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.