Good Morning. Today we will talk about chronic

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GoodMorning!
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LEPTOSPIROSIS TASK FORCE
(PSN/PSMID/PCCP) 2010
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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
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MILD LEPTOSPIROSIS 1. stable vital
signs2. anicteric sclerae3. good urine
output4. 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
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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
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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
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locally available diagnostic tests A. Direct
Detection Method1. Culture and isolation
- GOLD standard - 6 to 8 weeks for the
result2. 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
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B. Indirect Detection Methods1.
Microagglutination Test (MAT) - highly
sensitive and specific - time-consuming
- hazardous to perform because of the risk of
exposure to the live antigen2.
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
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• laboratory findings/markers of severe
  leptospirosis
• CBC leucocytosis (WBCgt12,000 cells/cumm)
• neutrophilia and
  thrombocytopenia (lt100,000 cells/cu mm)
• 2. Serum creatinine gt 3 mg/dL (or CrCl lt 20
  ml/min) and
• BUN gt 23 mg/dL
• 3. Liver function tests - AST/ALT ratio gt 4x
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  Bilirubin gt 190 umol/L
• 4. prolonged prothrombin time (PT) lt 85

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laboratory findings/markers of severe
leptospirosis 5. Serum potassium gt 4 mmol/L 6.
ABG- severe metabolic acidosis (phlt 7.2, HCO3 lt
10) hypoxemia (PaO2 lt 60 mmHg,
SaO2 lt 90) 7. Chest radiograph - extensive
alveolar infiltrates 8. Electrocardiogram -
heart block, myocarditis
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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
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Antibiotic therapy should be completed for
7 days, except for azithromycin dihydrate which
could be given for 3 days. Grade A
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Any one of the following is an indication for
dialysis Grade Aa. Uremic symptoms
Nausea, vomiting, altered mental status,
seizure, comab.
Serum creatinine gt 3mg /dLc. Serum K gt 5 meq /L
in an oliguric patientd. ARDS /pulmonary
hemorrhagee. pH lt 7.2f. Fluid overloadg.
Oliguria despite measures following the
algorithm
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Algorithm for the Management of Oliguria in
Leptospirosis
Oliguria - lt0.5 ml/kg/hr or lt400 ml/day or
self-report of low or no urine output in 12 hrs.
Mean Arterial Pressure lt/65 mm Hg
YES
Start Norepinephrine and titrate to keep MAP gt65
mmHg
NO
Assess Fluid Status

• 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

YES
Hypovolemic?
NO
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• Monitor hourly and adjust rate of IVF to
  maintain euvolemia
• Reassess kidney status

Yes
Urine Output gt/ 0.5ml/kg/hr?
Furosemide 40 mg IV bolus or Bumetamide 1 mg IV
No
Urine Output gt/ 0.5ml/kg/hr?

• Monitor hourly and adjust rate of IVF to
  maintain euvolemia
• Reassess kidney status

Yes
No
Double dose of furosemide (or Bumetamide) hourly
up to a maximum of 160 mg (or 4 mg)

• Monitor hourly and adjust rate of IVF to
  maintain euvolemia
• Reassess kidney status

Yes
Urine Output gt/ 0.5ml/kg/hr?
No
Acute Renal Replacement Therapy
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PHILIPPINE SOCIETY OF NEPHROLOGY
DISASTER RESPONSE TO CRUSH INJURY / CRUSH
SYNDROME
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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
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Specific indications for nephrology
referralElevated serum creatinineHyperkalemia
HypocalcemiaHyperphosphatemiaHyperuricemiaMetab
olic acidosisElevated total CK of gt 5,000
IU/LPresence of reddish-brown urine / urine
myoglobinDecreased urine output (lt0.5 ml/kg/hr x
4 hours) Fluid overload
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Indications for renal replacement therapySerum
creatinine gt 8 mg/dl Serum K gt 6 mEq/LSerum pH
lt 7.1 or serum HCO3 lt 10 Pulmonary congestion /
EdemaUremiaProphylactic dialysis may be
indicated in rapidly progressing hyperkalemia
even if the above parameters are not met
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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
GIVE SALINE AT 0.5 L/HR (REASSESS EVERY 2-4 HRS)
NO
IS IT SAFE TO HYDRATE THE VICTIM?
YES
ATTEMPT ORAL HYDRATION FOR THOSE THAT CAN BE
REACHED
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
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POST EXTRICATION MANAGEMENT OF POTENTIAL CRUSH
INJURY VICTIM(PRE-HOSPITAL PHASE)
EXTRICATED VICTIM

• INDICATIONS FOR NEPHROLOGY REFERRAL
• (Please see nephrology notes)
• Hyperkalemia on ECG
• Presence of reddish-brown urine
• Decreased urine output (lt0.5 ml/kg/hr x 4 hours)
• Fluid overload

PRIMARY SURVEY
MULTIDISCIPLINARY REFERRAL (PLEASE REFER TO
SPECIFIC INDICATIONS FOR NEPHROLOGY REFERRAL)
YES
PRESENCE OF OTHER MEDICAL CONDITION
NO
GIVE 1L/HR OF ISOTONIC SOLUTION FOR 2HRS REASSESS
AFTER 2HRS
YES
DOES THE VICTIM NEED TO BE HYDRATED?
GIVE SALINE AT 0.5L/HR REASSESS EVERY 2-4 HRS
NO
IS IT SAFE TO MAINTAIN HYDRATION?
YES
VICTIM MAY BE DISCHARGED WITH PROPER ADVICE
NO
MAY DO SECONDARY SURVEY AS NEEDED
LIMIT HYDRATION TO 1L/DAY
ADMIT TO HOSPITAL
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THANKYOU