重症A-H1N1 的救治-ICU 席修明www.book118.com 流感对人类的威胁1918 流感的世界大流行导致5000 万人死亡，美国估计675,000 人1957 的流感导致全球1-200 万人死亡，美国至少70,000 人成为今天是否做好公共卫生准备的试金石When it came to treating influenza patients, doctors, nurses and druggists were at a loss. 判断流行病的严重程度Pandemic Severity Index 流行病的死亡率是评价流行严重程度的重要指标The severity index 可以很好预测流行为流感今后的流行提供决策Pre-Pandemic Planning: Pandemic Severity Index The Persistent Legacy of the 1918 Influenza Virus Map: International Co-circulation of 2009 H1N1 and Seasonal Influenza(As of September 4, 2009; posted September 11, 2009, 6:00 PM ET) Map: International Co-circulation of 2009 H1N1 and Seasonal Influenza(As of October 2, 2009; posted October 2, 2009, 11:00 AM ET) Map: International Co-circulation of 2009 H1N1 and Seasonal Influenza(As of October 16, 2009; posted October 16, 2009, 3:00 PM ET) Map: International Co-circulation of 2009 H1N1 and Seasonal Influenza(As of October 23, 2009; posted October 23, 2009, 3:00 PM ET) Influenza Positive Tests Reported to CDC by U.S. WHO/NREVSSCollaborating Laboratories, National Summary, August 30-October 17, 2009 Percentage of Visits for Influenza-like Illness (ILI) Reported bythe U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet),Weekly National Summary, October 1, 2006 - October 17, 2009 EIP Influenza Laboratory-Confirmed Cumulative Hospitalization Rates,2009-10 and Previous Three Seasons Weekly Laboratory-Confirmed Influenza-Associated Hospitalizations andDeaths, National Summary, August 30 –October 17, 2009 Number of Influenza-Associated Pediatric Deaths by Week of Death:2005-06 season to present Bacterial Coinfections in Lung Tissue Specimens from Fatal Cases of 2009 Pandemic Influenza A (H1N1) United States 22 (29%) of the 77 patients, including 10 caused by Streptococcus pneumo- 10 cases with S. pneumoniae, six with S. pyogenes, seven with S. aureus, two with Streptococcus mitis, and one with H. influenzae; four cases involved multiple pathogens ICU 严重新型流感A (H1N1)-Michigan June 2009 Initial Radiograph of the Lung and Lung-Tissue Sample from Patient 18 例H1N1 流感重症病人分析-墨西哥18 例H1N1 流感重症病人分析-墨西哥H1N1 阳性与阴性危重病人的比较12 例机械通气病人的设置Intensive care adult patients with severe respiratory failure caused by InfluenzaA (H1N1)v in Spain Intensive care adult patients with severe respiratory failure caused by InfluenzaA (H1N1)v in Spain H1N1 的危险因素机械通气患者的预后 Doctors call for guidance on prioritising A/H1N1 critically ill Critical care doctors want escalated pandemic planning 病人常需要数周的机械通气病人常需要积极的、非常规的方法纠正低氧血症，高频通气、一氧化氮、俯卧位通气、压力释放通气6 例病人使用了ECMO 加拿大卫生部宣布购买370 台呼吸机This is an ICU disease ！Intensivists and theglobal society must be prepared. Critical Care 2009, 13:R148 Critical Care 2009, 13:R148 Critical Care 2009, 13:R148 Critical care bed numbers may have to double at height of flu epidemic BMJ 2009;339:b3092 CMAJ SEPTEMBER 1, 2009 181(5) H1N1: ECMO The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators. Extracorporeal membrane oxygenation for 2009 Influenza A(H1N1) acute respiratory distress syndrome. JAMA 2009 H1N1: ECMO The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators. Extracorporeal membrane oxygenation for 2009 Influenza A(H1N1) acute respiratory distress syndrome. JAMA 2009 H1N1: ECMO The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators. Extracorporeal membrane oxygenation for 2009 Influenza A(H1N1) acute respiratory distress syndrome. JAMA 2009 中国大陆危重病例截止2009年10月5日各地共报告甲型H1N1流感感染21000 例其中危重病例13例出院8例死亡1例存活者平均住院日11.4 ± 7.7天中国大陆危重病例(n = 13) 男性9例平均年龄37.5 ± 23 岁基础疾病COPD		3 高血压	2 肥胖	2 糖尿病	1 先天性心脏病1 诊断距发病时间4.5 ± 3.5 天中国大陆危重病例(n = 13) 入院时体温正常4 WCC		9.8 ± 5.0 LDH		771 ± 1130		 CPK		324 ± 316 CRP		48.5 ± 34.7 中国大陆危重病例(n = 13) 急性呼吸功能衰竭10 休克			3 肾功能衰竭ARF				1 慢性肾衰急性加重1 CPR				3 中国大陆危重病例(n = 13) 机械通气	9 有创通气	6 PEEP 16 ± 11 (5 –30) 无创通气	4 （1例NIV 转为IPPV ）升压药物	5 NE, DA & DB CRRT			2 Severe Case (1) M/14 yo, febrile x 6 d, diarrhea x 3 d Oct. 2, fever (39 –40°C) Oct. 4, abdominal pain, diarrhea, watery stool Oct. 7, local hospital BT 37.8°C, BP 60/30 mmHg, RR 24 bpm, HR 112 bpm WCC 12.3, N 94%, plt 89 AXR compatible with intestinal obstruction CXR suggestive pneumonia Severe Case (1) Oct. 7, referral hospital BT 37.5°C, HR 124, RR 34, BP 76/31 137/71 @ DA 6 Abdomen: tender (+) WCC 2.98, plt 35.8, PT 18.7, aPTT 74.3 TBil 37.4, Cr 306 ABG: 7.253/33.7/89.8/-11.3/LA 11.16 Oct 10 BT 37.2 –38.2°C, HR 140 –150, RR 48, BP 115/57 @ DA 10 Peripheral arterial embolism WCC 24.9, plt 9.66, PT 16.3, aPTT 64.2 TBil 109.9, Cr 115 ABG: 7.416/32.8/91.3/-3/LA 9.89 Severe Case (1) Oct 10 FFP & platelet & LMWH for overt DIC Hemodynamic monitoring with PiCCO CO 8.82, CI 5.67, SVRI 1144, GEDI 562, ELWI 8 Intubation and mechanical ventilation to protect airway PS 15, PEEP 10, FiO2 0.4, P/F 225 Oct 22 Febrile (39.6°C), comatose HR 99, BP 118/61, RR 26, SpO2 96% DA D/C on Oct 15, tracheostomy on Oct 17 Thrombocytopenia (18.6), hemophagocytic syndrome suspected Severe Case (2) F/38 yo, Productive cough associated with fatigue x 7 d, febrile x 2 d Oct 8, intermittent cough one week after contact with her son (febrile) white copious sputum treated with clindamycin and subsequently azithromycin Oct 13, local hospital BT 38.5 –39.4°C WCC 1.42 –3.81, N 66.7 –82.4%, L 13.8 –24.2% SpO2 83% @ O2 5 lpm CXR: suggestive of pneumonia Severe Case (2) Severe Case (2) Oct 15, referral hospital ABG 7.39/38/66 @ O2 10 lpm WCC 1.30, N 76.3%, Plt 169 Intubation and mechanical ventilation due to desaturation Initial settings: FiO2 1.0, PS 16, PEEP 10, SpO2 90% SpO2 increased to 98% after RM (opening pressure 45, PEEP 25) Settings after RM FiO2 0.6 0.45, PS 16 14, PEEP 15 12 Oct 21, referral hospital FiO2 0.4, PS 12, PEEP 6, SpO2 96% Severe Case (3) M/19 yo, febrile x 2 d, altered mental status x 8 h Oct 1, hospital admission BT 40.6°C HR 150 –160 bpm, BP 60/30 mmHg WCC 7.7, Plt 87 K 2.6, Na 136, BUN 4.7, Cr 152 unresponsive to fluid resuscitation dopamine intubation due to desaturation ICU admission after 5 hrs Severe Case (3) Oct 1 Oct 2 Oct 3 Oct 1 Oct 2 Oct 3 WCC 7.7 12.75 19.14 CK 5353 5817 N (%) 83 87 94 LDH 582 857 Lymph 0.11 0.08 0.04 cTnI 7.93 6.33 Cr 152 145.1 146 pH 7.24 7.31 7.25 BUN 4.75 5.5 10.6 PCO2 37 34 46 ALT 127 111 PO2 47 42 45 AST 380 484 SaO2 74 72 72 TBil 33.8 17.7 BE -11.5 -9.2 -7.0 PT 18.9 18.3 13.9 LA 4.1 3.4 1.4 aPTT 78.7 75.7 50.7 ICU 医生要做好：1 应对流感大流行的准备，对危重病人应准备静脉抗病毒药，研究哪些药物适用于危重病人2 医疗操作应有严格的隔离防护措施3 注意治疗流感并发症如细菌性肺炎4 ICU 医生有义务参加医院、地区、国家随机发生的救灾项目，媒体和卫生部门应注意出现“flu fatigue”Crit Care Med 2008; 36:2660–2666 * * n engl j med 361;3 nejm.org july 16, 2009 Influenza in ICU NIH 过敏与感染研究所教授John H. Beigel, MD2008 发表回顾性文章美国200000 人/年因季节性流感住院41000 人/年死亡2006 年死因排位第七卫生人员的免疫接种率仅有35-40% ，40% 的医生认为流感不需要治疗Crit Care Med 2008; 36:2660–2666 Centers for Disease Control and Prevention 2009-2010 Influenza Season –Week 41, ending October 17, 2009 死亡人数超过季节性流感！美国进入紧急状态H1N1: Hospitalized Patients Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients with 2009 H1N1 Influenza in the United States, April-June 2009. N Engl J Med 2009; 361 H1N1 vs. Flu: Age Shift Age 5-59 Chowell G, Bertozzi SM, Colchero MA, et al. Severe respiratory disease concurrent with the circulation of H1N1 influenza. N Engl J Med 2009; 361: 674-679 1072 MMWR October 2, 2009 Vol. 58 / No. 27 MMWR 751 N Engl J Med 2009;361. 7/18 （39% ）死亡10/18 （56% ）入ICU 机械通气9/18 （50% ）扩容后仍低血压4/11 死亡病例>15<50 岁11/18 （61% ）>15<50 岁38 年龄（平均）9/18 （50% ）性别N Engl