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

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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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
hrs- episode of low BP(37/31mmHg)
Intermittent CPR . Noradrenaline and adrenaline infusions
1926hrs- Thrombolysed with tenecteplase
hrs- Vasopressors reduced by 75%

10. 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

11. 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

12. 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

13. 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

14. Swine Flu- What do we know?
NSW 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)

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

16. 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)

17. 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

18. 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

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