嚴重急性呼吸道症候群 SARS (Part-5)

上接: 嚴重急性呼吸道症候群 SARS Part-4

嚴重急性呼吸道症候群 SARS (Part-5)

九、治療，台大資料為主（陳怡君）

 

Treament ?      (Peiris et al,  The Lancet)

1. Antibiotics for possible bacterial pneumonia


2. (IVIG early in the course；convalescent serum，要多少？) 


3. Ribavirin (teratogen, hemolytic anemia) (or oseltamivir) 8 mg/kg, q8h,?. [NTUH: 30-33 mg/kg loading, po (< 2 gm )à16 mg/kg, q6hx4dà 8 mg/kg, q6hx6-8d; 1.2 gm ]    (效果不明)


4. Steroids: hydrocortisone 100 mg q 6 h, or 200 mg q 8 h, for 2 days (pulse therapy), or methylprednisolone 1–3 mg/kg q24h, for two to three doses and tail off ?

 

有可能是SARS，如何選用抗生素？  許清曉
先注意體重、腎機能！

•    發燒、呼吸道症狀、或已有肺炎

ü      Levofloxacin 500 mg, po qd

ü      Moxifloxacin 400 mg, po/iv, qd

ü      Amoxacillin/clavulanate 1.5 gm , q8h, iv + Klaricid 500 mg, po, bid

ü      Cefotaxime 2 gm , q6h, iv + Klaricid 500 mg, po, bid

•    發燒、腹瀉、加其他症狀

ü      Levofloxacin 500 mg, po qd

ü      Moxifloxacin 400 mg, po/iv, qd

ü      考慮加metronidazole 500 mg, po, q8h for ameba

 

Pathophysiology of SARS   NTUH

Incubation Onset of symptoms à Progression of diseaseàViremic phase ® ARDS

Hyperinflammation

Altered immune response

         Lymphoid depletion

         Hemophagocytosis

Antiviral + Immunomodulating agent(s)

  

IV Ribavirin   NTUH

•    IVIG （1,200 mg/vial）for severe infection。

•    Loading: 30-33 mg/kg in distilled H2O, or D5W, or N/S iv drip over 30 min. (max. 2 gm ) 。

•    Then 16 mg/kg (max. 1 gm ), q6h, x4 days。

•    Then 8 mg/kg (max. 500 mg), q8h, x3-6 days。

•    注意bradycardia、allergic reactions、teratogenicity 。

 

Oral ribavirin: candidate 陳怡君NTUH

•    Probable SARS

ü      Fever (>38 ° C) and abnormal CXR

ü      Close contact to patients hospitalized due to probable SARS

•    Suspect SARS, high probability

ü      Unexplained fever (> 38°C ) ³3 days & normal CXR

ü      Close contact to patients hospitalized due to probable SARS

ü      Myalgia, diarrhea, normal WBC, elevated CRP, abnormal GOT/GPT/CPK, etc.

 

Oral ribavirin: candidate 陳怡君NTUH

•    Probable SARS

ü      Fever (>38 ° C) and abnormal CXR

ü      Close contact to patients hospitalized due to probable SARS

•    Suspect SARS, high probability

ü      Unexplained fever (> 38°C ) ³3 days & normal CXR

ü      Close contact to patients hospitalized due to probable SARS

ü      Myalgia, diarrhea, normal WBC, elevated CRP, abnormal GOT/GPT/CPK, etc.

 

Oral ribavirin  陳怡君NTUH

•    Dosage: 2000 mg loading dose then,

                600 mg bid (weight > 75 kg ) or 

                1000mg/day (400 mg & 600 mg bid;

                     weight 75 kg or less) for 10 days.

•    200 mg capsules，take with food.

•    contraceptive precautions for 6 months after cessation of ribavirin therapy

 

Post-exposure prophylaxis or pre-emptive therapy for health care workers (NTUH)

•    Candidate: close contact to hospitalized SARS patients and become febrile

•    Oral ribavirin for 10 days:

•    BW > 75 kg : 600 mg bid

•    BW 75 kg or less: 400 mg morning dose, 600 mg evening dose

•    Consultation is mandatory

 

Respiratory care for SARS
Oxygen therapy    NTUH

•    Indicated for patients with SpO2 < 95% or PaO2 < 80 mmHg when breathing room air

•    Maintain SpO2 > 90% or PaO2 > 60 mmHg (by nasal cannula, non-rebreathing mask),

•    Simple O2 mask is NOT recommended for SARS.

•    Avoid nebulizer or nebulized aerosol medication throughout the treatment course.

 

Indication for intubation   NTUH

1. Absolute indication: PaO2/FiO2 < 150 mmHg , or

       non-rebreathing mask PaO2 < 100 mmHg)

2. Relative indication: PaO2 < 200 mmHg or

        PaCO2 > 50 mmHg or pH < 7.25 (due to respiratory acidosis)

# Note: 

(1)   Non-invasive ventilation (BiPAP, CPAP, NIPPV) is NOT recommended for SARS

(2)   perform early, and safely, after adequate induction.

 

Ventilatory care after intubation    NTUH

1. As usually care for patients with ARDS (adjust FiO2 and PEEP to maintain oxygenation; VT 6 -8 cm /kg; plateau pressure < 30-35 cmH2O)

2. Adjunctive procedures that may be helpful for arterial oxygenation (suggested by initial experience): prone positioning (usually effective); albumin infusion and negative I/O balance

 

Steroid    NTUH

•    ARDS late stage (>/= 7days) (current practice, under study): 1-3mg/kg/day

             (Marin et al. NEJM 1995; 332:27-37)

•    Acute interstitial pneumonitis (evidence-base): >1 mg/kg/day

•    Viral pneumonitis with ARDS (controversial)

 

The use of steroid after initiation of ribavirin therapy： still controversial    陳怡君NTUH

•    Do not use within 48 h of initiation of ribavirin, usually should be after day 7 of disease onset

•     Consider when significant disease progression after ribavirin, (persistent fever with multiple lobe pneumonia, plus multiple laboratory abnormalities, such as hyponatremia, elevated CPK, GOT/GPT, LDH), surge or resurge of CRP, or SpO2 < 95% under nasal O2 5 L /min.

•     Recommended dose: methylprednisolone 2 mg/kg/day or higher (no evidence support pulse therapy with methylprednisolone 0.5 g ~ 1g /day is better than lower dose steroid)

 

免疫球蛋白IVIG infusion  NTUH

•    For severe cases: 有haemophagocytosis現象，就是leucopenia, thrombocytopenia, anemia, increased serum ferritin。

•    IVIG，1 gm/kg/day, continuous infusion, x 2 days。

•    Convalescent serum or immunoglobulin應該最佳, dose?

 

Adverse reactions to IVIG < 5%  (Michel et al. NEJM 2001; 345:747-755)

•    Anaphylaxis

•    Headache, chills, nausea, fatigue, myalgia, arthralgia, back pain,

•    Increased blood pressure in patients at risk for hypertension

•    acute aseptic meningitis with pleocytosis occur within 48~72 hr

•    Transient increase in creatinine levels within 2~5 days

•    Acute renal failure is related to tubular damage induced by sucrose in the IVIG preparation, particularly in elderly patients, patients with diabetes or impaired renal function

•    Transmission of blood-borne agents ?

 

(  continued to :   嚴重急性呼吸道症候群 SARS Part-6 )