Pandemic Influenza A H1N1 in Critically Ill Patients

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• Pandemic Influenza A (H1N1) in Critically Ill
  Patients
• Clinician Outreach and Communication Activity
  (COCA) Conference CallNovember 18, 2009

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• As a reminder, this call is intended to be an
  educational opportunity for health care
  providers. If you have any questions about
  sharing or distributing information from this
  call please contact us at the email address
  coca_at_cdc.gov.

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CASE 1

• Malignant Catatonia

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29 y.o. Male

• 5 days of fevers to 103.5F and myalgias
• 2 days of increasing shortness of breath
• Presented to ED with worst HA of life
• Given hydromorphone, nalbuphine, and ketorolac
• O2 Sats 79 on RA placed on 100 NRB
• CXR with diffuse bilateral infiltrates
• Nasal Swab neg for Influenza, but tracheal
  secretions PCR positive for H1N1
• Admitted to MICU

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29 y.o. Male

• PMHx None
• SocHx tob 1 pdd X 15 yrs social ETOH
• No illicit drug use
• He wife work in healthcare field
• FamHx Mom DM Dad COPD
• no neuro or psychiatric illnesses
• Meds prn ibuprofen
• All NKDA

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On Admission to MICU

• T 101.3F HR 104 BP 129/69 RR 32
• Oxygen sats 85 on 100 NRB
• ABG7.38 / pCO2 43 / pO2 56 on 100 NRB
• Neck no meningeal signs
• Pulm diffuse crackles
• Cor RRR, tachy, normal S1 S2, no m/g/r
• Abd BS, soft, NT/ND
• Ext no c/c/e no rash
• Neuro
• A, O X 3
• CN 2-12 intact strength 5/5 throughout, normal
  reflexes

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Hospital Course

• Intubated, required mech vent for 18 days
• Worst settings 80 FiO2, PEEP 16
• Febrile for first 25 days (101.5F 103.0F)
• Difficult to sedate
• Propofol for 5 days
• Midazolam/fentanyl drips for 10 days
• Dexmedetomidine for 2 days
• Last 7 days of intubation haloperidol 5-10 mg
  q8h and promethazine 25 mg q6hr prn agitation

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Hospital Course

• Post-extubation
• Continued low grade fevers and labile HR/BP
• Very flat affect
• Resting pill-rolling tremor RgtL upper extrem
• Delirium
• Hyperreflexia 3 in LE and 2 in UE
• Bradykinesia
• Diffuse weakness although not cooperative w/ exam

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Neuro Testing

• LP (day 2) 4 RBC, 2 wbc (75L, 23 mono)
• OP 27 mm, Glu 101 prot 27 gram stain
• H1N1 negative special stains neg
• EEG generalized irregular slow activity no
  ictal or epileptiform discharges
• Head MRI linear nonspecific T2 white matter
  hyperintensity in R centrum semiovale and Left
  frontal centrum semiovale
• Might be seen in demyelination but non-specific
• Normal CPK

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Psychiatry Consult Malignant Catatonia

• Findings
• Frontal release signs
• Negativism, mutism
• Waxy flexibility, rigidity
• Autonomic Instability
• Dx encephalitis lethargica 2o to flu
• Lorazepam Challenge
• 2 mg, patient more alert and began speaking
• 4 mg, resolution of rigidity
• ECT therapy X 3 considerable improvement

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CASE 2

• Obese Patient

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Initial Presentation

• 18 yo with morbid obesity presents with one day
  of fever (Tmax 103), cough, and body aches
• PMHx asthma, OSA, mild aortic stenosis,
  tetrahydrofolate reductase deficiency
  (heterozygous), PE one year ago now asymptomatic
• Arrived on 12L NRB with O2 sats in the low 90s
• Initial vitals T 38.8 RR 50 HR 102 BP
  151/63 wt 160kg
• Initial VBG 7.36/52/3
• Pertinent labs HCO3 31, BUN 13, Cr 1.1
• WBC 5 with 88 segs, plts 71, INR 1.2
• H1N1 flu positive

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Clinical Course

• After arrival, he was placed on NIV PS
  ventilation 20/11 with 15L oxygen flow and
  continuous albuterol for increased work of
  breathing
• Started on IV methylprednisolone at asthma dosing
  for 5 days
• Also started on vancomycin, gentamicin,
  piperacillin/tazobactam, and oseltamivir
  initially (completed 10 days)
• NIV was increased the following day to 30/15 as
  pt continued to show increased effort

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Clinical Course

• HD4 pt was intubated for significant work of
  breathing (RR 40-50) despite maximal NIV
  settings, decreased alertness, and desaturations
  (to 50) while coughing
• Unable to oxygenate with conventional ventilator
  settings on maximal settings and pt was
  transitioned to HFOV MAP 36, amp 75, Hz 3, FiO2
  .60-1
• Initial OI 38

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Clinical Course day 4-7

• After intubation he was started on iNO at 20ppm
  to further aid oxygenation
• Pt was dosed with surfactant x 1
• ECHO obtained on HD4 showed moderate to severe
  depression of RV and LV systolic performance and
  stable mild valvar aortic stenosis
• Started on milrinone drip at 0.25mcg/kg/min
• Pt initially did not tolerate diuresis with
  rising Cr and hypotension amenable to fluid
  replacement

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Clinical Course day 8 - 14

• After a week on HFOV, pt remained on high
  settings MAP 28, amp 70, Hz 4
• OI 25-30 and iNO remains at 20ppm
• ECHO on HD10 showed significant change with
  further deterioration of the left ventricular
  systolic performance which is now severely
  depressed

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Clinical Course day 14 - current

• HD22 pt had repeat ECHO now with low nl LV
  function
• Bronchoscopy done at the bedside showed clear
  airways
• IV methylprednisolone 2mg/kg/day x 14 days
  started on HD22
• Weaned off iNO and back to conventional
  ventilation on HD23 with PC/PS PIP38 PEEP 12
  PS 15 FiO2 .65
• Tracheostomy and PEG obtained on HD30
• Currently doing CPAP trials, but in between
  remains on PRVC with TV 500ml PEEP 10 PS 15

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Problem List

• Influenza (H1N1)
• ARDS and respiratory failure
• Renal insufficiency
• Clinical myocarditis
• Skin breakdown - stage 3 decubitus

• Obesity
• OSA and asthma
• Developmental delay
• Aortic stenosis
• Heterozygous Tetrahydrofolate reductase
  deficiency with history of pulmonary embolism