Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
MEDICAL GRANDROUNDS OCTOBER 22, 2009 LEDESMA HALL LEONID ZAMORA MD OBJECTIVES To present a case of a young female who developed complicated pneumonia secondary to Influenza A(H1N1) Virus Infection To discuss the latest updates on the Virus. General Data AMG 23 years old Female Single Filipino a student from DLSU Lives in Paranaque Known Diabetic Chief Complaint DYSPNEA HISTORY OF PRESENT ILLNESS 5 DAYS PTA non-productive cough body malaise high grade fever (Tmax 40.5C) Consult at RITM throat swab done voluntary isolation at home HISTORY OF PRESENT ILLNESS 2 DAYS PTA persistence of the above symptoms self-medicated with Cefuroxime 500mg 2x a day No consult HISTORY OF PRESENT ILLNESS Few hours PTA increasing frequency and severity of cough Dyspnea No chest pains, orthopnea, paroxysmal nocturnal dyspnea Throat swab done in RITM POSITIVE ER consult Review of Systems No headache No loss of consciousness No blurring of vision No nausea, vomiting No dysuria, hematuria No diarrhea/constipation No bleeding No polyuria, polydipsia, polyphagia Past Medical History Diabetes since 2007 – on Metformin 500mg TID and Rosiglitazone 4mg OD Hypertensive since 2008 - no maintenance medications (HBP 150/90 – UBP 130/80) (+) PCOS x 5 months on Norethisterone (Primolut) and Medroxyprogesterone acetate (Provera) No previous hospitalizations or surgeries No known allergies. Family History Diabetes and Hypertension both parents (+) Asthma maternal side (cousins) No Asthma No Cancer Personal and Social History Non smoker Occasional alcoholic beverage drinker No recent Travel outside Metro Manila Student of DLSU – was recently closed due to reported cases of positive Inluenza A(H1N1) Physical Examination Conscious, coherent, in respiratory distress BP 110/70 HR 115 reg RR 30 Temp 39 C Ht 162.5cm Wt 109kg BMI 41.3 Warm moist skin. No active dermatosis. Pink palpebral conjunctivae, anicteric sclerae, moist buccal mucosa, nonhyperemic posterior pharyngeal wall, tonsils not enlarged, (+) alar flaring. Supple neck, no cervical lymphadenopathies, (+) neck vein distention, no carotid bruit. Physical Examination Symmetrical chest expansion, no lagging, (+) tight air entry, (+) wheezes, bilateral. Adynamic precordium, AB at 5th Left intercostal space, Mid clavicular line, tachycardic, regular rhythm, no murmurs, no gallop rhythm. Flabby abdomen, normoactive bowel sounds, nontender, no masses, no organomegaly. No abdominal bruit. Full and equal pulses. No cyanosis. No edema. Salient Features 23 years old, Female in respiratory distress. a student from DLSU BP 110/70 Diabetic Obese Dyspnea Increasing severity of cough Fever POSITIVE for A(H1N1) HR 115 reg RR 30 Temp 39C (+) alar flaring (+) neck vein distention (+) tight air entry (+) wheezes, bilateral. ADMITTING IMPRESSION • S eve re S ep s i s s e c o n d a r y t o • • • • C o m mu ni t y A c q u i re d P n e u m o n i a secondary to Influenza A(H1N1) D i ab e t e s M e l l i t u s, Ty p e 2 , N o n - i n s u l i n re q u i r i n g Obese Class III H y p e r t e n s i o n S t age 1 Po l ycys t i c O va r i a n S y n d ro me COURSE IN THE WARD At the ER In respiratory distress VS BP 110/70 HR 115 reg RR 30 Temp 39 C O2 sat 82% at room air NPO CBC, CXR, ECG, ABGs Hooked to Pulse Oximeter MVM 0.5 PNSS 1L x 100ml/hr Rx: Fenoterol + Ipratropium (Berodual) nebulization q4h, Oseltamivir 75mg tab q12h, Budesonide 500mcg BID nebulization, Hydrocortisone 100mg q8h Paracetamol 300mg q4h CXR (July 6, 2009) hazy infiltrates in the upper lobe likely due to pneumonia, infiltrates in the right paracardiac and left lower lobe Sinus Tachycardia NSSTTWC 12 – L ECG Arterial Blood Gases pO2 pH pCO2 HCO3 O2sat BE TotCO2 FiO2 RR 58.9 7.39 39.1 23.4 90.5 -1.2 24.6 50 26 Complete Blood Count Hemoglobin Hematocrit WBC Seg Lymphocytes Monocytes Eosinophils Platelets 12.7 38.7 4.76 82 15 3 230 COURSE IN THE WARD At the ER Infectious Disease In respiratory distress VS Referral BP 110/70 HR 115 reg RR 30 Temp 39 C O2 sat 82% Imp: Acute Respiratory Distress Syndrome Sputum GS/CS Spec 16 Started with Piperacillin-Tazobactam 4.5g IV q8h Levofloxacin 500mg IV q24h Pulmonology and Endocrinology Referral ACUTE RESPIRATORY DISTRESS SYNDROME Acute onset of Respiratory Failure Diffuse Bilateral infiltrates on Chest radiograph Absence of left atrial hypertension (PCWP < 18 mmHg or no clinical evidence of increased left atrial pressure) Hypoxemia, PaO2/FiO2 < 200 COURSE IN THE WARD At the ER In respiratory distress VS BP 110/70 HR 115 reg RR 30 Temp 39 C O2 sat 84% at MVM 0.5 BIPAP not available Pulmonology DDIMER Start Enoxaparin 60mg SQ BID Do ABGs q1h Standby intubation Arterial Blood Gases pO2 pH pCO2 HCO3 O2sat BE TotCO2 FiO2 RR 49.1 7.4 42.4 25.7 84.7 +0.7 27 50 48 COURSE IN THE WARD At the ER In respiratory distress VS BP 110/70 HR 115 reg RR 32-34 O2 sats 83-84% on MVM Shift MVM to inline neb at 0.6 FiO2 COURSE IN THE WARD 1st Hospital Day At the ER In respiratory distress Intubate O2 sat 75% on in line neb at 0.6 FiO2 MV settings AC FiO2 100 Vt 330 RR 20 PEEP 10 CXR post intubation ABGs 30 min post Transfer to MICU Reintubated CXR Increase infiltrates in the right lung. ET tube in place Arterial Blood Gases 30 mins post Intubation pO2 pH pCO2 HCO3 O2sat BE TotCO2 FiO2 RR 34.5 7.39 45 26.8 65.5 +1.4 28.1 100 30 COURSE IN THE WARD 1st Hospital Day MICU Fever Tmax 39C O2 sat 83% at FiO2 1.0 Infectious Disease Discontinue Levofloxacin Start Moxifloxacin 400mg IV q24h Blood CS x 2 sites SPEC M Refer to Nephrology for co management Increase Vt to 500 COURSE IN THE WARD 1st Hospital Day MICU Nephrology Fever Tmax 39.8C BP 95/47 HR 114 Start IV Ig 50g + 500 ml sterile H2O 1st Hour – 63.5 ml/hr 2nd Hour – 127 ml/hr 3rd Hour – 190 ml/hr 4th Hour – 254 ml/hr until consumed Pentoxifylline drip 300mg x 8h x 6 doses Pentoxifylline in severe sepsis: a double-blind, randomized placebocontrolled study KH STAUBACH, J SCHRÖDER, P ZABEL AND F STÜBER DEPT. OF SURGERY, MEDICAL UNIVERSITY OF LÜBECK AND KIEL, FORSCHUNGSZENTRUM BORSTEL Critical Care 1998, 2(Suppl 1):P017doi:10.1186/cc147 51 patients MOF-score lower in POF treated patients PaO2/FioO2-ratio was significantly improved in POF treated patients Pressure-adjusted heart rate (HR×CVP/MAP) was significantly improved from day 6 to day 10 (P < 0.05) Polyclonal Intravenous Immunoglobulin for the Treatment of Severe Sepsis and Septic Shock in Critically Ill Adults: A Systematic Review and Meta-analysis Conclusion: Demonstrates an overall reduction in mortality with the use of IVIg for the adjunctive treatment of severe sepsis and septic shock in adults Critical Care Medicine: Kevin B. Laupland, MD, MSc; Andrew W. Kirkpatrick, MD; Anthony Delaney, MBBS, MSc. Published: 01/14/2008 COURSE IN THE WARD 1st Hospital Day MICU Fever Tmax 39.8C BP 95/47 HR 114 CVP 20 Nephrology Start Dopamine 400mg/100ml PNSS at 3mcg/kg/min Dobutamine 500mg/1ooml PNSS at 10mcg/kg/min Voluven 6% 500ml x 25oml/hr Hydrocortisone 50mg IV q8h Furosemide 120mg IV now COURSE IN THE WARD 1st Hospital Day MICU Albumin 3 Nephrology Plasma Cortisol CBC, CXR portable , DDIMER, CRP, Spec 16, Urinalysis, ABGs, Urine CS Foley Catheter inserted Start Esomeprazole 40mg IVOD Human Albumin 25% 100ml x 1 hr Arterial Blood Gases pO2 pH pCO2 HCO3 O2sat BE TotCO2 FiO2 RR 48.3 7.53 27.6 23 89.2 +1.7 23.8 100 34 COURSE IN THE WARD 1st Hospital Day MICU Pulmonology VS O2 sats 83% BP 123/64 Mech Vent Settings AC FiO2 1.0 Vt 400 RR 34 PEEP 20 Shift Berodual to Terbutaline nebulization q8h Acetylcysteine neb 600mg COURSE IN THE WARD 2nd Hospital Day Febrile Tmax 38.2 BP 114/60 r/o Pneumocystis Carinii Pneumonia CVP 22.5 Start Dobu 5mcg, Dopa 3mcg HR 139 O2 sats 92% Impression: Infectious Disease Cotrimoxazole 400/80mg IV q8h Sputum for PCP – IF Nephrology Furosemide 20mg IV q6h Mannitol 50mg IV drip 30min after furosemide dose COURSE IN THE WARD 2ND Hospital Day As treatment for fibroproliferative phase of ARDS Pulmonology Start Methylprednisolone 4mg/kg q8h Decrease FiO2 to 0.85 0.75 Methylprednisolone Infusion in Early Severe ARDS*Results of a Randomized Controlled Trial CONCLUSIONS: Methylprednisoloneinduced down-regulation of systemic inflammation was associated with significant improvement in pulmonary and extrapulmonary organ dysfunction and reduction in duration of mechanical ventilation and ICU length of stay AU Meduri GU; Golden E; Freire AX; Taylor E; Zaman M; Carson SJ; Gibson M; Umberger R SO Chest. 2007 Apr;131(4):954-63 COURSE IN THE WARD 3RD Hospital Day HR 120s, RR 30s, dyspnea O2sats 95% at FiO2 0.75 ECG sinus tachycardia Hold Terbutaline Increase FiO2 to 1.0 Nephrology Na 151 Shift IVF to 1/2NSS x 40ml/hr Dec Furosemide 20mg q8h Dec Mannitol 50mg to q8h Give 2nd dose of IV Ig COURSE IN THE WARD 4th Hospital Day Keep decreasing FiO2 below 1.0 to keep O2 sats above 90% 7th Hospital Day 8th Hospital day VS BP 120/70 Afebrile O2sats 96% Weaning from Mech vent started Patient was transferred out of MICU Pip-Tazo Discontinued Methylprednisolone tapering started COURSE IN THE WARD 14TH Hospital Day VS Patient was extubated Shifted to MVM 0.5 BP 120/70 O2 sats 92% On T-piece FiO2 0.35 RSB 18.87 15th Hospital Day ABGs pO2 – 75.7 (115) At MVM 0.5 Hooked to BIPAP IPAP 15 EPAP 5 SIDEFLOW 70 COURSE IN THE WARD 17TH Hospital Day ABGs pO2 – 85.6 on BIPAP 21st Hospital Day CBC (07/27/09) Urine CS E.Coli WBC – 23.65 (14.4) Sensitive to Cefuroxime Imp: Hospital Acquired UTI BIPAP shifted to O2 at 3LPM Start Cefuroxime 500mg BID Foley cath removed COURSE IN THE WARD 28TH Hospital Day HRCT done 31st Hospital Day MGH Clinical Course of ARDS Exudative Phase (Day 1-7) Proliferative Phase (Day 7-21) Fibrotic Phase FINAL DIAGNOSIS • Severe Complicated Pneumonia H1N1 infection with • • • • Acute Respiratory Distress Syndrome Diabetes Mellitus, Type 2, Non insulin Requiring Obese Class III Hypertension Stage I Polycystic Ovarian Syndrome Influenza A (H1N1) Influenza is usually a respiratory infection Transmission Regular person-to-person transmission Primarily through contact with respiratory droplets Transmission from objects (fomites) possible National Center for Disease Prevention and Control, DOH Key Characteristics Communicability Viral shedding can begin 1 day before symptom onset Peak shedding first 3 days of illness Correlates with temperature Subsides usually by 5-7th day in adults Infants, children and the immuno-compromised may shed the virus longer National Center for Disease Prevention and Control, DOH Incubation period Time from exposure to onset of symptoms 1 to 4 days (average = 2 days) Seasonality In temperate zones, sharp peaks in winter months In tropical zones, circulates year-round with seasonal increases. National Center for Disease Prevention and Control, DOH Individuals at Increased Risk for Hospitalizations and Death Elderly > 65 years Children less than two years Certain chronic diseases Heart or lung disease, including asthma Metabolic disease, including diabetes HIV/AIDs, other immuno-suppression Conditions that can compromise respiratory function or the handling of respiratory secretions Pregnant women National Center for Disease Prevention and Control, DOH INTENSIVE-CARE PATIENTS WITH SEVERE NOVEL INFLUENZA A (H1N1) VIRUS INFECTION --- MICHIGAN, JUNE 2009 10 patients wiith Influenza A(H1N1) and ARDS admitted at ICU. Of the 10 patients 9 were obese (BMI>30) including 7 who are extremely obese (BMI>40). Five had pulmonary emboli; Nine had MODS. 3 patients died. Clinicians should be aware of the potential for severe complications of H1N1 virus infection in extremely obese patients. Conclusion Predominance of males High prevalence of obesity Frequency of clinically significant pulmonary emboli and MODS Influenza A Viruses Influenza A viruses categorized by subtype • Classified according to two surface proteins Hemagglutinin (H) – 16 known Neuraminidase (N) – 9 known N H National Center for Disease Prevention and Control, DOH Nomenclature Virus type Strain number Virus subtype A / Sydney / 05 / 97 (H3N2) Place virus isolated Year isolated National Center for Disease Prevention and Control, DOH Region WHO Regional Office for (AFRO) WHO Regional Office for the (AMRO) WHO Regional Office for the (EMRO) WHO Regional Office for (EURO) WHO Regional Office for (SEARO) WHO Regional Office for the Western Pacific (WPRO) Total Cumulative total as of 11 October 2009 Cases* Deaths 12456 70 153697 3406 13855 90 Over At least 61000 207 39522 530 118702 432 Over 399232 At least 4735 Influenza A (H1N1) is a novel virus Unusual combination of genetic material from pigs, birds & humans which have re-assorted Affects all age groups Vaccines for human seasonal flu can not protect humans against the novel virus National Center for Disease Prevention and Control, DOH Swine Influenza Viruses RNA viruses Pigs can be infected by avian influenza and human influenza viruses as well as swine influenza viruses. Re-assort and new viruses that are a mix of swine, human and avian influenza viruses can EMERGE National Center for Disease Prevention and Control, DOH Genetic Re-assortment SIV National Center for Disease Prevention and Control, DOH Signs & Symptoms of Influenza A (H1N1) Fever Lethargy Lack of appetite Coughing Runny Nose Sore throat Nausea / Vomiting Diarrhea National Center for Disease Prevention and Control, DOH Swine H1N1 vs. Human H1N1 swine H1N1 flu virus NOT the same as human H1N1 virus antigenically very different from human H1N1 viruses vaccines for human seasonal flu can not protect humans from swine H1N1 National Center for Disease Prevention and Control, DOH Transmission: Food-Borne? NO Influenza A (H1N1) viruses are not transmitted through food Safe to eat properly handled and cooked pork and pork products Cook pork at an internal temperature of 70°C (160°F) National Center for Disease Prevention and Control, DOH Diagnosis and Laboratory Confirmation Clinically diagnosed Respiratory Specimen • • first 4 to 5 days of illness can shed for 10 days or longer Specimens sent to US CDC • ONLY laboratory that can isolate and identify swine influenza type A virus National Center for Disease Prevention and Control, DOH Specimens Upper respiratory tract specimens as recommended are the most appropriate. taken from the deep nostrils (nasal swab), nasopharynx (nasopharyngeal swab), Nasopharyngeal aspirate, throat or bronchial aspirate. Laboratory Diagnosis Rapid Influenza Diagnostic Test Antigen detection test that detect influenza viral nucleoprotein antigen Can provide results within 30 minutes Sensitivity 40-69% CDC rRT-PCR Swine Flu Assay Sensitivity : 99.8% Specificity: 92% Table 1. Comparison of Available Influenza Diagnostic Tests1 Influenza Diagnostic Tests Method Availability Typical Sensitivity3 Processing for 2009 Time2 H1N1 influenza Distinguishes 2009 H1N1 influenza from other influenza A viruses? Rapid influenza diagnostic Antigen tests (RIDT)4 detection Wide 0.5 hour 10 – 70% No Direct and indirect immunofluorescence assays (DFA and IFA)5 Wide 2 – 4 hours 47–93% No Viral isolation in tissue cell Virus culture isolation Limited 2 -10 days - Yes 6 Nucleic acid amplification RNA tests (including rRT-PCR) detection Limited8 48 – 96 86 – 100% hours [6-8 hours to perform test] 7 Antigen detection Yes Treatment Influenza A (H1N1) is sensitive to: Oseltamivir (tamiflu) Zanamivir Self medication is discouraged, may induce drug resistance Chemoprophylaxis Oseltamivir National Center for Disease Prevention and Control, DOH Table 1. Antiviral medication dosing recommendations for treatment or chemoprophylaxis of novel influenza A (H1N1) infection. (Table extracted from IDSA guidelines for seasonal influenza.) Agent, group Treatment Chemoprophylaxis Oseltamivir 75-mg capsule twice per day for 5 days 75-mg capsule once per day 15 kg or less 60 mg per day divided into 2 doses 30 mg once per day 16-23 kg 90 mg per day divided into 2 doses 45 mg once per day 24-40 kg 120 mg per day divided into 2 doses 60 mg once per day >40 kg 150 mg per day divided into 2 doses 75 mg once per day Adults Two 5-mg inhalations (10 mg total) twice per day Two 5-mg inhalations (10 mg total) once per day Children Two 5-mg inhalations (10 mg total) twice per day (age, 7 years or older) Two 5-mg inhalations (10 mg total) once per day (age, 5 years or older) Adults Children ≥ 12 months Zanamivir CDC Health Advisory Distributed via Health Alert Network July 09, 2009 Three Reports of Oseltamivir Resistant Novel Influenza A (H1N1) Viruses ANTI VIRAL CHEMOPROPHYLAXIS Post-exposure prophylaxis for health care workers, first responders and workers who did not have adequate PPE when in contact. Anti-viral prophylaxis is not recommended to close contacts except when they belong to high risk group. Vaccine Process of production is underway, but may take 5 – 6 months Seasonal influenza vaccine provides protection against the seasonal human influenza strains only National Center for Disease Prevention and Control, DOH Vaccine Supplier Vaccine Form MedImmune (nasal spray) Live virus 0.2 mL (nasal spray sprayer) Sanofi (IM)a Inactivated 0.25 mL prefilled syringe 0.5 mL prefilled syringe 5 mL multidose vial Mercury µg/0.5 mL 0 Age 2-49 yrsb 0 0 25 6-35 mosb > 36 mosb > 6 mosb Novartis (IM)a 5 mL multidose vial 0.5 mL prefilled syringe 25 < 1.0 ≥ 4 yrsb > 4 yrsb CSL Biotherapies, Inc (IM)a 0.5 mL prefilled syringe 5.0 mL multidose vial 0 24.5 > 18 yrs > 18 yrs 0.5 mL doses contain 15 µg hemagglutinin of the vaccine strain A/California/7/2009 (H1N1) Two doses separated by 4 weeks for children 2-9 years (CDC. Update on influenza A (H1N1) monovalent vaccines. MMWR Morb Mortal Wkly Rep. 2009;58:1100-1101.) INTERIM GUIDELINES NO.2: INFECTION CONTROL AND USE OF PERSONAL PROTECTIVE EQUIPMENT IN INFLUENZA A HEALTH CARE PERSONNEL Standard and droplet precautions when working in direct contact If there is risk of splashes: particulate respirator; eye protection;clean, non-sterile, long sleeved gown; sterile gloves Frequent and proper handwashing Isolate patient in a single room. Reinforce standard precautions with droplet and contact precaution Use appropriate Personal Protective Equipment for all those entering patients rooms. Restrict number of visitors. Healthcare workers on direct contact should monitor their own temperature 2X a day and report any febrile event. INTERIM GUIDELINES NO.17: REVISED CLINICAL CASE MANAGEMENT OF INFLUENZA A(H1N1) VIRUS INFECTION Vaccination Influenza vaccine is the best prevention for seasonal influenza. Inactivated viruses in the vaccine developed from three circulating strains (generally 2 Type A and 1 Type B strain) Therefore, seasonal “flu shot” only works for 3 influenza subtypes and will not work on pandemic strains. Live, intranasal spray vaccine for healthy non- pregnant persons 5-49 years Inactivated, injectable vaccine for persons 6 months and older National Center for Disease Prevention and Control, DOH Influenza Viruses Classified into types A, B, and C • • • Only Types A and B cause significant disease Types B and C limited to humans Type A viruses More virulent Affect many species C Goldsmith, CDC National Center for Disease Prevention and Control, DOH American Journal of Kidney Diseases Prehypertension, Obesity, and Risk of Kidney Disease: 20 year follow up The HUNT 1 Study in Norway (June 11, 2009) Participants with prehypertension are not at increased risk of serious kidney outcomes if BMI is less than 30kg/m2. However, the risk of Kidney disease increases substantially if prehypertension is present in obese participants. CBC 7/6/09 7/08/09 7/09/09 7/11/09 7/13/09 7/15/09 7/17/09 Hemoglobin 12.7 12.1 12.1 12.4 13.4 12.7 12.3 Hematocrit 38.7 36.6 37.3 38.9 40.2 37.9 37.1 WBC 4.76 4.78 10.96 20.33 13.15 13.52 14.4 Seg 82 68 79 91 90 89 93 Lymphocytes 15 20 13 4 5 4 4 Monocytes 3 12 6 5 3 6 2 2 1 1 427 482 538 Eosinophils Platelets 2 230 272 337 423 CBC 7/21/09 7/31/09 Hemoglobin 15 11.3 Hematocrit 44.8 35.1 WBC Seg Lymphocytes 23.65 93 5 8.34 80 14 2 4 Monocytes Eosinophils Platelets 2 665 306 Chemistry Na K BUN Crea Co2 Glucose Calcium Albumin ALP AST ALT Total Bili Uric acid Triglycerides Cholesterol HDL LDL DDIMER 7/7/09 4.2 12 0.8 163 7.9 3 63 125 74 0.4 5 189 192 18 144 7/08/09 7/09/09 7/11/09 7/13/09 7/15/09 145 3.4 12 0.8 28 240 7.9 3 63 112 65 0.5 4.5 151 3.4 13 1 144 3.7 25 1 134 3.6 24 0.7 132 3.1 30 0.8 3.1 3 63 67 217 8.98 3 79 54 78 1.24 3.17 165 207.45 4250 2910 3 99 7/17/09 7/21/09 134 4.6 36 0.8 138 5.5 51 0.8 CORTISOL 1659.731 nmol/L 7/13/09 ESR 70 mm/hr HbA1c – 8.1% HRCT: Predominantly interstitial infiltrates in both lungs with associated ground glass opacities in both upper lobes. The interstitial infiltrates may represent interstitial fibrosis with superimposed acute alveolar inflammatory or infectious process. Minimal pneumomediastinum and subcutaneous emphysema. CXR: Jul 6 – Hazy infiltrates in the right upper lobe likely due to pneumonia. There are also infiltrates in the right paracardiac and left lower lobe. Heart is magnified. Bones and soft tissues are normal. Jul 7 – Increase infiltrates in the right lung. ET tube in place. Jul 8 – right suprahilar and paracardiac infiltrates appear confluent, however there is partial clearing of the infiltrates seen in the peripheral chest. Infiltrates in the left are unchanged. Jul 13 – Complete resorption of the right side pneumothorax. Slight clearing of Pulmonary congestion. ET tube in place. Jul 17 – No significant change in the opacities in both lungs. Minimal subcutaneous emphysema. Jul 19 – Moderate resorption of subcutaneous emphysema. No significant change in infiltrates. 7/06 7/07 7/08 7/09 7/10 7/11 7/17 7/20 7/23 7/30 pO2 49.1 47.9 49 62.5 51.6 69 68.8 116.9 85.6 80 pH pCO2 7.4 42.4 7.49 35.7 7.49 40.1 7.58 33.6 7.55 38.7 7.45 42.3 7.48 27.8 7.42 36.9 7.41 39.4 7.44 34.7 HCO3 25.7 26.8 30.1 30.8 33.6 29.3 19.9 23.8 24.7 23.4 O2sat 84.7 87.2 87.7 95 90.8 94.6 95.1 98.4 96.6 96.3 BE +0.7 +3.7 +8.9 +10.6 +4.9 -2.2 -0.1 +0.3 -0.1 TotCO2 27 27.9 31.3 31.9 34.8 30.6 20.8 24.9 25.9 24.4 FiO2 50 100 100 100 90 60 35 35 Bipap Ra RR 48 38 34 36 34 27 24 18 24 20 +6.3 The FDA has approved 4 vaccine preparations. The following data highlight relevant issues: All influenza vaccine preparations in the United States for the 2009-2010 season contain residual egg protein and none contain adjuvant; Children 6 months to 9 years of age who are given influenza A (H1N1) monovalent vaccine should receive 2 doses separated by about 4 weeks; persons ≥ 10 years of age should receive 1 dose; The influenza A (H1N1) monovalent vaccines were made according to standards used for seasonal and influenza vaccines and have the same age group indications, precautions, and contraindications as vaccines that are FDA-approved for seasonal flu; preliminary data indicate that the safety and efficacy of the 2009 Influenza A (H1N1) monoclonal vaccine is the same as winter; There is minimal evidence of significant antigenic change since the first characterization of the virus in April 2009, indicating that the virus continues to be well matched with the vaccine strain; and The vaccines of the 4 suppliers have some differences that are important to recognize:for seasonal flu vaccines; Side effects, including local pain at the injection site, were reported in 46% of recipients, and systemic reactions (headache, malaise or myalgias) were reported in 45%; the safety profile is consistent with the experience with seasonal flu vaccine; Influenza activity due to influenza A (H1N1) increased in September 2009 and is expected to continue through fall and Children 6 months to 9 years of age should receive 2 doses separated by 3 weeks. Children 10 years and older and adults should receive 1 dose. The following groups should receive the vaccine as soon as it becomes available: •Pregnant women; •People who live with or care for infants younger than 6 months of age; •Healthcare workers (HCWs) and emergency medical personnel; •Persons 6 months to 24 years of age; •Persons 25-64 years of age who have chronic diseases (including immunodeficiency states) that pose risk for influenza. When more vaccine becomes available, the following persons should be vaccinated: •Healthy persons ages 25-64 years; and •Adults 65 years of age and older.