Transcript leptospirosis task force

Good
Morning!
LEPTOSPIROSIS TASK FORCE
(PSN/PSMID/PCCP)
2010
Suspected leptospirosis case [Grade A]
1. acute febrile illness of at least 2 days
2. residing in a flooded area
or
high-risk exposure
(wading in floods and contaminated water, contact with animal fluids,
swimming in flood water or ingestion of contaminated water)
3. presenting with at least two of the following
symptoms:
myalgia, calf tenderness, conjunctival
suffusion, chills, abdominal pain, headache,
jaundice, or oliguria
MILD LEPTOSPIROSIS
1. stable vital signs
2. anicteric sclerae
3. good urine output
4. no evidence of meningismus / meningeal irritation,
sepsis , difficulty of breathing nor jaundice
5. can take oral medications
6. can be managed on an OUT-PATIENT SETTING
[Grad e A]
MODERATE TO SEVERE LEPTOSPIROSIS
1. unstable vital signs
2. jaundice/icteric sclerae
3. abdominal pain, nausea, vomiting and diarrhea
4. oliguria/anuria
5. meningismus /meningeal irritation
6. sepsis / septic shock
7. altered mental states
8. difficulty of breathing and hemoptysis
9. BEST managed in a HEALTHCARE / HOSPITAL
SETTING. [Grade A]
Diagnosis ?
- generally, it is not necessary to confirm the diagnosis or
wait for the result of the tests before starting treatment
- the clinical assessment and epidemiologic history are more
important
- early recognition and treatment is MORE important to
prevent complications and mortality
locally available diagnostic tests
A. Direct Detection Method
1. Culture and isolation
- GOLD standard
- 6 to 8 weeks for the result
2. Polymerase Chain Reaction (PCR)
- early confirmation of the diagnosis especially during the acute
leptospiremic phase (first week of illness)
- not generally available because of the cost-limiting
nature of the test and the need for trained personnel
B. Indirect Detection Methods
1. Microagglutination Test (MAT)
- highly sensitive and specific
- time-consuming
- hazardous to perform because of the risk of exposure to the live
antigen
2. Specific IgM Rapid Diagnostic Tests
l
LeptoDipstick®, Leptospira IgM ELISA (PanBio), MCAT and Dridot®
- serologic tests in a single test format for the quick detection
of Leptospira genus-specific IgM antibodies in human sera
3. Nonspecific Rapid Diagnostic Tests like LAATS
(Leptospira Antigen-Antibody Agglutination Test )
- This is used as a screening test but is NOT sensitive
- A positive result should be confirmed with MAT
laboratory findings/markers of severe leptospirosis
1.CBC – leucocytosis (WBC>12,000 cells/cumm)
neutrophilia and thrombocytopenia (<100,000 cells/cu mm)
2. Serum creatinine > 3 mg/dL (or CrCl < 20 ml/min) and
BUN > 23 mg/dL
3. Liver function tests - AST/ALT ratio > 4x
Bilirubin > 190 umol/L
4. prolonged prothrombin time (PT) < 85%
laboratory findings/markers of severe leptospirosis
5. Serum potassium > 4 mmol/L
6. ABG- severe metabolic acidosis (ph< 7.2, HCO3 < 10)
hypoxemia (PaO2 < 60 mmHg, SaO2 < 90%)
7. Chest radiograph - extensive alveolar infiltrates
8. Electrocardiogram - heart block, myocarditis
Antibiotic Treatment :
1.Doxycycline
- drug ofchoice
- Alternative drugs : amoxicillin and azithromycin
dihydrate.
[Grade B]
2. For moderate-severe leptospirosis :
- penicillin G - the drug of choice
- Alternative drugs : parenteral ampicillin, 3rd generation
cephalosporin (cefotaxime, ceftriaxone), and parenteral
azithromycin dihydrate. [Grade A]
Antibiotic therapy should be completed
for 7 days, except for azithromycin dihydrate
which could be given for 3 days. [Grade A]
Any one of the following is an indication for dialysis : [Grade A]
a. Uremic symptoms – Nausea, vomiting, altered mental status,
seizure, coma
b. Serum creatinine > 3mg /dL
c. Serum K > 5 meq /L in an oliguric patient
d. ARDS /pulmonary hemorrhage
e. pH < 7.2
f. Fluid overload
g. Oliguria despite measures following the algorithm
Algorithm for the Management of Oliguria in Leptospirosis
Oliguria - <0.5 ml/kg/hr or <400 ml/day or
self-report of low or no urine output in 12 hrs.
YES
Mean Arterial Pressure
</=65 mm Hg
Start Norepinephrine and titrate
to keep MAP >65 mmHg
NO
Assess Fluid Status
YES
Hypovolemic?
NO
• Fast drip Normal Saline Solution, 20 ml/kg/hr
and reassess after 15 minutes
• Continue hydration till euvolemic
•Adjust IVF rate to suit patient needs
Furosemide 40 mg IV bolus or
Bumetamide 1 mg IV
Urine Output
>/= 0.5ml/kg/hr?
Urine Output
>/= 0.5ml/kg/hr?
No
Yes
No
No
Acute Renal Replacement Therapy
• Reassess kidney
status
• Monitor hourly and
adjust rate of IVF to
maintain euvolemia
• Reassess kidney
status
Double dose of furosemide (or Bumetamide)
hourly up to a maximum of 160 mg (or 4 mg)
Urine Output
>/= 0.5ml/kg/hr?
Yes
• Monitor hourly and
adjust rate of IVF to
maintain euvolemia
Yes
• Monitor hourly and
adjust rate of IVF to
maintain euvolemia
• Reassess kidney
status
PHILIPPINE SOCIETY
OF NEPHROLOGY
DISASTER
RESPONSE TO
CRUSH INJURY /
CRUSH SYNDROME
Crush injury
- a direct injury caused by collapsing material and debris resulting in
manifest muscle swelling and/or neurological disturbances in the
affected parts of the body
Crush Syndrome
- patients with crush injury and systemic manifestation due to
muscle cell damage which would include: acute kidney injury, sepsis,
acute respiratory distress syndrome, diffuse intravascular
anticoagulation, bleeding, hypovolemic shock, cardiac failure,
arrhythmias, electrolyte disturbances
Specific indications for nephrology referral:
Elevated serum creatinine
Hyperkalemia
Hypocalcemia
Hyperphosphatemia
Hyperuricemia
Metabolic acidosis
Elevated total CK of > 5,000 IU/L
Presence of reddish-brown urine / urine myoglobin
Decreased urine output (<0.5 ml/kg/hr x 4 hours)
Fluid overload
Indications for renal replacement therapy:
Serum creatinine > 8 mg/dl
Serum K > 6 mEq/L
Serum pH < 7.1 or serum HCO3 < 10
Pulmonary congestion / Edema
Uremia
Prophylactic dialysis may be indicated in rapidly progressing
hyperkalemia even if the above parameters are not met
PRE-EXTRICATION MANAGEMENT OF POTENTIAL CRUSH INJURY
VICTIM
VICTIM UNDER THE RUBBLE
VEIN IS
AVAILABLE
YES
GIVE 1L/HR OF ISOTONIC
SOLUTION FOR THE 1ST 2 HRS.2,10-13
NO
ATTEMPT ORAL
HYDRATION FOR
THOSE THAT CAN BE
REACHED
IS IT SAFE TO
HYDRATE THE
VICTIM?
GIVE SALINE
AT 0.5 L/HR
YES (REASSESS
EVERY 2-4
HRS)
NO
LIMIT HYDRATION
TO 1L/DAY
CONTINUE MANAGEMENT UNTIL EXTRICATION WITH CONTINUOUS CLOSE MONITORING OF
FLUID STATUS ONCE EXTRICATED PLEASE PROCEED TO POST-EXTRICATION ALGORITHM
POST –EXTRICATION MANAGEMENT OF POTENTIAL CRUSH INJURY
VICTIM
(PRE-HOSPITAL PHASE)
EXTRICATED VICTIM
INDICATIONS FOR
NEPHROLOGY REFERRAL
(Please see nephrology notes)
PRIMARY SURVEY
PRESENCE OF OTHER
MEDICAL
CONDITION
YES
MULTIDISCIPLINARY REFERRAL
(PLEASE REFER TO SPECIFIC
INDICATIONS FOR NEPHROLOGY
REFERRAL)
1. Hyperkalemia on ECG
2. Presence of reddish-brown
urine
3. Decreased urine output
(<0.5 ml/kg/hr x 4 hours)
4. Fluid overload
NO
DOES THE VICTIM
NEED TO BE
HYDRATED?
NO
VICTIM MAY BE
DISCHARGED WITH
PROPER ADVICE
YES
GIVE 1L/HR OF ISOTONIC
SOLUTION FOR 2HRS
REASSESS AFTER 2HRS
IS IT SAFE TO
MAINTAIN
HYDRATION?
NO
YES
GIVE SALINE AT
0.5L/HR
REASSESS EVERY 2-4
HRS
MAY DO SECONDARY SURVEY AS NEEDED
LIMIT HYDRATION TO
1L/DAY
ADMIT TO HOSPITAL
THANK
YOU