Page 984 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 77: Management of the Critically Ill Traveler 715

Severe (including cerebral) malaria, meningococcal meningitis and sepsis, as based on the ARDS Network algorithm should be used in all causes as
dengue fever, viral hemorrhagic fevers (VHF) (eg, Ebola, Marburg), severe it has been proven to lower mortality in patients with ARDS. Initial tidal
coronaviruses (SARS and MERS-CoV), influenza, plague, and tularemia volumes of 6 mL/kg ideal body weight should be employed and lowered
are lethal pathogens causing rapid multiorgan system failure in a traveler if the plateau pressures remain elevated above 30 cm H O. Higher levels
2
and will require rapid recognition for both therapeutic and protective mea- of positive end-expiratory pressure (PEEP) should also be employed, par-
sures, particularly with highly contagious diseases such as viral hemorrhagic ticularly if the Pa O 2 /Fi O 2 remains low. 19,20 Other maneuvers or modalities,
fever, influenza, plague, and severe coronaviruses (MERS-CoV). 1,6,7,9,11,16-18 including prone positioning or nonconventional forms of mechanical
Figure 77-1 outlines a stepwise approach to the critically ill traveler. Once ventilation (eg, airway pressure release ventilation), have never been
recognized, all travelers should undergo respiratory and contact isolation. shown to reduce mortality, and thus should be used sparingly. 20-22 Other
Due to the high risk of malaria, all critically ill patients in areas endemic adjuvant therapies for a critically ill traveler with ARDS have been tried
for malaria should undergo a thick or thin blood smear with Giemsa or as well without consistent success. Steroids and other anti-inflammatory
Romanowsky stain. Blood cultures, respiratory cultures, and urine cul- agents have been used in influenza, avian influenza, anthrax, and
tures should be obtained in all cases. If signs of meningitis or encephalitis VHF. 23,24 However, this experience has been limited to case reports only
are present, a lumbar puncture should be performed. Addition of a nasal and in some cases may be harmful. Other agents, such as immunoglobu-
swab for respiratory viruses (especially influenza) is rapidly available in lin therapy and aerosolized antibiotics have also been employed on a case
most institutions and should be performed regardless of seasonal varia- report basis and cannot be recommended routinely. The management
tion given the travel history to potential areas of influenza endemicity. of septic shock should likewise be supportive. Resuscitation with intra-
Finally, additional blood should be drawn, and stored, for serology for venous fluids, colloid, blood, and subsequent vasopressor therapy, and
the wide number of pathogens possible. 1,6,7,9,11,16-18 For example, VHFs renal replacement therapy should be administered. As with all patients in
require specialized testing in state and federal laboratories, and thus all septic shock, the effect of therapy should be measured closely (eg, central
samples will need shipment with a time delay before yielding a diagnosis. venous catheter, mixed Sv O 2 , lactate, etc). 21,23
8
Additional testing based on the risk factors or clinical syndromes outlined The role of noninvasive positive pressure ventilation (NPPV) in a
in Tables 77-5 and 77-6 should be performed, but results can take time, so traveler with hypoxemic respiratory failure and ARDS is more com-
the initial testing outlined in Figure 77-1 is essential regardless of clinical plicated. In heterogeneous patient populations with acute hypoxemic
syndromes or epidemiologic risk. 8 respiratory failure, NPPV has been shown to reduce the likelihood of
■ SUPPORTIVE MEASURES endotracheal intubation (57%), ICU length of stay, and mortality in some
patient populations (eg, cardiogenic pulmonary edema, obstructive lung
In a critically ill patient with multiorgan failure, ARDS and sepsis will disease). Regarding ARDS from an infectious agent as the cause for
25
require certain support regardless of etiologic agent. Paramount is the use acute hypoxemic respiratory failure, a recent study at experienced NPPV
of a lung-protective ventilation strategy. 19,20 Low-tidal-volume ventilation centers showed that early application of NPPV led to improvement in

Admission to ICU with
severe acute fever after travel
Clinical findings, gram stain, culture,
epidemiological evaluation
Obvious source known Unclear source based on
(eg, Pneumococcus) risk or exam
Targeted therapy Droplet or airborne isolation
No isolation unless Obtain blood, urine, respiratory
specified bacterial cultures thick/thin smear
pathogen Samples for serology
Start antimalarial therapy
(quinine or artesunate),
doxycycline, oseltamivir,
and broad spectrum antibodies

Diagnosis
determined No etiology found

Specific targeted therapy Broad pathogens possible
Isolation until Continues isolation
improved Further testing based on
Public health risk and clinical syndrome
notification as required (Table 5/6)
Contact public health officials
and refer sample to public
health laboratory

Public health
investigation
Sample analysis Public health initiation
Case definition

FIGURE 77-1. A stepwise approach to the critically ill traveler.

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