid 3.76, ABG: pH 7.18 / pCO2 51 / paO2 71 / HCO3 21 • Oseltamivir, Vancomycin, Meropenem, Azithromycin • Stress dose steroids initiated; Influenza A PCR – positive H1N1 • ECMO posed risks of further pulmonary hemorrhage, parental concerns regarding risks

  9. Day 1 : 10.00 am – 01.00 pm • Activated Factor VII administered to control ongoing hemoptysis which transitioned to pink frothy secretions • Surgery re-consulted for ECMO cannulation with SaO2 in the mid 80’s • VV ECMO cannulation: Rt Femoral and Rt IJ cutdown • Asystolic event during VV cannulation : ROSC 18 mins • Rt. sided pneumothorax noted – Chest tube inserted • Vitals after VV ECMO: HR 125, BP 94/40, SaO2 78% • Post ECMO ABG: pH 6.98, pCO2 44, paO2 59, HCO3 11

  10. PICU Course • Hyperkalemia and oliguria med mgmt; CVVHD • Hct – 29 despite multiple transfusions • Rising lactic acidosis: 10 to 20 • Blood culture positive for gram positive cocci (MRSA) • Converted to VA ECMO 6 hrs post VV ECMO in view of rising acidosis • Also on: Milrinone; Nitroprusside + Thiosulphate • No improvement despite VA ECMO X 3 days • Pupils – Non reactive, No purposeful movements • Exam – Consistent with brain death ( PICU day 4) • Support withdrawn

  11. Post Mortem Findings H1-N1 influenza virus confirmed by pre- and postmortem PCR Hemorrhagic necrosis involving both lungs, acute inflammation Focal areas of hyaline membrane, suggestive of ARDS Scattered basophilic structures suspicious for viral inclusions Culture Results: MRSA positive in the postmortem lung tissue cultures and premortem blood culture Aspergillusfumigatus, right lung and left pleural fluid Bone marrow with rare MRSA Multi-organ system failure with associated areas of necrosis involving lungs, liver, spleen, and adrenal glands

  12. Points to Ponder • Combination of Influenza and secondary MRSA – lethal • Pulmonary hemorrhage a poor prognostic sign • Therapeutic response to Oseltamivir, antibiotics? • Limited access to “adult” HFOV • Myocardial dysfunction as possible co-morbidity, consider initiating ECMO • Veno-Venous Vs. Veno-Arterial ECMO?

  13. Case Presentation-Previously healthy 5 year old male CDC/HHS-ASPR Clinical Call on Severe Pediatric H1N1 Infections 21 October 2009

  14. History / Presentation • Previously healthy 5 year old male with cough and fever to 101oF x 24 hours • Seen by PCP-mild improvement with albuterol neb and steroids • Presented to outside ED that evening with increased WOB • RA sat 73%, failed trial BiPAP due to persistent hypoxemia • Intubated and transferred to TCH PICU • Exam: • T 38.5; HR 150s; SpO2 91%; • Vent settings: FiO2 1.0, f 30, Vt 9ml/kg, 27-30/10 • Poor aeration, prolonged expiratory phase, bilateral wheeze and rales. • Labs: • ABG: 7.27/48/85/-5 • WBC 12.8, 94% segs, 4% bands, 2 lymphs • H1N1 PCR positive • BCx obtained • Past Medical History: • Previous episodes of RAD, occasional albuterol with URIs • No hospitalizations • No ED visits or steroids bursts for over 1 year

  15. Diagnoses: • H1N1 infection • Reactive component • Treatment: • Tamiflu • Methylpred, albuterol • Dopamine

  16. Hospital Course • Hospital Day 2 • Conventional ventilation: Vt 6 ml/kg, PIPs 30s • Remains hypoxemic with poor compliance • Oxygenation Index ([100 x FiO2 x MAP]/PaO2) = 30 o • Transitioned to HFOV: 6 Hz, MAP 20, delta P 49 • Initial ABG: 7.16/73/71/-4.4 • OI = 40 • Hospital Day 4 • OI on HFOV decreased to 12 • CXR reveals large pneumomediastinum • Transitioned back to CMV

  17. Hospital Day 4 • Intubated on CMV • OI = 15 • Remains intermittently febrile • Improved aeration on exam, scattered rhonchi, crackles throughout • All cultures remain negative

  18. Jaime E. Fergie, M.D.Director, Infectious DiseasesDriscoll Children's HospitalAssociate Professor of PediatricsTexas A&M University

  19. Previously healthy 12-years-old adolescent female. 9/24 in the evening: not feeling well, only specific complain was sore throat 9/25 at 7am 102.7ºF. Now with cough. Given ibuprofen and cough medication .At 8:30pm abdominal pain. At 10:30pm shaking, fever 104ºF. Vomited 3 times. Unable too walk, and crying with generalized pain. Profuse watery diarrhea. Intermittently unresponsive. Driscoll Children’s Hospital ER: 104.8ºF, received I.V. boluses. Admitted but shortly after arrival with profuse watery diarrhea in bed. Less responsive. PICU: Head CT Scan followed by brain MRI and MRA. Required intubation before imaging studies. Rapid Influenza A test + Received oseltamivir 75mg q 12h and acyclovir

  20. Review of systems: No rhinorrhea, no conjunctival injection or rashes. Past medical history: febrile seizure at 9 months of age and tympanostomy tube placement at 8 years of age. IUTD. Family history; Mother 39 years old with hypothyroidism and hypertension, father 40 years old an healthy. Brother 18 years old and healthy Epidemiological history: Corpus Christi, TX No recent illness at home School: 6th grade. Several children sick with ILI. Played soccer on 9/18. Parents remember there were many mosquitoes that evening Physical examination: On conventional mechanical ventilation HR:58, RR 12, O2Sat 100%, BP 106/52 No exanthem or enanthem Lungs: CTA Heart: RRR Abdomen: Soft. No visceromagaly No lymphadenopaties

  21. 9/26/09 Influenza A antigen + WBCs:5,400. 4b, 66s, 27 l, HgB:14gm/dl, Plts:213,000 Bun 15mg/dl, Cr1.3 mg/dl SGOT 79, SGPO 46 u/L T.Protein 5.4 mg/dl, albumin 3,1 gm/dl PT;16.1secs, PTT 42 secs. Blood, CSF and Urine cultures, all no growth for bacteria. CSF WBCs:2 RBCs:7 Glucose 78mg/dl Protein: 192 mg/dl Gram: NOS 9/27/09 RT-PCR + Influenza A, H1 and H3 negative. (local health department confirmed in second sample swine origin H1N1) 9/29/09 ETT culture: Influenza A and Parainfluenza 3 Laboratories

  22. Admission 9/26/09 9/28/09 ( 1 day before death)

  23. Brain MRI on Admission 9/26/09

  24. Hospital Course • Within the first 24 hours after admission developed dysautonomia, with wide fluctuations in her heart rate and blood pressure. Pupils from pinpoint to dilated and unresponsive, loss of gaga and cough reflex and no spontaneous respiratory effort • Brain CT scan 9/27 1pm: Pending herniation. 7pm: progressive herniation • Brain death on 9/28

  25. DCH 352720 DCH352720

  26. Continuing Education Credit/Contact Hours for COCA Conference Calls Continuing Education guidelines require that the attendance of all who participate in COCA Conference Calls be properly documented. ALL Continuing Education credits/contact hours (CME, CNE, CEU and CECH) for COCA Conference Calls are issued online through the CDC Training & Continuing Education Online system http://www2a.cdc.gov/TCEOnline/.   Those who participate in the COCA Conference Calls and who wish to receive CE credit/contact hours and will complete the online evaluation by November 20, 2009 will use the course code EC1265. Those who wish to receive CE credits/contact hours and will complete the online evaluation between November 21, 2009 and October 21, 2010 will use course code WD1265. CE certificates can be printed immediately upon completion of your online evaluation. A cumulative transcript of all CDC/ATSDR CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user.

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