Zusammenfassung
Wir berichten über 17 Patienten mit Influenza A H1N1v assoziiertem schweren Lungenversagen (ARDS), welche zwischen 11. Juni 2009 und 10. August 2010 an einer Intensivstation (ICU) aufgenommen wurden (w/m: 8/9; Alter: median 39 (IQR 29–54) Jahre; SAPS II: 35 (29–48)). Der Body Mass Index war 26 (24–35); 24 % waren übergewichtig und 29% fettleibig. Der Charlson Comorbidity Index war 1 (0–2) und nur ein Patient hatte keinerlei Vorerkrankungen. Die mediane Zeit zwischen Symptombeginn und ICU Aufnahme betrug 5 Tage (Range 0–14). Keiner der Patienten hatte eine H1N1v Vakzine erhalten. Neun Patienten erhielten Oseltamivir, jedoch lediglich zwei innerhalb der ersten 48 Stunden nach Symptombeginn. Alle Patienten entwickelten ein schweres ARDS (PaO2/FiO2-Ratio: 60 (55–92); lung injury score: 3.8 (3,3–4,0)), waren maschinell beatmet und benötigten Vasopressoren. Vierzehn Patienten erhielten Corticosteroide, 7 wurden hämofiltriert, und 10 Patienten benötigten extrakoporale Membranoxygenation (ECMO; 8 Patienten veno-venös, 2 Patienten veno-arteriell). Drei Patienten erhielten eine ILA (Intenventional Lung Assist), und 2 Patienten eine pumpengetriebene extrakorporale low-flow CO2-Elimination. Sieben von 17 Patienten (41 %) verstarben auf der Intensivstation (4 aufgrund von Blutungen, 3 aufgrund von Multiorganversagen), alle anderen überlebten das Krankenhaus (59 %). Die ECMO-Mortalität betrug 50 %. Die mediane ICU Liegedauer betrug 26 (19–44) vs. 21 (17–25) (Überlebende vs. Nichtüberlebende), die Beatmungsdauer 18 (14–35) vs. 20 (17–24), und die ECMO Dauer 10 (8–25) vs. 13 (11–16) Tage (p = n.s.). Verglichen mit einer Kontrollgruppe von 241 erwachsenen ICU Patienten ohne H1N1v war die Liegedauer, Beatmungsrate, Beatmungsdauer, und der TISS 28 Score bei Patienten mit H1N1v signifikant höher. Die Kontrollgruppe bot ein tendeziell höheres ICU-Überleben (79 vs. 59 %; p = 0,06). Patienten mit H1N1v an unseren ICUs waren jung, überproportional übergewichtig, und hatten fast alle Vorerkrankungen. Alle Patienten entwickelten ein schweres ARDS, welches unerwartet häufig mit extrakoroporalem Gasaustausch behandelt werden musste. Patienten mit H1N1v hatten kompliziertere Verläufe verglichen mit Kontrollpatienten.
Summary
We report on 17 patients with influenza A H1N1v-associated Adult Respiratory Distress Syndrome who were admitted to the intensive care unit (ICU) between June 11th 2009 and August 10th 2010 (f/m: 8/9; age: median 39 (IQR 29–54) years; SAPS II: 35 (29–48)). Body mass index was 26 (24–35), 24% were overweight and 29% obese. The Charlson Comorbidity Index was 1 (0–2) and all but one patient had comorbid conditions. The median time between onset of the first symptom and admission to the ICU was 5 days (range 0–14). None of the patients had received vaccination against H1N1v. Nine patients received oseltamivir, only two of them within 48 hours of symptom onset. All patients developed severe ARDS (PaO2/FiO2-Ratio 60 (55–92); lung injury score 3.8 (3.3–4.0)), were mechanically ventilated and on vasopressor support. Fourteen patients received corticosteroids, 7 patients underwent hemofiltration, and 10 patients needed extracorporeal membrane-oxygenation (ECMO; 8 patients veno-venous, 2 patients veno-arterial), three patients Interventional Lung Assist (ILA) and two patients pump driven extracorporeal low-flow CO2-elimination (ECCO2–R). Seven of 17 patients (41%) died in the ICU (4 patients due to bleeding, 3 patients due to multi-organ failure), while all other patients survived the hospital (59%). ECMO mortality was 50%. The median ICU length-of-stay was 26 (19–44) vs. 21 (17–25) days (survivors vs. nonsurvivors), days on the ventilator were 18 (14–35) vs. 20 (17–24), and ECMO duration was 10 (8–25) vs. 13 (11–16) days, respectively (all p = n.s.). Compared to a control group of 241 adult intensive care unit patients without H1N1v, length of stay in the ICU, rate of mechanical ventilation, days on the ventilator, and TISS 28 scores were significantly higher in patients with H1N1v. The ICU survival tended to be higher in control patients (79 vs. 59%; p = 0.06). Patients with H1N1v admitted to either of our ICUs were young, overproportionally obese and almost all with existing comorbidities. All patients developed severe ARDS, which could only be treated with extracorporeal gas exchange in an unexpectedly high proportion. Patients with H1N1v had more complicated courses compared to control patients.
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Schellongowski, P., Ullrich, R., Hieber, C. et al. A surge of flu-associated adult respiratory distress syndrome in an Austrian tertiary care hospital during the 2009/2010 Influenza A H1N1v pandemic. Wien Klin Wochenschr 123, 209–214 (2011). https://doi.org/10.1007/s00508-011-1557-8
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DOI: https://doi.org/10.1007/s00508-011-1557-8