Influenza AH1N1 and ARDS by Leonid Zamora Medical
Download
Report
Transcript Influenza AH1N1 and ARDS by Leonid Zamora Medical
MEDICAL GRANDROUNDS
OCTOBER 22, 2009
LEDESMA HALL
LEONID ZAMORA MD
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.
General Data
AMG
23 years old
Female
Single
Filipino
a student from DLSU
Lives in Paranaque
Known Diabetic
Chief Complaint
DYSPNEA
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
HISTORY OF PRESENT ILLNESS
2 DAYS PTA
persistence of the above
symptoms
self-medicated with
Cefuroxime 500mg 2x a
day
No consult
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
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
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.
Family History
Diabetes and Hypertension both parents
(+) Asthma maternal side (cousins)
No Asthma
No Cancer
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)
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.
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, nontender, no masses, no organomegaly. No abdominal
bruit.
Full and equal pulses. No cyanosis. No edema.
Salient Features
23 years old, Female
in respiratory distress.
a student from DLSU
BP 110/70
Diabetic
Obese
Dyspnea
Increasing severity of
cough
Fever
POSITIVE for A(H1N1)
HR 115 reg
RR 30 Temp 39C
(+) alar flaring
(+) neck vein distention
(+) tight air entry
(+) wheezes, bilateral.
ADMITTING IMPRESSION
• S eve re S ep s i s s e c o n d a r y t o
•
•
•
•
C o m mu ni t y A c q u i re d P n e u m o n i a
secondary to Influenza A(H1N1)
D i ab e t e s M e l l i t u s, Ty p e 2 , N o n - i n s u l i n
re q u i r i n g
Obese Class III
H y p e r t e n s i o n S t age 1
Po l ycys t i c O va r i a n S y n d ro me
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
CXR (July 6, 2009)
hazy infiltrates in the
upper lobe likely due to
pneumonia, infiltrates in
the right paracardiac
and left lower lobe
Sinus Tachycardia
NSSTTWC
12 – L ECG
Arterial Blood Gases
pO2
pH
pCO2
HCO3
O2sat
BE
TotCO2
FiO2
RR
58.9
7.39
39.1
23.4
90.5
-1.2
24.6
50
26
Complete Blood Count
Hemoglobin
Hematocrit
WBC
Seg
Lymphocytes
Monocytes
Eosinophils
Platelets
12.7
38.7
4.76
82
15
3
230
COURSE IN THE WARD
At the ER
Infectious Disease
In respiratory distress
VS
Referral
BP 110/70
HR 115 reg
RR 30
Temp 39 C
O2 sat 82%
Imp: Acute Respiratory
Distress Syndrome
Sputum GS/CS
Spec 16
Started with
Piperacillin-Tazobactam
4.5g IV q8h
Levofloxacin 500mg IV
q24h
Pulmonology and
Endocrinology Referral
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
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
Arterial Blood Gases
pO2
pH
pCO2
HCO3
O2sat
BE
TotCO2
FiO2
RR
49.1
7.4
42.4
25.7
84.7
+0.7
27
50
48
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
COURSE IN THE WARD
1st Hospital Day
At the ER
In respiratory distress
Intubate
O2 sat 75% on in line
neb at 0.6 FiO2
MV settings
AC
FiO2 100
Vt 330
RR 20
PEEP 10
CXR post intubation
ABGs 30 min post
Transfer to MICU
Reintubated
CXR
Increase infiltrates in
the right lung. ET tube
in place
Arterial Blood Gases 30 mins post Intubation
pO2
pH
pCO2
HCO3
O2sat
BE
TotCO2
FiO2
RR
34.5
7.39
45
26.8
65.5
+1.4
28.1
100
30
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
COURSE IN THE WARD
1st Hospital Day
MICU
Nephrology
Fever Tmax 39.8C
BP 95/47
HR 114
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
Pentoxifylline in severe sepsis: a
double-blind, randomized placebocontrolled study
KH STAUBACH, J SCHRÖDER, P ZABEL AND F STÜBER
DEPT. OF SURGERY, MEDICAL UNIVERSITY OF LÜBECK
AND KIEL, FORSCHUNGSZENTRUM BORSTEL
Critical Care 1998, 2(Suppl 1):P017doi:10.1186/cc147
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)
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
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
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
Arterial Blood Gases
pO2
pH
pCO2
HCO3
O2sat
BE
TotCO2
FiO2
RR
48.3
7.53
27.6
23
89.2
+1.7
23.8
100
34
COURSE IN THE WARD
1st Hospital Day
MICU
Pulmonology
VS
O2 sats 83%
BP 123/64
Mech Vent Settings
AC
FiO2 1.0
Vt 400
RR 34
PEEP 20
Shift Berodual to
Terbutaline nebulization
q8h
Acetylcysteine neb 600mg
COURSE IN THE WARD
2nd Hospital Day
Febrile Tmax 38.2
BP 114/60
r/o Pneumocystis Carinii
Pneumonia
CVP 22.5
Start
Dobu 5mcg, Dopa 3mcg
HR 139
O2 sats 92%
Impression:
Infectious Disease
Cotrimoxazole 400/80mg
IV q8h
Sputum for PCP – IF
Nephrology
Furosemide 20mg IV q6h
Mannitol 50mg IV drip
30min after furosemide
dose
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
Methylprednisolone Infusion in
Early Severe ARDS*Results of a
Randomized Controlled Trial
CONCLUSIONS: Methylprednisoloneinduced 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
COURSE IN THE WARD
3RD Hospital Day
HR 120s, RR 30s, dyspnea
O2sats 95% at FiO2 0.75
ECG sinus tachycardia
Hold Terbutaline
Increase FiO2 to 1.0
Nephrology
Na 151
Shift IVF to 1/2NSS x
40ml/hr
Dec Furosemide 20mg
q8h
Dec Mannitol 50mg to q8h
Give 2nd dose of IV Ig
COURSE IN THE WARD
4th Hospital Day
Keep decreasing FiO2
below 1.0 to keep O2 sats
above 90%
7th Hospital Day
8th Hospital day
VS
BP 120/70
Afebrile
O2sats 96%
Weaning from Mech vent
started
Patient was transferred
out of MICU
Pip-Tazo Discontinued
Methylprednisolone
tapering started
COURSE IN THE WARD
14TH Hospital Day
VS
Patient was extubated
Shifted to MVM 0.5
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
Hooked to BIPAP
IPAP 15
EPAP 5
SIDEFLOW 70
COURSE IN THE WARD
17TH Hospital Day
ABGs pO2 – 85.6 on
BIPAP
21st Hospital Day
CBC (07/27/09)
Urine CS E.Coli
WBC – 23.65 (14.4)
Sensitive to Cefuroxime
Imp: Hospital Acquired
UTI
BIPAP shifted to O2 at
3LPM
Start Cefuroxime 500mg
BID
Foley cath removed
COURSE IN THE WARD
28TH Hospital Day
HRCT done
31st Hospital Day
MGH
Clinical Course of ARDS
Exudative Phase (Day 1-7)
Proliferative Phase (Day 7-21)
Fibrotic Phase
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
Influenza A
(H1N1)
Influenza is usually a respiratory infection
Transmission
Regular person-to-person transmission
Primarily through contact with respiratory droplets
Transmission from objects (fomites) possible
National Center for Disease Prevention and Control, DOH
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
Incubation period
Time from exposure to onset of symptoms
1 to 4 days (average = 2 days)
Seasonality
In temperate zones, sharp peaks in winter months
In tropical zones, circulates year-round with seasonal
increases.
National Center for Disease Prevention and Control, DOH
Individuals at Increased Risk for
Hospitalizations and Death
Elderly > 65 years
Children less than two years
Certain chronic diseases
Heart or lung disease, including asthma
Metabolic disease, including diabetes
HIV/AIDs, other immuno-suppression
Conditions that can compromise respiratory function or the
handling of respiratory secretions
Pregnant women
National Center for Disease Prevention and Control, DOH
INTENSIVE-CARE PATIENTS WITH
SEVERE NOVEL INFLUENZA A (H1N1)
VIRUS INFECTION --- MICHIGAN,
JUNE 2009
10 patients wiith Influenza A(H1N1) and ARDS admitted at ICU.
Of the 10 patients 9 were obese (BMI>30) including 7 who are
extremely obese (BMI>40). Five had pulmonary emboli; Nine
had MODS. 3 patients died. Clinicians should be aware of the
potential for severe complications of H1N1 virus infection in
extremely obese patients.
Conclusion
Predominance of males
High prevalence of obesity
Frequency of clinically significant pulmonary emboli
and MODS
Influenza A Viruses
Influenza A viruses categorized by subtype
• Classified according to two surface proteins
Hemagglutinin (H) – 16 known
Neuraminidase (N) – 9 known
N
H
National Center for Disease Prevention and Control, DOH
Nomenclature
Virus type
Strain number
Virus subtype
A / Sydney / 05 / 97 (H3N2)
Place virus
isolated
Year isolated
National Center for Disease Prevention and Control, DOH
Region
WHO Regional Office for (AFRO)
WHO Regional Office for the (AMRO)
WHO Regional Office for the (EMRO)
WHO Regional Office for (EURO)
WHO Regional Office for (SEARO)
WHO Regional Office for the Western Pacific
(WPRO)
Total
Cumulative total
as of 11 October
2009
Cases* Deaths
12456
70
153697
3406
13855
90
Over At least
61000
207
39522
530
118702
432
Over
399232
At least
4735
Influenza A (H1N1) is a novel virus
Unusual combination of genetic material from pigs,
birds & humans which have re-assorted
Affects all age groups
Vaccines for human seasonal flu can not protect
humans against the novel virus
National Center for Disease Prevention and Control, DOH
Swine Influenza Viruses
RNA viruses
Pigs can be infected by avian influenza and human
influenza viruses as well as swine influenza viruses.
Re-assort and new viruses that are a mix of swine,
human and avian influenza viruses can EMERGE
National Center for Disease Prevention and Control, DOH
Genetic Re-assortment
SIV
National Center for Disease Prevention and Control, DOH
Signs & Symptoms of Influenza A (H1N1)
Fever
Lethargy
Lack of appetite
Coughing
Runny Nose
Sore throat
Nausea / Vomiting
Diarrhea
National Center for Disease Prevention and Control, DOH
Swine H1N1 vs. Human H1N1
swine H1N1 flu virus NOT the same as human H1N1
virus
antigenically very different from human H1N1
viruses
vaccines for human seasonal flu can not protect
humans from swine H1N1
National Center for Disease Prevention and Control, DOH
Transmission: Food-Borne?
NO
Influenza A (H1N1) viruses are not transmitted
through food
Safe to eat properly handled and cooked pork and
pork products
Cook pork at an internal temperature of 70°C
(160°F)
National Center for Disease Prevention and Control, DOH
Diagnosis and Laboratory Confirmation
Clinically diagnosed
Respiratory Specimen
•
•
first 4 to 5 days of illness
can shed for 10 days or longer
Specimens sent to US CDC
•
ONLY laboratory that can isolate and
identify swine influenza type A virus
National Center for Disease Prevention and Control, DOH
Specimens
Upper respiratory tract specimens as
recommended are the most appropriate.
taken from the deep nostrils (nasal swab),
nasopharynx (nasopharyngeal swab),
Nasopharyngeal aspirate, throat or bronchial
aspirate.
Laboratory Diagnosis
Rapid Influenza Diagnostic Test
Antigen detection test that detect influenza viral
nucleoprotein antigen
Can provide results within
30 minutes
Sensitivity 40-69%
CDC rRT-PCR Swine Flu Assay
Sensitivity : 99.8%
Specificity: 92%
Table 1. Comparison of Available Influenza Diagnostic Tests1
Influenza Diagnostic Tests Method
Availability
Typical
Sensitivity3
Processing for 2009
Time2
H1N1
influenza
Distinguishes
2009 H1N1
influenza from
other influenza
A viruses?
Rapid influenza diagnostic Antigen
tests (RIDT)4
detection
Wide
0.5 hour
10 – 70%
No
Direct and indirect
immunofluorescence
assays (DFA and IFA)5
Wide
2 – 4 hours
47–93%
No
Viral isolation in tissue cell Virus
culture
isolation
Limited
2 -10 days
-
Yes 6
Nucleic acid amplification RNA
tests (including rRT-PCR) detection
Limited8
48 – 96
86 – 100%
hours
[6-8 hours to
perform test]
7
Antigen
detection
Yes
Treatment
Influenza A (H1N1) is sensitive to:
Oseltamivir (tamiflu)
Zanamivir
Self medication is discouraged, may induce drug
resistance
Chemoprophylaxis
Oseltamivir
National Center for Disease Prevention and Control, DOH
Table 1. Antiviral medication dosing recommendations for treatment or chemoprophylaxis of
novel influenza A (H1N1) infection.
(Table extracted from IDSA guidelines for seasonal influenza.)
Agent, group
Treatment
Chemoprophylaxis
Oseltamivir
75-mg capsule twice per day
for 5 days
75-mg capsule once per day
15 kg or less
60 mg per day divided into 2
doses
30 mg once per day
16-23 kg
90 mg per day divided into 2
doses
45 mg once per day
24-40 kg
120 mg per day divided into 2
doses
60 mg once per day
>40 kg
150 mg per day divided into 2
doses
75 mg once per day
Adults
Two 5-mg inhalations (10 mg
total) twice per day
Two 5-mg inhalations (10 mg
total) once per day
Children
Two 5-mg inhalations (10 mg
total) twice per day (age,
7 years or older)
Two 5-mg inhalations (10 mg
total) once per day (age,
5 years or older)
Adults
Children ≥ 12 months
Zanamivir
CDC Health Advisory
Distributed via Health Alert Network
July 09, 2009
Three Reports of Oseltamivir Resistant
Novel Influenza A (H1N1) Viruses
ANTI VIRAL CHEMOPROPHYLAXIS
Post-exposure prophylaxis for health care workers,
first responders and workers who did not have
adequate PPE when in contact.
Anti-viral prophylaxis is not recommended
to close contacts except when they belong
to high risk group.
Vaccine
Process of production is underway, but may take 5 –
6 months
Seasonal influenza vaccine provides protection
against the seasonal human influenza strains only
National Center for Disease Prevention and Control, DOH
Vaccine
Supplier
Vaccine Form
MedImmune
(nasal spray)
Live virus 0.2 mL
(nasal spray sprayer)
Sanofi (IM)a
Inactivated
0.25 mL prefilled
syringe
0.5 mL prefilled
syringe
5 mL multidose vial
Mercury
µg/0.5 mL
0
Age
2-49 yrsb
0
0
25
6-35 mosb
> 36 mosb
> 6 mosb
Novartis (IM)a
5 mL multidose vial
0.5 mL prefilled
syringe
25
< 1.0
≥ 4 yrsb
> 4 yrsb
CSL Biotherapies,
Inc (IM)a
0.5 mL prefilled
syringe
5.0 mL multidose
vial
0
24.5
> 18 yrs
> 18 yrs
0.5 mL doses contain 15 µg hemagglutinin of the vaccine strain A/California/7/2009 (H1N1)
Two doses separated by 4 weeks for children 2-9 years
(CDC. Update on influenza A (H1N1) monovalent vaccines. MMWR Morb Mortal
Wkly Rep. 2009;58:1100-1101.)
INTERIM GUIDELINES NO.2: INFECTION CONTROL AND
USE OF PERSONAL PROTECTIVE EQUIPMENT IN
INFLUENZA A
HEALTH CARE PERSONNEL
Standard and droplet precautions when working
in direct contact
If there is risk of splashes: particulate respirator;
eye protection;clean, non-sterile, long sleeved
gown; sterile gloves
Frequent and proper handwashing
Isolate patient in a single room.
Reinforce standard precautions with droplet and
contact precaution
Use appropriate Personal Protective Equipment for
all those entering patients rooms.
Restrict number of visitors.
Healthcare workers on direct contact should
monitor their own temperature 2X a day and
report any febrile event.
INTERIM GUIDELINES NO.17: REVISED
CLINICAL CASE MANAGEMENT OF
INFLUENZA A(H1N1) VIRUS INFECTION
Vaccination
Influenza vaccine is the best prevention for
seasonal influenza.
Inactivated viruses in the vaccine developed from
three circulating strains (generally 2 Type A and 1
Type B strain)
Therefore, seasonal “flu shot” only works for 3 influenza
subtypes and will not work on pandemic strains.
Live, intranasal spray vaccine for healthy non-
pregnant persons 5-49 years
Inactivated, injectable vaccine for persons 6
months and older
National Center for Disease Prevention and Control, DOH
Influenza Viruses
Classified into types A, B, and C
•
•
•
Only Types A and B cause
significant disease
Types B and C limited to
humans
Type A viruses
More virulent
Affect many species
C Goldsmith, CDC
National Center for Disease Prevention and Control, DOH
American Journal of Kidney
Diseases
Prehypertension, Obesity, and
Risk of Kidney Disease: 20 year
follow up The HUNT 1 Study in
Norway (June 11, 2009)
Participants with prehypertension are not at increased
risk of serious kidney outcomes if BMI is less than
30kg/m2. However, the risk of Kidney disease increases
substantially if prehypertension is present in obese
participants.
CBC
7/6/09
7/08/09
7/09/09
7/11/09
7/13/09
7/15/09
7/17/09
Hemoglobin
12.7
12.1
12.1
12.4
13.4
12.7
12.3
Hematocrit
38.7
36.6
37.3
38.9
40.2
37.9
37.1
WBC
4.76
4.78
10.96
20.33
13.15
13.52
14.4
Seg
82
68
79
91
90
89
93
Lymphocytes
15
20
13
4
5
4
4
Monocytes
3
12
6
5
3
6
2
2
1
1
427
482
538
Eosinophils
Platelets
2
230
272
337
423
CBC
7/21/09
7/31/09
Hemoglobin
15
11.3
Hematocrit
44.8
35.1
WBC
Seg
Lymphocytes
23.65
93
5
8.34
80
14
2
4
Monocytes
Eosinophils
Platelets
2
665
306
Chemistry
Na
K
BUN
Crea
Co2
Glucose
Calcium
Albumin
ALP
AST
ALT
Total Bili
Uric acid
Triglycerides
Cholesterol
HDL
LDL
DDIMER
7/7/09
4.2
12
0.8
163
7.9
3
63
125
74
0.4
5
189
192
18
144
7/08/09
7/09/09
7/11/09
7/13/09
7/15/09
145
3.4
12
0.8
28
240
7.9
3
63
112
65
0.5
4.5
151
3.4
13
1
144
3.7
25
1
134
3.6
24
0.7
132
3.1
30
0.8
3.1
3
63
67
217
8.98
3
79
54
78
1.24
3.17
165
207.45
4250
2910
3
99
7/17/09 7/21/09
134
4.6
36
0.8
138
5.5
51
0.8
CORTISOL 1659.731 nmol/L 7/13/09
ESR 70 mm/hr
HbA1c – 8.1%
HRCT: Predominantly interstitial infiltrates in both lungs with
associated ground glass opacities in both upper lobes. The
interstitial infiltrates may represent interstitial fibrosis with
superimposed acute alveolar inflammatory or infectious
process.
Minimal pneumomediastinum and subcutaneous emphysema.
CXR:
Jul 6 – Hazy infiltrates in the right upper lobe likely due to
pneumonia. There are also infiltrates in the right paracardiac and left
lower lobe. Heart is magnified. Bones and soft tissues are normal.
Jul 7 – Increase infiltrates in the right lung. ET tube in place.
Jul 8 – right suprahilar and paracardiac infiltrates appear
confluent, however there is partial clearing of the infiltrates seen in the
peripheral chest. Infiltrates in the left are unchanged.
Jul 13 – Complete resorption of the right side pneumothorax.
Slight clearing of Pulmonary congestion. ET tube in place.
Jul 17 – No significant change in the opacities in both lungs.
Minimal subcutaneous emphysema.
Jul 19 – Moderate resorption of subcutaneous emphysema.
No significant change in infiltrates.
7/06
7/07
7/08
7/09
7/10
7/11
7/17
7/20
7/23
7/30
pO2
49.1
47.9
49
62.5
51.6
69
68.8
116.9
85.6
80
pH
pCO2
7.4
42.4
7.49
35.7
7.49
40.1
7.58
33.6
7.55
38.7
7.45
42.3
7.48
27.8
7.42
36.9
7.41
39.4
7.44
34.7
HCO3
25.7
26.8
30.1
30.8
33.6
29.3
19.9
23.8
24.7
23.4
O2sat
84.7
87.2
87.7
95
90.8
94.6
95.1
98.4
96.6
96.3
BE
+0.7
+3.7
+8.9
+10.6
+4.9
-2.2
-0.1
+0.3
-0.1
TotCO2
27
27.9
31.3
31.9
34.8
30.6
20.8
24.9
25.9
24.4
FiO2
50
100
100
100
90
60
35
35
Bipap
Ra
RR
48
38
34
36
34
27
24
18
24
20
+6.3
The FDA has approved 4 vaccine preparations. The following data highlight relevant
issues:
All influenza vaccine preparations in the United States for the 2009-2010 season contain
residual egg protein and none contain adjuvant;
Children 6 months to 9 years of age who are given influenza A (H1N1) monovalent
vaccine should receive 2 doses separated by about 4 weeks; persons ≥ 10 years of age
should receive 1 dose;
The influenza A (H1N1) monovalent vaccines were made according to standards used
for seasonal and influenza vaccines and have the same age group indications,
precautions, and contraindications as vaccines that are FDA-approved for seasonal flu;
preliminary data indicate that the safety and efficacy of the 2009 Influenza A (H1N1)
monoclonal vaccine is the same as winter;
There is minimal evidence of significant antigenic change since the first characterization
of the virus in April 2009, indicating that the virus continues to be well matched with the
vaccine strain; and
The vaccines of the 4 suppliers have some differences that are important to
recognize:for seasonal flu vaccines;
Side effects, including local pain at the injection site, were reported in 46% of recipients,
and systemic reactions (headache, malaise or myalgias) were reported in 45%; the
safety profile is consistent with the experience with seasonal flu vaccine;
Influenza activity due to influenza A (H1N1) increased in September 2009 and is
expected to continue through fall and
Children 6 months to 9 years of age should receive 2 doses separated by
3 weeks. Children 10 years and older and adults should receive 1 dose.
The following groups should receive the vaccine as soon as it becomes
available:
•Pregnant women;
•People who live with or care for infants younger than 6 months of age;
•Healthcare workers (HCWs) and emergency medical personnel;
•Persons 6 months to 24 years of age;
•Persons 25-64 years of age who have chronic diseases (including
immunodeficiency states) that pose risk for influenza.
When more vaccine becomes available, the following persons should be
vaccinated:
•Healthy persons ages 25-64 years; and
•Adults 65 years of age and older.