H1N1 Kedua Yang Melibatkan Kematiaan di Icu Klang

H1N1 Mortality Report

Name: xxxxxxxxxxxx
I/C xxxxxxxxxxxxx

Date of admission: 12/8/09@2257h
Date of death: 19/8/2009@1450h

This 54 years old lady is a known diabetes mellitus type 2 and hypertension for more than 20 years under KK Pandamaran follow up, recently admitted to HTAR ward 7A for uncontrolled DM and was discharged with S/C insulin on 9/8/09. However, she came to the hospital again on 12/8/09 with complaints of cough, fever, and dyspnoea of 4 days (since discharge), in respiratory distress.

She was noted to have SpO2 of 58% on room air abd intubated immediately by the casualty MO, and subsequently admitted directly to ICU. CXR showed extensive bilateral haziness, blood gases showed metabolic acidosis post intubation and increased lactate. Urine ketone was 1+ but blood ketone negative. She was started on Tazosin and Azithromycin by the oncall medical officer, and given aggressive fluid resuscitation.

On 13/8/09, she was seen by the ICU medical specialist, a throat and nasal swab for H1N1 RT PCR was sent and Tamiflu 75mg bd started (renal adjustment as creatinine on admission 192), in view of recent admission to hospital and risk of exposure in the hospital.

Over the next few days her BP gradually deteriorated despite aggressive fluid correction with CVP guidance, requiring occasional sodium bicarbonate for severe persistent acidosis, with a third inotropic agent started on 17/8/09. There was an episode of hypotension for about 5 hours despite IV Noradrealine, Dobutamine, and Dopamine all at 15ml/hour with good CVP. The inotropic setting was readjusted by the anaesthesiologist to Vasopressin/ Noradrenaline/ Dopamine to 4/25/15, and her BP improved slightly. However, after the hypotensive episode her urine output worsen steadily and had minimal urine output.

Her condition was still worsening with a borderline BP afterwards, and on 18/8/09 she was started on CVVH due to persistent hyperkalemia, acidosis and oliguria, with urea of 25 and creatinine of 337. On that afternoon her H1N1 results also came back and was reported as positive.

On 19/8/09, her antibiotics was stepped up to Meronem for increasing white cell count, and despite CVVH and inotropic support, her BP still deteriorated suddenly at 1435h, whereby CVVH was stopped and CPR commenced, but the patient was unrevivable and pronounced dead at 1450h. Cause of death: Sepsis due to pneumonia, underlying uncontrolled DM, acute renal failure secondary to sepsis with preceding H1N1 influenza infection.

report by : Medical Assistant Oficer ( Mohd Fazil Mohammad Tahir )