North York General Hospital - Managing patients with SARS

Prepared by Dr. Mona Loutfy  - June 2, 2003

 

What to expect during the disease?

·         This is a 3 week disease with 3 phases

·         Phase I: prodrome – day 1 – 5: headache, fever, myalgias – can vary

·         Phase II: respiratory illness – day 6 – 14: cough, SOB on exertion, desaturation, abnormal CXR  – severity will vary (this is the phase to watch out for)

·         Phase III: recovery phase – day 14 – 21: improvement – LDH and liver enzymes may go up during the phase, CXR starts improving

 

What signs and symptoms to ask about related to SARS?

·         Cough and sputum (usually non-productive) – patients should be wearing mask if coughing

·         Shortness of breath (at rest or exertion)

·         Desaturation

·         Headache, Myalgias, Fatigue

·         Nausea/vomiting, Diarrhea

 

What to WATCH OUT for?

·         Between day 6 – 11, patients can determinate quickly and require intubation in as little as 6 hours

·         This is usually preceded by desaturation – watch O2 sat – be concerned if O2 sat even falls from 99% to 92-3%

·         Patients tend to get SOB when talking and exertion as well

 

When to transfer to the ICU?

·         Patients should be transferred to the ICU EARLY

·         Oxygenation protocol: If O2 sat < 92% -> place on O2 and do VS q2H, if on 4-6L/min O2 call MD, if on facemask > 50% -> transfer to ICU

·         INTUBATION should be done in a controlled fashion

·         No bagging, BiPAP or nebulizers should be done due to increased risk of transmission

 

What laboratory tests to follow for SARS (tests should be done daily X 3 days then every other day and back by 11AM)?

·         WBC (Leukopenia, lymphopenia)

·         Platelet (thrombocytopenia early, in recovery – get a thrombocytosis)

·         AST, ALT, ALP

·         LDH is key marker of disease

·         CK

·         Lipase tends to be elevated (significance unknown)

·         Ca, Mg, K

·         PT/PTT

·         BS – 20% of cases develop diabetes -? SARS or steroids

 

When to do a CXR (If needed, CXR should be done by 11AM)?

·         Every day or every other day early in disease since CXR finding occur first

·         Later in disease, when there is clinical worsening

·         When considering to discharge patient

 

When to use steroids?

·         No set guidelines for steroids, Each case is individual

·         If febrile and has CXR abN - start prednisone 50 mg BID or Solumedrol 40 mg IV q12H for 3-5 days (write 5 days but if improves quickly can taper earlier) then taper to 50 mg OD X 2-3 days then 40, 30, 20, 10 X 2d each

·         If respiratory progression (requiring > 4-6L/min O2), give Solumedrol 500 –mg OD X 3 days then 125 BID X 2 days then 125 mg OD X 2 days then pred taper

·         Check HepBsAg, if positive, give 3TC 100 mg OD during steroids + 8 weeks after

·         Watch Blood sugar

 

When can a patient be discharged?

·         Afebrile for at least 48 hours, maybe even 72 hours

·         Improving CXR

·         Improving SOB and cough

·         On prednisone 20-30 mg