If it looks like a pig, walks like a pig, sounds like a pig, it must be swine flu or is it?

Benoj Varghese ICU Registrar, Liverpool July 29th 2009 ICU Case of the month Benoj Varghese ICU Registrar, Liverpool July 29th 2009

Presentation to Hospital (17/07/09) 46/M Bronchial Asthma DVT- 7years ago Social drinker/ex-smoker Flu like symptoms for 5/7 Other family members had flu like symptoms recently Treated with Amoxicillin/Clavulunate by GP

Presentation to Hospital (17/07/09) Presented to Campbelltown ED with SOB PR 99bpm BP 117/83mmHg RR 43bpm SPO2 93% (on CPAP 0.6/5cm H2O ) Bibasilar crackles on auscultation Biochemistry- Urea-10 Creatinine- 199 Imp- Severe CAP with hypoxic respiratory failure and azotemia. ? Influenza

Campbelltown ICU (18/07/09) CPAP (FiO2-0.6-1.0, CPAP 10-16mmHg) ABG- 7.37/74/40/-2/23 Tachypnoea (RR-44bpm) Worsening azotemia (Creatinine- 230) Treated with Moxifloxacin/Oseltamivir

Campbelltown ICU (19/07/09) Ongoing fevers Worsening tachypnoea (RR-60bpm, SPO285%) ABG- 7.44/34/58/0/23 CXR- ?R apical PTX NIV changed to BIPAP R ICC inserted Influenza H1N1 positive

Campbelltown ICU (20/07/09) Still febrile Ongoing CPAP (RR-30bpm, SPO297%) ABG- 7.44/37/78/0/24 (FiO2-0.8,CPAP 16mmHg)

Campbelltown ICU (21/07/09) Still febrile Ongoing CPAP (RR-49bpm, SPO2-86%) CPAP(FiO2-0.9,CPAP 13mmHg) Episodes of SVT- treated with verapamil

Campbelltown ICU (21/07/09) 1700hrs- RSI Post intubation SPO2-78% on FiO2-1.0 1830hrs- BP 76/59mHg(MAP-66mmHg) Noradrenaline started 1845hr- ventricular escape rhythm 1913-1925hrs- episode of low BP(37/31mmHg) Intermittent CPR . Noradrenaline and adrenaline infusions 1926hrs- Thrombolysed with tenecteplase 1929-2015hrs- Vasopressors reduced by 75%

Campbelltown ICU Respiratory failure- hypoxia and hypercapnia Mechanical ventilation- sedated and paralysed Hypotension requiring noradrenaline infusion ARF- CRRT initiated Tazocin added d/w RPA- not for ECMO Transferred to Liverpool on 23/07/09

Liverpool ICU (23/07/09) PCV FiO2- 1.0 PC/PEEP- 20/14cmH2O VT 600ml SPO2 78% TOE- LV normal RV dilated. No clots RV size reduced after 3 doses of prostatcyclin SPO2 improved to 92% with prostatcyclin nebulisation

Liverpool ICU (24/07/09) CTPA- bilateral segmental PEs Desaturated down to 76% Peripheral VV ECMO 2 access cannulas- R femoral vein, R IJV 1 return cannula- L femoral vein CVVH via ECMO circuit Episodes of AF treated with amiodarone

Liverpool ICU (today) Stable on ECMO pump rate- 6-7Lpm Ventilation- SIMV 0.5/500/ 20/12 Radiological improvement SPO2- 100% Ongoing CVVHDF- persistent anuria

Swine Flu- What do we know? NSW- 3173 case (990 in SSWAHS) 659 cases hospitalized since May 09 96 ICU admissions and 17 deaths (as of 22/07/09) 50% of hospitalised and 72% of ICU pts 15-59yrs Currently 41 confirmed and 43 suspected H1N1 adult cases in ICU with 5 on ECMO. 2 confirmed and 2 suspected paediatric case (as of 28/07/2009)

Confirmed H1N1 case in NSW by date of onset till 22/07/09 Source – NSW DOH

Swine Flu- What do we know? Liverpool ICU- 9 H1NI, 10 Influenza A (from 9/7/09 to 28/07/09) 70% female. Average age 36.1 (25-53)

Swine Flu- What do we know? Most patients present with flu like symptoms (respiratory and GI) with lobar consolidation, but more commonly bilateral patchy infiltrates Rapid progression to hypoxic respiratory failure in patients requiring ICU Apparent risk factors include female sex, pregnancy and obesity, ethnicity (Islander) Tracheal secretions (mini BAL) more sensitive than nasopharyngeal swabs No evidence of resistance to oseltamivir yet Use of double dosing of oseltamivir for 10days being practised in some units in Australia & NZ

Issues Timing of antiviral therapy Role of NIV/ timing of endotracheal intubation Timing of transfer Role of repeat thrombolysis Role/usefulness of prostacycline/proning/HFO ECMO- patient selection use of second access cannula Weaning off ECMO

Issues Swine flu Dose and duration of oseltamivir Role for zaminivir Role of steroids Protection of staff- viral filters/ PPEs