Archive for October 12, 2009

Critically Ill Patients With 2009 Influenza A(H1N1) in Mexico

JAMA  October 12, 2009 V.302  N.17

Guillermo Domínguez-Cherit, MD; Stephen E. Lapinsky, MB, BCh, MSc; Alejandro E. Macias, MD; Ruxandra Pinto, PhD(Stat); Lourdes Espinosa-Perez, MD; Alethse de la Torre, MD; Manuel Poblano-Morales, MD; Jose A. Baltazar-Torres, MD; Edgar Bautista, MD; Abril Martinez, MD; Marco A. Martinez, MD; Eduardo Rivero, MD; Rafael Valdez, MD; Guillermo Ruiz-Palacios, MD; Martín Hernández, MD; Thomas E. Stewart, MD; Robert A. Fowler, MD, MS(Epi)

Division of Pulmonary and Critical Care (Dr Domínguez-Cherit), Hospital Epidemiology Department (Drs de la Torre and Macias), Infectious Disease Department (Dr Ruiz-Palacios), and Department of Critical Care Medicine (Dr Rivero), Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán,” México City, México; Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto and Mount Sinai Hospital, Toronto, Ontario, Canada (Dr Lapinsky); School of Medicine, Instituto Tecnologico de Estudios Superiores de Monterrey, Monterrey, México (Dr Espinosa-Perez); Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto (Dr Pinto); Hospital Juarez de México, México City (Dr Poblano-Morales); Hospital de Especialidades Centro Medico La Raza, IMSS, México City (Dr Baltazar-Torres); Instituto Nacional de Enfermedades Respiratorias, México City (Dr Bautista); Department of Internal Medicine (Drs A. Martinez and M. A. Martinez) and Infectious Disease Hospital (Dr Valdez), Hospital General “Dr. Manuel Gea Gonzalez,” México City; Hospital San Jose-Tec de Monterrey, Monterrey City (Dr Hernández); Interdepartmental Division of Critical Care Medicine and Department of Medicine and Anaesthesia, University of Toronto, Mount Sinai Hospital, University Health Network, Toronto (Dr Stewart); and Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto (Dr Fowler).

Context In March 2009, novel 2009 influenza A(H1N1) was first reported in the southwestern United States and Mexico. The population and health care system in Mexico City experienced the first and greatest early burden of critical illness.

Objective To describe baseline characteristics, treatment, and outcomes of consecutive critically ill patients in Mexico hospitals that treated the majority of such patients with confirmed, probable, or suspected 2009 influenza A(H1N1).

Design, Setting, and Patients Observational study of 58 critically ill patients with 2009 influenza A(H1N1) at 6 hospitals between March 24 and June 1, 2009. Demographic data, symptoms, comorbid conditions, illness progression, treatments, and clinical outcomes were collected using a piloted case report form.

Main Outcome Measures The primary outcome measure was mortality. Secondary outcomes included rate of 2009 influenza (A)H1N1–related critical illness and mechanical ventilation as well as intensive care unit (ICU) and hospital length of stay.

Results Critical illness occurred in 58 of 899 patients (6.5%) admitted to the hospital with confirmed, probable, or suspected 2009 influenza (A)H1N1. Patients were young (median, 44.0 [range, 10-83] years); all presented with fever and all but 1 with respiratory symptoms. Few patients had comorbid respiratory disorders, but 21 (36%) were obese. Time from hospital to ICU admission was short (median, 1 day [interquartile range {IQR}, 0-3 days]), and all patients but 2 received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia (median day 1 ratio of PaO2 to fraction of inspired oxygen, 83 [IQR, 59-145] mm Hg). By 60 days, 24 patients had died (41.4%; 95% confidence interval, 28.9%-55.0%). Patients who died had greater initial severity of illness, worse hypoxemia, higher creatine kinase levels, higher creatinine levels, and ongoing organ dysfunction. After adjusting for a reduced opportunity of patients dying early to receive neuraminidase inhibitors, neuraminidase inhibitor treatment (vs no treatment) was associated with improved survival (odds ratio, 7.4; 95% confidence interval, 1.8-31.0).

Conclusion Critical illness from 2009 influenza A(H1N1) in Mexico occurred in young individuals, was associated with severe acute respiratory distress syndrome and shock, and had a high case-fatality rate.

abstract

http://jama.ama-assn.org:80/cgi/content/abstract/2009.1536v1?etoc

PDF

http://jama.ama-assn.org/cgi/reprint/2009.1536v1

October 12, 2009 at 3:13 pm Leave a comment

Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Canada

JAMA  October 12, 2009  V.302  N.17

Anand Kumar, MD; Ryan Zarychanski, MD; Ruxandra Pinto, PhD; Deborah J. Cook, MD, MSc; John Marshall, MD; Jacques Lacroix, MD; Tom Stelfox, MD, PhD; Sean Bagshaw, MD, MSc; Karen Choong, MD; Francois Lamontagne, MD; Alexis F. Turgeon, MD, MSc; Stephen Lapinsky, MD; Stéphane P. Ahern, MD; Orla Smith, MSc; Faisal Siddiqui, MD; Philippe Jouvet, MD, PhD; Kosar Khwaja, MD; Lauralyn McIntyre, MD, MSc; Kusum Menon, MD, MSc; Jamie Hutchison, MD; David Hornstein, MD; Ari Joffe, MD; Francois Lauzier, MD; Jeffrey Singh, MD, MSc; Tim Karachi, MD; Kim Wiebe, MD; Kendiss Olafson, MD; Clare Ramsey, MD; Satendra Sharma, MD; Peter Dodek, MD, MHSc; Maureen Meade, MD, MSc; Richard Hall, MD; Robert Fowler, MD, MSc; for the Canadian Critical Care Trials Group H1N1 Collaborative

Section of Critical Care Medicine, Health Sciences Centre and St Boniface Hospital, Winnipeg, Manitoba, Canada (Drs Kumar, Siddiqui, Wiebe, Olafson, Ramsey, and Sharma); Department of Medical Oncology and Hematology, Cancercare Manitoba, Winnipeg (Dr Zarychanski); Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Pinto and Fowler); Departments of Clinical Epidemiology and Biostatistics (Drs Cook and Meade) and Medicine (Dr Karachi), McMaster Children’s Hospital (Dr Choong), McMaster University, Hamilton, Ontario, Canada; Department of Critical Care Medicine, St Michael’s Hospital, Toronto, Ontario, Canada (Dr Marshall and Ms Smith); Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada (Drs Lacroix and Jouvet); Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada (Dr Stelfox); Division of Critical Care Medicine, University of Alberta, Edmonton (Drs Bagshaw and Joffe); Department of Medicine, Centre Hospitalier, Université de Sherbrooke, Sherbrooke, Quebec, Canada (Dr Lamontagne); Centre de Recherche du CHA, Hôpital de l’Enfant-Jésus, Université Laval, Quebec City, Quebec, Canada (Drs Turgeon and Lauzier); Intensive Care Unit, Mount Sinai Hospital (Dr Lapinsky) and University Health Network (Dr Singh), University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Hôpital Maisonneuve-Rosemont, University of Montréal, Montréal, Quebec, Canada (Dr Ahern); Trauma Services, McGill University Health Centre, Montréal, Quebec, Canada (Dr Khwaja); Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa, Ontario, Canada (Dr McIntyre); Clinical Research Unit, Children’s Hospital of Eastern Ontario, Ottawa (Dr Menon); Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada (Dr Hutchison); SMBD-Jewish General Hospital, Montréal, Québec, Canada (Dr Hornstein); University of British Columbia, Vancouver (Dr Dodek); and Department of Anesthesia, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada (Dr Hall).

Context Between March and July 2009, the largest number of confirmed cases of 2009 influenza A(H1N1) infection occurred in North America.

Objective To describe characteristics, treatment, and outcomes of critically ill patients in Canada with 2009 influenza A(H1N1) infection.

Design, Setting, and Patients A prospective observational study of 168 critically ill patients with 2009 influenza A(H1N1) infection in 38 adult and pediatric intensive care units (ICUs) in Canada between April 16 and August 12, 2009.

Main Outcome Measures The primary outcome measures were 28-day and 90-day mortality. Secondary outcomes included frequency and duration of mechanical ventilation and duration of ICU stay.

Results Critical illness occurred in 215 patients with confirmed (n = 162), probable (n = 6), or suspected (n = 47) community-acquired 2009 influenza A(H1N1) infection. Among the 168 patients with confirmed or probable 2009 influenza A(H1N1), the mean (SD) age was 32.3 (21.4) years; 113 were female (67.3%) and 50 were children (29.8%). Overall mortality among critically ill patients at 28 days was 14.3% (95% confidence interval, 9.5%-20.7%). There were 43 patients who were aboriginal Canadians (25.6%). The median time from symptom onset to hospital admission was 4 days (interquartile range [IQR], 2-7 days) and from hospitalization to ICU admission was 1 day (IQR, 0-2 days). Shock and nonpulmonary acute organ dysfunction was common (Sequential Organ Failure Assessment mean [SD] score of 6.8 [3.6] on day 1). Neuraminidase inhibitors were administered to 152 patients (90.5%). All patients were severely hypoxemic (mean [SD] ratio of PaO2 to fraction of inspired oxygen [FIO2] of 147 [128] mm Hg) at ICU admission. Mechanical ventilation was received by 136 patients (81.0%). The median duration of ventilation was 12 days (IQR, 6-20 days) and ICU stay was 12 days (IQR, 5-20 days). Lung rescue therapies included neuromuscular blockade (28% of patients), inhaled nitric oxide (13.7%), high-frequency oscillatory ventilation (11.9%), extracorporeal membrane oxygenation (4.2%), and prone positioning ventilation (3.0%). Overall mortality among critically ill patients at 90 days was 17.3% (95% confidence interval, 12.0%-24.0%; n = 29).

Conclusion Critical illness due to 2009 influenza A(H1N1) in Canada occurred rapidly after hospital admission, often in young adults, and was associated with severe hypoxemia, multisystem organ failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.

abstract

http://jama.ama-assn.org:80/cgi/content/abstract/2009.1496v1?etoc

PDF

http://jama.ama-assn.org/cgi/reprint/2009.1496v1

October 12, 2009 at 3:09 pm Leave a comment


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