eMedicine Specialties > Emergency Medicine > Infectious Diseases

Hantavirus Cardiopulmonary Syndrome: Treatment & Medication

Author: Juliet D Caldwell, MD, Assistant Professor, Department of Emergency Medicine, Weill Medical College of Cornell University; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital, Weill-Cornell Medical Center
Contributor Information and Disclosures

Updated: Jan 29, 2009

Treatment

Prehospital Care

Prehospital care of Hantavirus cardiopulmonary syndrome (HCPS) is supportive.

  • Aggressive fluid resuscitation with crystalloids is indicated.
  • Administer oxygen by nasal cannula, Venturi, or nonrebreather mask.
  • Intubation is warranted for severe respiratory distress.
  • Rapid transfer to a tertiary care center with ICU and ECMO capabilities, if possible, is indicated.
  • Standard respiratory precautions for infectious agents should be followed.

Emergency Department Care

The ED physician's main challenge and responsibility is to diagnose HCPS and to admit for close observation. Early recognition of HCPS and early implementation of hemodynamic support are associated with increased survival. In cases of advanced HCPS, aggressive resuscitation and transfer to an ICU are paramount.32 Resuscitate the patient in the familiar ABC fashion.

  • Airway/breathing
    • Administer oxygen by facemask or nonrebreather mask.
    • Intubate patients with respiratory failure. It is unusual for patients to die solely from respiratory failure in centers equipped with sophisticated ventilatory support.33,34
    • Patients’ hemodynamic statuses may deteriorate after intubation secondary to preload dependence and loss of adrenergic drive; cardiac arrest at time of intubation is not uncommon and ECMO preparations, if available, should be underway.24
  • Circulation
    • Obtain large-bore intravenous (IV) access.
    • Fluid resuscitation with crystalloids is indicated for any sign of hemodynamic compromise. Because of massive capillary leakage, administer fluids judiciously and use vasoactive infusions early and liberally.
    • Dobutamine is the preferred inotrope, with dopamine or norepinephrine24 added as necessary to maintain blood pressure. Patients with HCPS may require large doses of vasopressors to maintain a stable blood pressure.  
    • If possible, avoid placing central lines in the right subclavian, the right internal jugular, and one femoral vein. These veins are used for venous access for ECMO.  
  • Broad-spectrum antibiotics are indicated for most patients presenting with respiratory distress and fever.  
  • Use strict universal precautions.

Consultations

Patients with suspected or confirmed Hantavirus cardiopulmonary syndrome (HCPS) require ICU admission.

  • Consult a medical intensivist early.
  • If applicable, consult the ECMO team early. Vascular surgery is typically needed for ECMO catheter placement.

Medication

Currently, no Food and Drug Administration-approved antiviral drugs, vaccines, or immunotherapeutic agents are available for Hantavirus cardiopulmonary syndrome (HCPS). Though ribavirin, a nucleoside analogue, has shown a statistically significant 7-fold reduction in mortality when initiated early in the treatment of hemorrhagic fever with renal syndrome (HFRS),35 it has shown no benefit when used for HCPS. One double-blind, placebo-controlled study and one nonrandomized trial demonstrated no survival benefit of ribavirin in the treatment of HCPS,36,37 though questions remain regarding study design and lack of power. Nonetheless, no evidence exists to support an off-label use of ribavirin in the treatment of HCPS.

Some indirect evidence supports the use of neutralizing antibodies, or passive immunotherapy, for HCPS. Bharadwaj et al found that patients who had higher titers of neutralizing antibodies suffered milder disease.38 Studies addressing the role of passive immunotherapy for treatment or postexposure prophylaxis of HCPS have not yet been published.

Liberal employment of high-dose vasopressors and inotropes, as well as standard administration of antibiotics, is strongly encouraged. (See Emergency Department Care.) 

Inotropes

Used in the implementation of hemodynamic support.


Dopamine (Intropin)

Stimulates beta1- and alpha1-adrenergic and dopaminergic receptors in a dose-dependent fashion; stimulates release of norepinephrine. Lower doses (2-5 mcg/kg/min) mainly stimulate dopamine receptors, producing renal and mesenteric vasodilation. Doses between 5 and 10 mcg/kg/min predominantly stimulate beta1-receptors, causing increased chronotropy, inotropy, and cardiac output. Doses >10 mcg/kg/min stimulate alpha1-receptors, causing marked vasoconstriction. After initiating therapy, dose may be increased by 1-4 mcg/kg/min q5min until optimal response.

Adult

5-20 mcg/kg/min IV infusion

Pediatric

Administer as in adults

Phenytoin, alpha- and beta-adrenergic blockers, general anesthesia, and MAOIs increase and prolong effects

Documented hypersensitivity; pheochromocytoma; ventricular fibrillation

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Closely monitor urine flow, cardiac output, pulmonary wedge pressure, and BP during infusion; prior to infusion, correct hypovolemia with either whole blood or plasma, as indicated; monitoring central venous pressure or left ventricular filling pressure may be helpful in detecting and treating hypovolemia


Dobutamine (Dobutrex)

Stimulates alpha1-, beta1-, and beta 2-adrenergic receptors; has potent inotropic effects with minimal chronotropic effect; causes vasodilation; is vasopressor of choice in HCPS.

Adult

2-20 mcg/kg/min IV infusion

Pediatric

Administer as in adults

Beta-adrenergic blockers antagonize effects; general anesthetics may increase toxicity

Documented hypersensitivity; idiopathic hypertrophic subaortic stenosis; atrial fibrillation or flutter

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Following MI, use with extreme caution; correct hypovolemic state before using this drug


Norepinephrine (Levophed)

Stimulates alpha1- and beta 1-adrenergic receptors; increases inotropy and chronotropy; is potent vasoconstrictor.

Adult

2-4 mcg/min IV

Pediatric

0.05-0.1 mcg/kg/min IV; titrate up prn; not to exceed 1-2 mcg/kg/min

Tricyclic antidepressants, MAOIs, antihistamines, guanethidine, methyldopa, and ergot alkaloids increase effects; atropine may block reflex tachycardia caused by norepinephrine and enhance pressor response

Documented hypersensitivity; peripheral or mesenteric ischemia because ischemia may be increased and tissue necrosis may occur

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Central line administration preferred due to vasoconstricting effects; extravasation may cause severe tissue necrosis—administer into a large vein


Epinephrine (Adrenalin, EpiPen)

Stimulates alpha1-, alpha2-, beta1-, and beta2-adrenergic receptors, increasing cardiac muscle contractility and heart rate as well as vasoconstriction. As a result, increases systemic BP and coronary blood flow.

Adult

1-4 mcg/kg/min IV; start at 2 mcg/kg/min and titrate to effect

Pediatric

0.1 mcg/kg/min IV and titrate to effect

Increases toxicity of beta- and alpha-blocking agents and halogenated inhalational anesthetics

Documented hypersensitivity; cardiac arrhythmias; angle-closure glaucoma

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in elderly persons, prostatic hypertrophy, hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias

Antivirals

These agents inhibit or reduce severity of some viral infections.


Ribavirin (Virazole)

Proven effective in HFRS caused by Old World Hantaviruses; no demonstrated benefit in HCPS.

Adult

1 g IV q6h

Pediatric

Not established

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Possible teratogen; withhold breastfeeding while on drug; may cause significant anemia and pancreatitis; closely monitor patients with COPD or asthma for deterioration of respiratory function

More on Hantavirus Cardiopulmonary Syndrome

Overview: Hantavirus Cardiopulmonary Syndrome
Differential Diagnoses & Workup: Hantavirus Cardiopulmonary Syndrome
Treatment & Medication: Hantavirus Cardiopulmonary Syndrome
Follow-up: Hantavirus Cardiopulmonary Syndrome
Multimedia: Hantavirus Cardiopulmonary Syndrome
References
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Further Reading

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Keywords

hantavirus, hantavirus pulmonary syndrome, HCPS, hanta, Sin Nombre virus, deer mouse, Peromyscus maniculatus, Muerto Canyon virus, four corners virus, Hantaan virus, hemorrhagic fever with renal syndrome, HFRS, HPS

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Contributor Information and Disclosures

Author

Juliet D Caldwell, MD, Assistant Professor, Department of Emergency Medicine, Weill Medical College of Cornell University; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital, Weill-Cornell Medical Center
Juliet D Caldwell, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical 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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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