感染症診療の原則

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数百例を経験した救急医のTip 診療中の先生がた、ご覧下さい!

2020-03-29 | Aoki Office

ミズーリ州の大庭先生が転送して下さった情報。板橋中央病院の加藤良太朗先生によりますと、この情報は加藤先生のMentorでらした元ワシントン大学のDr. Daniel Goodenberger(現セントルイスVA病院内科主任部長)の同僚の方からとのことです。
すでに数百例のCOVID-19症例を診ておられるようです。
以下、編集長が勝手にSamplingしたもの。重要と思ったものは日本語も追加した。

臨床経過は定型的/予想通りに動く:Clinical course is predictable.
・潜伏期間:2-11 days after exposure (day 5 on average) flu like symptoms start.
・良くある症状は発熱、頭痛、乾性咳嗽、筋肉痛、悪心(嘔吐なし)、腹部不快感、時に下痢、嗅覚障害、食欲低下、疲労感、(編集長:やはり咽頭痛少ない?)Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.
・発症5日目、呼吸苦増加し、両側性のウイルス性肺炎的、肺実質のウイルス自身による障害・・Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.
・発症10日目、サイトカインの嵐でARDSに他臓器不全。これが数時間で・・Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.
・81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

来院時の臨床像はマチマチ、Patient presentation is varied. :
低酸素だが呼吸苦がない(編集長:レントゲンの陰影のサイズの割に症状かるいので思いの外ゆっくり進むのか、特殊なVQ mismatchを生じない病態なのか、でも低酸素)・・Patients are coming in hypoxic (even 75%) without dyspnea.
・脳症、腎不全、脱水、DKAの症例・・I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA.
I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it.
・COVID-19症例で2例のインフルエンザ陽性(これは編集長も肺炎球菌、インフルエンザ、レジオネラ、マイコプラズマなどの合併を見聞きしている)・・Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well.
Somehow this ***** has told all other disease processes to get out of town.

心臓:
・中国のでは15%の症例で心臓の問題が。China reported 15% cardiac involvement.
心筋炎、心外膜炎、心不全、心房細動・・I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation.
I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.

診断:Diagnostic

単純写真:
・CXR-基本は両側性間質性肺炎 bilateral interstitial pneumonia (両側性とは限らない。anecdotally starts most often in the RLL so bilateral on CXR is not required).
単純写真の程度と酸素化の問題は比例しない・・The hypoxia does not correlate with the CXR findings.
・聴診所見はたいしたことない(有用ではない-皿谷先生ゴメン)Their lungs do not sound bad.
聴診器は使わず、視診と酸素飽和度で診療・・(皿谷先生ゴメン)Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.

検査Labs:
・白血球数低め、リンパ球低め、血小板低めから普段より低め・・WBC low, Lymphocytes low, platelets lower then their normal,
プロカルシトニンが正常で、CRPとフェリチンが上昇。(編集長:CRPはこう使いたいね!!) Procalcitonin normal in 95%。CRP and Ferritin elevated most often.
・次の検査も異常が多い。CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
・Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia.
造影剤の使用で腎不全になり人工呼吸器が早期に必要に。The patients receiving IV contrast are going into renal failure and on the vent sooner.
基本的に両側性肺炎+正常白血球+リンパ球減少+正常プロカルシトニン+CRP、Ferritin高値ならCOVID-19だ。PCRは要らない:Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.
好中球とリンパ球の比が3.5以上なら予後がわるい。イギリスでは、このような症例は臨床像に関係無く自動的に挿管する:A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.
IL6の上昇はサイトカインの嵐をしめす。警戒せよ:An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.
血小板減少、肝機能が正常値の5倍以上も悪い予後を示唆:Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.

入院か帰宅か:Disposition/
・今までのようには入院させない、させられない
以前は多発性肺炎の症例を院外で診るなんてありえなかったが、今は1回の勤務シフトで12-15回はする:I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift.
・以前は酸素が必要な症例を帰すなんてありえなかったが、今は患者が酸素で大丈夫+酸素飽和度が92%以上なら帰している。こういう症例は救急隊員の会社と契約して2回/日、酸素飽和度をチェックし、見守りに行ってもらう・・勿論、一部、大事に至ることもあるかもしれないので不安:2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.
病棟は一杯である:We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

治療:Treatment
・支持療法:Supportive
・人工呼吸器の適応例の86%は亡くなる。抜管できるのは中国で10日目、シアトルで11日目。worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.
・Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.
アジスロマイシン使っているが不足気味:We are also using Azithromycin, but are intermittently running out of IV.
脱水気味にする!通常の敗血症的な輸液するな。注意しないと呼吸不全になりやすい。例外はDKAと脱水による腎機能障害。脱水気味に!:Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.
うつ伏せは酸素化に非常に有効。Nasalの患者も自分でうつ伏せになると良い:Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.
・人工呼吸器の設定はARDS的・・:Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.
Bipedやめておけ。有効でないしエアロゾルの高リスク・・Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.
・同様にネブライザー治療もだめ。MDIを勧める・・The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.
ステロイドは使うな・・Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.
・薬の不足も・・We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.
・31歳の同僚が罹患した・・One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.
赤目も注意・・Also, “pink eye” also called “red eyes” was actually the first diagnostic finding notes on the Washington home patients that were Covid-19 positive

予防・防護
・自分で可能な範囲でPPEしてる・・I PPE best I have. I do wear a MaxAir PAPR the entire shift.
仕事中はPPEを脱がず、食べず、飲まず、そのまま自宅のガレージで脱衣してシャワーに直行。妻と子供は両親のもとに逃げた・・I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg.
仕事のストレスと家庭での孤独は辛いが、みんな経験していること。みんな恐れながらやってる。でも救急室のリーダーとして同僚や看護師には親切でいたい・・The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.”

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