Hantavirus Cardiopulmonary Syndrome (HCPS) Treatment & Management

Updated: Jun 04, 2019
  • Author: Sally Lynne Westcott, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Treatment

Prehospital Care

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

  • Early but judicious use of 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 is indicated if the diagnosis is suspected.

  • Standard respiratory precautions for infectious agents should be followed.

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Emergency Department Care

The ED physician's main challenge is to recognize HCPS and to admit for close observation. Given the possibility for rapid deterioration, early implementation of hemodynamic support is critical and is associated with increased survival. In cases of advanced HCPS, skilled resuscitation with judicious use of fluids and early institution of pressors, as well as transfer to an ICU, are paramount. [52] The general approach to a patient presenting with early HCPS symptoms remains the same as with any acutely ill patient with some special considerations: Resuscitate the patient in the familiar ABC fashion. 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. [53, 38] 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. [34]

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 norepinephrine [34] added 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.

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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. ECMO has been used with reported success in a number of institutions and has been shown to improve the likelihood of survival. [43, 54] ECMO has been implemented in patients with criteria predictive of 100% mortality with a reported success of achieving a 66% survival rate. [55] An important criterion for implementation of this rescue therapy has been demonstration of severely depressed myocardial function. Vascular surgery consult is typically needed for ECMO catheter placement.

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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. [33, 56, 57, 58, 59]

China and Korea offer a killed-virus vaccine for Hantaan virus and Seoul virus, but cost precludes widespread usage in many affected areas. A study of inactivated hantavirus vaccine (IHV) in Korea has demonstrated that it is moderately effective in endemic areas among high-risk individuals. [60]

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. [61]  Additionally, administration of antisera harvested from those who survived HCPS appears to mitigate the severity of disease in actively infected individuals. [62]  Given these findings, further study is warranted.

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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 1994-2010 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 51 patients who qualified, approximately two thirds survived to recover completely. [43, 55]  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. [43, 34, 37, 55]  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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