H1N1 Influenza Management
in the
Critical Care Areas
2012
Table of Contents
Page No.
H1N1 Influenza management in the ICU & HDU ……………………….
3
Infection Control Precautions / Personal Protective Equipment (PPE)
4-6
Clinical Care Practice Points ……………………………………………..
7-8
Audit ………………………………………………………………………..
9
2
H1N1 Influenza Management in the ICU / HDU
There has been a significant increase in recent weeks of patients referred to critical
care with H1N1 associated acute lung injury. This has been particularly marked in the
UK, but is now impacting in Ireland.
We are re-issuing these guidelines with very few modifications from last year, but
advise that all should keep abreast of new international guidelines as they evolve. This
guideline shall be updated as the situation evolves.
Further resources available for up-to-date information would include:
The Health Protection Surveillance Centre, Ireland with the following link:
http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/SeasonalInfluenza/
The Health Protection Agency in the UK, with the following link –
http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/11919421
71468
Information and contacts for ECMO in Ireland can be accessed through
http://www.mater.ie/ECLS/
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Infection Control Precautions / Personal Protective
Equipment (PPE)
Please refer to HSE/HSPC guidelines infection prevention and control of suspected or
confirmed pandemic (H1N1) 2009/seasonal influenza in healthcare setting 21/12/201.
http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/SeasonalInfluenza/
Personal protective equipment (PPE)
The patient should wear a surgical mask when outside their single room
and during chest physiotherapy if tolerated.
HCWs (even if vaccinated against pandemic H1N1 or seasonal
influenza) must wear the following PPE:
PPE for routine care for suspected or confirmed pandemic (H1N1)
/seasonal influenza case.
Patients aged ≥ 5 years:
• Surgical mask. Wear gloves/apron/gown/goggles if risk of
contact with blood, body fluids, mucous membranes or nonintact
skin anticipated as per Standard Precautions.
Patients aged < 5 years:
• Surgical mask, gloves, apron/gown (and goggles if risk of
spraying or splashing of blood or body fluids).
PPE for an AGP and if remaining in or entering the patients’ room
within one hour after cessation of the AGP:
• FFP2 or FFP3 mask (correctly fitted), goggles, long sleeved
disposable gown, gloves.
• See appendix B for list of AGPs and appendix C for donning and
removing PPE
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HCWs when putting on and removing PPE must:
• Replace if damp, wet or torn.
• Put on and remove in the correct sequence (see appendix C for donning and
removing PPE).
• Remove and dispose of gloves & apron/gown inside the single room.
• Remove and dispose of mask in the ante room or immediately outside the single
room if there is no ante room. Ensure door is closed.
• Discard masks as healthcare risk waste.
• Discard gloves/aprons/gowns/goggles as healthcare risk waste if contaminated with
blood or body fluids.
• Decontaminate hands immediately after removing PPE.
Visitors should:
• Be kept to a minimum.
• Wear a surgical mask while in patients’ room.
• Be educated on:
• Donning and removing PPE.
• Hand hygiene.
• Respiratory hygiene and cough etiquette.
5
Aerosol Generating Procedures (AGP)
In December 2009 the World Health Organization (WHO) updated its advice on
AGPs. (1)
The following are classified as AGPs:
• Intubation and related procedures, e.g. manual ventilation
• Respiratory and airway suctioning (including tracheostomy care and open suctioning
with invasive ventilation)
• Cardiopulmonary resuscitation
• Bronchoscopy
• Collection of lower respiratory tract specimens (e.g. bronchial and tracheal
aspirates)
• Autopsy procedures
The following procedures are not classified as AGPs:
• Mechanical ventilation or respiratory therapy treatment unless an AGP is being
performed on an open system
• Closed suctioning with invasive ventilation
• Non-invasive positive pressure ventilation (BiPAP)
• Bi-level positive airway pressure (BPAP)
• Nasopharyngeal aspiration
• Nebulisation (but it should be performed in an area physically separate from other
patients)
Chest physiotherapy is not considered an AGP but a surgical mask should
be worn by the patient if tolerated and HCWs should wear PPE as
recommended for routine care (see 2.6).
In dental practice, AGPs include the use of hand pieces (especially air
rotor) in the patient’s mouth, and scaling using an ultrasonic or air scaler
(but not hand scaling).
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Clinical Care Practice Points
Patients referred to ICU / HDU shall be the critically ill. This patient area has no
surge capacity and cannot be used to cohort patients not requiring this level of
dependency.
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.
Anticipate need for respiratory support such that as much as possible this can
be in a managed context.
3.
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.
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.
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.
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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.
GUT absorption may be a concern with critically ill.Oseltamivir is
available in an intravenous format on compassionate grounds, but
experience is limited.
- Dose adjustment required for Cr Clearance < 30ml/min
- Adamantanes – H1N1 resistant to adamantanes (Amantadine)
- Zanamivir (Relenza) – see HPSC Guidance on the Use of
Antivirals. Intravenous preparation is available for severely
immunocompromised patients where there is a higher risk of
developing oseltamivir resitance. Also consider if poor response to
oseltamivir first line therapy, or gut failure with inability to absorb
enteral oseltamivir. Do not use powder preparation to make up a
nebulized solution (may cause endotracheal tube blockage);
experience with (unlicensed) zanamivir is limited.
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
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13.
Duration of Isolation
- in consultation with Department of Infection Control and
Microbiology.
Audit
The national audit process for H1N1 remains that of the ICSI / HPSC
collaboration which has been very useful over the last two seasons. A number of
minor modifications have been made to simplify the process and remove previous
either repetitions of data-points not valuable to clear audit.
HPSC / ICSI ICU Enhanced Surveillance Forms have been circulated to all
intensive care units.
The internal process for collation and return to HPSC is presumed to be
unchanged for each unit unless advised to the HPSC.
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