H1N1 Influenza Management in the ICU / HDU
- These 2011 guidelines modified from last years publications
- Further resources at: The Health Protection Agency in the UK
- Also at the Faculty of Intensive Care Medicine UK and the Intensive Care Society
- Contacts for ECMO in Ireland can be accessed through http://www.mater.ie/ECLS/
Identifying the patient with H1N1
- Patients with community acquired pneumonia or with prior flu-like symptoms referred to critical careshould be considered as H1N1 carriers.
Infection Control Precautions / Personal Protective Equipment (PPE)
Isolation
- All patients suspected of having influenza require single rooms
- Positive or negative pressure is not required for these rooms
- Cohorting of patients with a proven diagnosis of H1N1 is acceptable
- Avoid use of fans (air recirculation)
- Visitors kept to a minimum and educated in standard infection control and PPE appropriate to level of contact (see “Staff”)
Staff
- standard precautions as always for all patients
- hand hygiene
- surgical mask if entry to cohorted area but no patient contact
- gloves, plastic apron, surgical mask, eye protection if patient contact
- gloves, gown , FFP3 mask, eye protection if aerosol generating procedure
- staff rostered to isolation cubicles should adopt the same precautions as for aerosol generating procedures - as per above.
- if not rostered to patient care in the cubicle, adopt precautions (1) (5) as per level of patient contact.
Environmental Cleaning and Disinfections
Clinical Care Practice Points
1. Diagnosis. Clinical diagnosis supported by appropriate specimen
sampling as per clinical context. Ensure nasopharyngeal swabs and (where intubated) tracheal aspirates are sent for viral culture. Ensure sample labelled correctly and specifically for H1N1.
2. Respiratory. Anticipate need for respiratory support such that as much as possible this can be in a managed context.
3. NIV. Non-Invasive Ventilation may be used where appropriate. In such circumstances FFP3 masks should be worn by staff, the ventilator should be turned on only after fitting to the patients face and turned off before removal. If NIV strategy likely only to postpone invasive ventilation, consider earlier progression to elective intubation and mechanical ventilation. Bacterial / Viral filter to expiratory circuit.
4. Ventilation. Mechanical Ventilation / Equipment
- current ventilator set-up appropriate for these patients, including tubing, humidification and bacterial / viral filter on expiratory circuit.
- Change of ventilator tubing should be as per current practice.
- Closed suctioning should be employed.
- Ventilator circuit should not be broken unless necessary (e.g. change of tubing).
- If circuit has to be broken, adopt aerosol generating procedure precautions.
- If HFOV, adopt aerosol generating procedure precautions at all times.
5. Ventilation strategies. Mechanical Ventilation Strategies
- follow standard ICU protocols / strategies as for respiratory failure and ARDS (ARDSnet protocol)
- pulmonary compliance often good and need to avoid overdistension.
- Beneficial effects have been noted with Nitric Oxide and Proning.
- HFOV may be useful in poorly compliant cases.
- ECMO has been utilised in cases refractory to the above measures.
6. Antiviral Therapy
- Oseltamivir (Tamiflu®) 150mg NG BD for 10 days in the critically ill. This is higher than the recommended treatment dose of 75mg dose in non-severe cases. The higher dose and duration has become common practice internationally in the critically ill, though there is no specific evidence to support this practice. Oseltamivir is not available in an intravenous format. GUT absorption may be an issue with critically ill.
- Dose adjustment required for Cr Clearance < 30ml/min
- Oseltamivir / ribavarin combination therapy – limited data
- Ribavarin Monotherapy – limited data
- Adamantanes – H1N1 resistant to adamantanes (Amantadine)
- Inhaled Zanamivir (Relenza) – see link below
Useful link for update on pharmacological and antiviral therapy:
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1287147812045
7. Fluid Balance - adopt a conservative fluid strategy.
8. Steroids - evidence to date suggests that steroids may be detrimental.
9. Acute Kidney Injury - approx 20% of critically ill H1N1 patients may require renal replacement therapy.
10. Thromboembolic prophylaxis - Important to ensure prophylaxis prescribed.
11. Bacterial Superinfection - Secondary bacterial infections should always be considered and routine tracheal aspirate sampling and routine surveillance should be adhered to.
- Streptococcal, staphylococcal and pneumococcal secondary infections have all been reported.
12. Disease Course - Beware of rapid deterioration in hospitalised patients. International experience has observed such deterioration within 24hrs of hospital admission, followed by referral to ICU, a further 48hrs of clinical worsening, followed by the beginnings of improvement. ICU stays have tended to be quite long. Hyperthermia may require active cooling, or consider earlier institution of CRRT
13. Duration of Isolation - in consultation with Department of Infection Control and Microbiology.
