screening cases for isolation
Hope NIPAH won't lead to any secondary case this time.
This small write up is not looking things lightly,but analyzing the situation comparing the previous years experience.
This time with early diagnosis containment,and awareness creation within such a short period was wonderful.
Administration, media and people from all walks of life joined hands to achieve this comparatively relaxed state of affairs.
This time no panic,awareness about the condition &need of precautions reaching even to the layman and preparedness to tackle even the worst situation.
Isolation and management facilities are set up in most of the major institutions.
Calicut having the best experience taking the lead.
In this context, sharing few thoughts/ dilemmas which most of us facing at this stage.
Arrangements made in different institutions vary depending on the infrastructure manpower.But basic points considered will be same
- 1.Pick up the possible cases early so that chance of human to human transmission is minimized.
- 2.Even though no definitive care available, give the best supportive care , at the same time avoid secondary cases during this stage.
Out of the two tasks more difficult is the first one.
In a busy OP picking up the suspect cases and directing them to screening section, and from the screening section , to decide where to keep the patient is real difficult task.
Most Crucial decision.
Admitting a case to general ward or ICU is lethal decision ,which you may be tempted to if the clinical condition is bad.
Keeping all cases in isolation facility is practically impossible.
So how to draw a line of safety in between?
For decision making i ll divide the cases in two different scenarios of NIPAH.
“Secretors “ OR the wet type. Nasal , throat ,chance of vomiting ,more likely to cause secondary cases if missed to pickup.Encephalitic group. Ie altered sensorium,headache ,fever.Chance of secondary cases less unless vomiting or secretions during seizure.
Out of 100 cases coming to OP almost 40 percent are fever,running nose sore throat situation, may be a bit different in adult and pediatric population, This is likely to go high in coming weeks.
3.There can be a combination.
Out of the three i ll take the encephalitis group in decision making .
It is bit easy to take decision about the second group.
We see infections and non infective conditions presenting this way.
There is high chance of missing common treatable entities in a context of NIPAH situation.
We see ,Pyogenic meningitis ,TBM, herpes encephalitis ,cerebral malaria,japanese encephalitis,west nile ,ricketsiels and and many more None of this will pose threat to the other persons or health workers .
In the present situation we are very likely to consider all cases with case definition findings as NIPAH and miss treatable cases.
May be the ideal best management for this situation in case if it is a treatable entity is less likely in a isolation facility.
So here comes the question,” in case this case turns out to be NIPAH” ?
In the present situation we are very likely to consider all cases with case definition findings as NIPAH and miss treatable cases.
So two questions relevant here ,
Can we treat these cases with encephalitis type presentation in conventional ICU and manage with all facilities.May be the ideal best management for this situation in case if it is a treatable entity is less likely in a isolation facility.
So here comes the question,” in case this case turns out to be NIPAH” ?
The chance of secondary case from this type of presentation is very limited.
Second option is to admit all cases which fits with case definition in isolation . Choosing a patient with mixed features. Ie features of encephalitis respiratory or throat features is better done in isolation . They may pose threat for secondary cases if we admit to common ICU.
Suppose a patient is admitted in an isolation facility with features of encephalitis. Management is modified a bit.
Second option is to admit all cases which fits with case definition in isolation . Choosing a patient with mixed features. Ie features of encephalitis respiratory or throat features is better done in isolation . They may pose threat for secondary cases if we admit to common ICU.
Suppose a patient is admitted in an isolation facility with features of encephalitis. Management is modified a bit.
- Limit number of investigations, to essential minimum.
- May be empirical treatment of treatable entities considering possibilities
- we may put him on ceftriaxone, acyclovir,mannitol and iv fluids.
- Minimum essential investigations a peripheral smear without EDTA ,(which can replace the counts and may be malarial parasites, I'll do sugar,(may be GRBS) and electrolytes,LFT) when i do the cannulation.
When to do LP?
Most of the centers Samples collected for sending to virology lab is once or twice during day time.If a patient comes in the evening hours give above treatment and do CSF studies one and half hour before the sample transport.
This is two way beneficial, If the patient improves during this time most likely it is not NIPAH,even though this is not a rule. May be such a situation we may take a decision to postpone the invasive procedures to one more day.If the patient is well after 48 hours he may be shifted boldly to the general ward of common ICU.
if the patient is not improving or deteriorating over this 12 hours do LP for virological studies.
This single case of NIPAH which happened now is In a way for good.
We were all in a relaxed mood after we conquered NIPAH in 2018.
Now with this episode, we have to set up facility to contain any infectious agent of similar nature within no time.
6/06/
Sharing an experience.
Yesterday evening a twelve year old girl was admitted with fever for last three days, altered sensorium since one day .One episode of vomiting. No convulsions . No past history of any significant illness.
They are from palakkad. They had been to idukki last month , spent three weeks there,was back on twenty third of May.
Categorization in suspect group was weak.
Take the first group of presentation , ie “secretors”
- If we take a decision to isolate all cases with fever running nose cough and dyspnea isolation facility ll be full within hours ,
- Most of the kids will need procedures like nebulisation which ll increase the chance of secondary cases
- So here consider the epidemiological link to decide.
In this small write up i was considering just one dilemma.
We should share the experiences good and bad , problems encountered in different centers, how you tackled to have a consensus.This single case of NIPAH which happened now is In a way for good.
We were all in a relaxed mood after we conquered NIPAH in 2018.
Now with this episode, we have to set up facility to contain any infectious agent of similar nature within no time.
6/06/
Sharing an experience.
Yesterday evening a twelve year old girl was admitted with fever for last three days, altered sensorium since one day .One episode of vomiting. No convulsions . No past history of any significant illness.
They are from palakkad. They had been to idukki last month , spent three weeks there,was back on twenty third of May.
Categorization in suspect group was weak.
- High grade fever,altered sensorium.
- No signs of meningeal irritation,
- No rash jaundice,lymph nodes
- No focal neurological deficits.
She was admitted in isolation,
Policy of minimizing investigation ,blood sample taken when securing iv line . Peripheral smear,blood counts ,electrolytes blood sugar was taken ,
Policy of minimizing investigation ,blood sample taken when securing iv line . Peripheral smear,blood counts ,electrolytes blood sugar was taken ,
She was put on Dextrose saline, ceftriaxone and acyclovir and manniol
Blood count came as 19000 ,with polymorph predominant ,and high ESR.
As we were getting many cases of viral meningitis and few encephalitis from malappuram and palakkad ,out of which few cases were proved to be enteroviral .
We were expecting this entity likely to confuse in the present scenario.
provisional diagnosis was kept as enteroviral meningitis with high intracranial pressure
Few of these viral meningitis cases had leukocytosis with neutrophil predominance.
CSF studies also most of them showed neutrophilia.
As she had a visit to idukki, possibility of cerebral malaria was also considered initially
With the high count malaria was less likely,
Rickettsial infections a few of them presented like this but the blood count used to be almost normal or a bit raised with not that high ESR.
Our plan was to watch for response and do CSF studies in the morning so that we can send samples for virological studies which is collected by ten o clock
Today morning her sensorium remained same. Even though policy in the isolation was to keep one bystander she needed three to restrain.
Blood count came as 19000 ,with polymorph predominant ,and high ESR.
As we were getting many cases of viral meningitis and few encephalitis from malappuram and palakkad ,out of which few cases were proved to be enteroviral .
We were expecting this entity likely to confuse in the present scenario.
provisional diagnosis was kept as enteroviral meningitis with high intracranial pressure
Few of these viral meningitis cases had leukocytosis with neutrophil predominance.
CSF studies also most of them showed neutrophilia.
As she had a visit to idukki, possibility of cerebral malaria was also considered initially
With the high count malaria was less likely,
Rickettsial infections a few of them presented like this but the blood count used to be almost normal or a bit raised with not that high ESR.
Our plan was to watch for response and do CSF studies in the morning so that we can send samples for virological studies which is collected by ten o clock
Today morning her sensorium remained same. Even though policy in the isolation was to keep one bystander she needed three to restrain.
We did LP with all precautions
- Fluid was turbulent,
- Plenty of pus cells.
- CSF biochemistry showed low sugar , less than fifty percent of blood sugar.
- Higher proteins
- Gram stain showed gram positive diplococci
So it was certain Pneumococcal meningitis
We shifted her to PICU
- We had bad experience with pneumococci last December many cases proved pneumococi not responding to CP and Ceftriaxone,, we thought of adding vancomycin
- We stopped acyclovir
But by noon she regained consciousness.
Now i feel differently
Is it necessary to add vancomycin?
The gram positive organism seen in the gram stain must be dead organism. Justification to upgrade only if the clinical response is not there, deterioration or status co after at least one day or culture positive
I think ceftriaxone alone could have worked
I think ceftriaxone alone could have worked
U made it so simple and practical sir, as always. What we do at Calicut is, we arranged a separate area for fever casualty. So we separate patients fever from non fever before entry into the hospital. In fever group we divide them into fever with a definite diagnosis like lepto dengue and fever with no alternative diagnosis. Fever with alternate diagnosis are admitted into general ward or Medicine ICU. From the other group, any patient with encephalitis, ARDS or both r sent to a separate ward. No time delay for these patients in casualty and they won't be sent to any common places like lab.
ReplyDeleteIn this group high suspicion of Nipah will be sent to Isolation rooms. The high suspicion group will b evaluated by a steering committee before planning any further actions. Sampling for Nipah will also be with their concurrence only as adequate precautions to be taken before each step. In less suspicious group, investigations will be sent from isolation ward including CSF for primary viral panel. They will be shifted to general ward, once an alternate diagnosis is made.
Thank you shameer
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