Severe CAP- review of IDSA/ATS guidelines

48 yo F brought into ED for severe SOB with respiratory distress after 3 days of URI/flu like symptoms, SOB and cough. While in the ED she tires out and goes into respiratory failure needing intubation and mechanical ventilation.

We reviewed the current combined IDSA/ATS guidelines for the follwing issues:

Criteria for admission to the ICU/ severe CAP definition: MAJOR: Either septic shock or needing mechanical ventilation. MINOR: 3 of the following: confusion, RR>30, multilobar PNA, thrombocytopenia, leukopenia, Pao2/Fio2<250, hypothermia, thrombocytopenia, hypotension needing IVFs, BUN>20.

All ICU admissions but selected non ICU hospital admissions need all testing: blood cx, sputum cx, legionella UAT, Strep pneum UAT.

We also discussed a new modality ECMO (extra-corporeal membrane oxygenation) and its use in adult medicine. It is a mechanical cardiopulmonary support which can oxygenate blood and also extract CO2 in addition to circulatory support (in VA type). INDICATIONS (amongst others):

  1. Acute respiratory failure (hypoxemia Pao2/FiO2<100 after vent optimization or hypercarbic respiratory failure pH<7.2)
  2. Refractory cardiogenic shock
  3. As a bridge to cardiac transplant/ LVAD placement
  4. ?ARDS (more recently NEJM article mentioning benefits)

There are 2 types: VV (venovenous) which gives respiratory support and VA (venoarterial) which in addition gives hemodynamic support.