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Hantavirus Cardiopulmonary Syndrome Follow-up

  • Author: Juliet D Caldwell, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Apr 01, 2015
 

Further Inpatient Care

Ventilator management

High positive end-expiratory pressure (PEEP) and high fraction of inspired oxygen (FIO2) are often useful.

Pressure-controlled ventilation and inverse inspiration/expiration (I/E) ratio ventilation are beneficial in select cases.

Hemodynamic management

Careful hemodynamic management optimizes survival.

Maintain mean arterial pressure greater than 70 mm Hg through a measured use of fluids and pressors.

Pulmonary artery catheterization may be used to avoid fluid overload: Maintain PAOP at 12 mm Hg or below.

Use vasoactive infusions early and liberally. (See Medication.)

Extracorporeal membrane oxygenation (ECMO)

The University of New Mexico Hospital (located in southeast corner of the four corners region) performed extensive research from 1994-2006 to determine the usefulness of ECMO rescue therapy in Hantavirus cardiopulmonary syndrome (HCPS). Given its investigational status, only patients with a projected 100% mortality rate and with clinical and laboratory evidence of HCPS were eligible to receive ECMO. Qualified patients had to demonstrate a cardiac index of less than 2 L/min, a PaO2/FIO2 ratio of less than 60, as well as refractory shock not responsive to standard medical therapy. Remarkably, among the 38 patients who qualified, approximately two thirds survived to recover completely.[37] The cardiovascular collapse of HCPS is profound but uniquely brief; rescue bridging with ECMO yields complete recovery in many previously believed to be irrecoverable.

ECMO therapy appears to improve survival in a select group of patients with severe disease; an early effort should be made to transfer patients suspected of having HCPS to facilities capable of ECMO.[37, 27, 47] It is possible that earlier institution of ECMO could yield even greater survival benefits.

Patients with prolonged cardiac arrest or prolonged cerebral hypoxia are not candidates for ECMO.

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Transfer

Most cases of HCPS occur in rural communities where facilities equipped for aggressive intensive care are often lacking. Given the precipitous nature of this disease, consider the following:

  • Transport early: A patient who subsequently does not require aggressive therapies at a tertiary care center is preferable to a patient who deteriorates suddenly and dies en route.
  • Transport quickly: Use the fastest and best-equipped transport, whether it be fixed-wing aircraft, rotor, or ground transportation, depending on proximity.
  • Transport to the highest level of care center possible: Again, anticipate the possible need for intensive care and possibly ECMO.
  • Prepare for clinical decline en route: Anticipate the need for fluids and vasopressors.
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Deterrence/Prevention

The best way to prevent HCPS is to avoid all exposure to rodents, especially deer mice, and their excreta.

Tips on rodent-proofing homes indoors and outdoor may be found at All About Hantaviruses - Prevention Indoors and Outdoors.

Never sweep or vacuum rodent-infested areas as this further aerosolizes the virus. Instead, wet the area thoroughly with disinfectant before cleaning, wearing rubber gloves. Other tips on cleaning infested areas may be viewed at All About Hantaviruses - Clean Up Infested Areas, Using Safety Precautions.

Homes with heavy infestations or homes of patients with confirmed HCPS require special precautions for cleaning. Contact the local health department for guidance. CDC recommendations may be found at All About Hantaviruses - Special Precautions for Homes of Persons with Confirmed Hantavirus Infection or Buildings with Heavy Rodent Infestations.

Persons who frequently handle or are exposed to rodents (eg, mammalogists, pest-control workers) in affected areas are probably at higher risk for Hantavirus infection than the general public because of their frequency of exposure. Therefore, enhanced precautions are warranted to protect them against Hantavirus infection. These precautions may be found at All About Hantaviruses - Precautions for Workers in Affected Areas Who are Regularly Exposed to Rodents.

Vaccines

Presently, no vaccines are approved for use against Hantaviruses in the United States. However, researchers are exploring the efficacy and safety of killed-virus vaccines as well as DNA vector derived antigen vaccines with some promising results in human and animal models.[26, 48, 49, 50, 51]

China and Korea offer a killed-virus vaccine for Hantaan virus and Seoul virus, but cost precludes widespread usage in many affected areas.

Although indirect evidence exists to suggest a role for passive immunization, no regimen has yet been developed. Interestingly, patients who present with high titers of neutralizing antibodies to Sin Nombre virus (SNV) tend to exhibit milder disease than those who present with low titers of neutralizing antibodies. Patients with low titers more often died or required extracorporeal membrane oxygen salvage therapy.[46] Additionally, administration of antisera harvested from those who survived HCPS appears to mitigate the severity of disease in actively infected individuals.[52] Given these findings, further study is warranted.

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Complications

Potential acute complications of Hantavirus cardiopulmonary syndrome (HCPS) include death, cardiovascular collapse, respiratory failure, anoxic brain injury, renal failure, pulseless electrical activity (PEA), ventricular tachycardia, and ventricular fibrillation.

ECMO has its own set of significant and not infrequent complications, including massive hemorrhage, sepsis, renal failure, and limb ischemia.[37] ECMO remains a rescue therapy for patients who are deteriorating despite maximal conventional medical therapy.

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Prognosis

HCPS currently carries a case-mortality rate of 35-40%.[47, 27] Preadolescents seem to experience a milder form of the disease and have had no reported deaths in the United States.

Experiences with HCPS at the University of New Mexico Hospital have identified several factors that resulted in a 100% mortality rate in several patients who do not receive ECMO. These include the following:

  • Cardiac index less than 2.5 L/min/m 2
  • Ventricular tachycardia, ventricular fibrillation, or PEA
  • Hypotension despite adequate fluid resuscitation and vasoactive pressors
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Patient Education

Educate patients and their families regarding the following:

  • Prodromal symptoms of HCPS
  • Risk of transmission by contact with rodents or rodent excreta
  • Techniques to safely clean-up infested areas
  • Rodent control measures (See Deterrence/Prevention.)
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Contributor Information and Disclosures
Author

Juliet D Caldwell, MD Assistant Professor, Department of Emergency Medicine, Weill Cornell Medical College; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital, Weill-Cornell Medical Center; Attending Physician, Department of Emergency Medicine, Long Island College Hospital

Juliet D Caldwell, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Barry J Sheridan, DO Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Acknowledgements

Scott Cameron, MD Consulting Staff, Department of Emergency Medicine, Regions Hospital

Disclosure: Nothing to disclose.

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Maureen Gang, MD Assistant Professor, Department of Emergency Medicine, New York University Medical Center

Disclosure: Nothing to disclose.

Mana Lumumba Kasongo, MD, MS Consulting Staff, Southwest Emergency Physicians

Disclosure: Nothing to disclose.

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Hantavirus cardiopulmonary syndrome (HCPS) precautions during the 1993 outbreak.
Peromyscus maniculatus - The deer mouse.
Geographic distribution and viral cause of Hantavirus cardiopulmonary syndrome (HCPS).
Hantavirus pulmonary syndrome cases by state of exposure.
Geographic distribution of Hantavirus cardiopulmonary syndrome (HCPS) and Peromyscus maniculatus.
Hantavirus pulmonary syndrome cases by outcome.
Hantavirus cardiopulmonary syndrome (HCPS) immunoblast.
Chest radiographic progression of Hantavirus cardiopulmonary syndrome (HCPS).
Clinical progression of hantavirus cardiopulmonary syndrome.
 
 
 
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