laboratory findings/markers of severe leptospirosis

1.CBC – leucocytosis (WBC>12,000 cells/cumm) neutrophilia and thrombocytopenia (<100,000 cells/cu mm)

2. Serum creatinine > 3 mg/dL (or CrCl < 20 ml/min) and BUN > 23 mg/dL

3. Liver function tests - AST/ALT ratio > 4x Bilirubin > 190 umol/L

4. prolonged prothrombin time (PT) < 85%

laboratory findings/markers of severe leptospirosis

5. Serum potassium > 4 mmol/L

6. ABG- severe metabolic acidosis (ph< 7.2, HCO3 < 10) hypoxemia (PaO2 < 60 mmHg, SaO2 < 90%)

7. Chest radiograph - extensive alveolar infiltrates

8. Electrocardiogram - heart block, myocarditis

Antibiotic Treatment :

1.Doxycycline - drug ofchoice - Alternative drugs : amoxicillin and azithromycin dihydrate. [Grade B]

2. For moderate-severe leptospirosis : - penicillin G - the drug of choice - Alternative drugs : parenteral ampicillin, 3rd generation cephalosporin (cefotaxime, ceftriaxone), and parenteral azithromycin dihydrate. [Grade A]

Antibiotic therapy should be completed for 7 days, except for azithromycin dihydrate which could be given for 3 days. [Grade A]

Oliguria - <0.5 ml/kg/hr or <400 ml/day or self-report of low or no urine output in 12 hrs.

Mean Arterial Pressure </=65 mm Hg

Start Norepinephrine and titrate to keep MAP >65 mmHg

Assess Fluid Status

Hypovolemic?

• Fast drip Normal Saline Solution, 20 ml/kg/hr and reassess after 15 minutes• Continue hydration till euvolemic•Adjust IVF rate to suit patient needs

YES

NO

YES

NO

Furosemide 40 mg IV bolus or Bumetamide 1 mg IV

Urine Output>/= 0.5ml/kg/hr?

Double dose of furosemide (or Bumetamide) hourly up to a maximum of 160 mg (or 4 mg)

Urine Output>/= 0.5ml/kg/hr?

Acute Renal Replacement Therapy

Urine Output>/= 0.5ml/kg/hr?

• Monitor hourly and adjust rate of IVF to maintain euvolemia

• Reassess kidney status

• Monitor hourly and adjust rate of IVF to maintain euvolemia

• Reassess kidney status

• Monitor hourly and adjust rate of IVF to maintain euvolemia

• Reassess kidney status

Yes

No

Yes

No

No

Yes

PHILIPPINE SOCIETYOF NEPHROLOGY

DISASTER RESPONSE TO

CRUSH INJURY / CRUSH SYNDROME

Crush injury - a direct injury caused by collapsing material and debris resulting in manifest muscle swelling and/or neurological disturbances in the affected parts of the body

Crush Syndrome - patients with crush injury and systemic manifestation due to muscle cell damage which would include: acute kidney injury, sepsis, acute respiratory distress syndrome, diffuse intravascular anticoagulation, bleeding, hypovolemic shock, cardiac failure, arrhythmias, electrolyte disturbances

VICTIM UNDER THE RUBBLE

VEIN IS AVAILABL

E

YES GIVE 1L/HR OF ISOTONIC SOLUTION FOR THE 1ST 2 HRS.2,10-13

NO

ATTEMPT ORAL HYDRATION FOR THOSE THAT CAN

BE REACHED

GIVE SALINE AT 0.5 L/HR (REASSESS EVERY 2-4

HRS)

YESIS IT SAFE TO HYDRATE THE

VICTIM?

LIMIT HYDRATION TO 1L/DAY

NO

CONTINUE MANAGEMENT UNTIL EXTRICATION WITH CONTINUOUS CLOSE MONITORING OF FLUID STATUS ONCE EXTRICATED PLEASE PROCEED TO POST-EXTRICATION ALGORITHM

EXTRICATED VICTIM

PRIMARY SURVEY

PRESENCE OF OTHER MEDICAL

CONDITION

DOES THE VICTIM NEED TO BE HYDRATED?

VICTIM MAY BE DISCHARGED WITH PROPER ADVICE

MULTIDISCIPLINARY REFERRAL (PLEASE REFER TO SPECIFIC

INDICATIONS FOR NEPHROLOGY REFERRAL)

INDICATIONS FOR NEPHROLOGY REFERRAL(Please see nephrology notes)

1.Hyperkalemia on ECG2.Presence of reddish-brown urine3.Decreased urine output (<0.5 ml/kg/hr x 4 hours)4.Fluid overload

GIVE 1L/HR OF ISOTONIC SOLUTION FOR 2HRS

REASSESS AFTER 2HRS

IS IT SAFE TO MAINTAIN

HYDRATION?

GIVE SALINE AT 0.5L/HR

REASSESS EVERY 2-4 HRS

LIMIT HYDRATION TO 1L/DAY

MAY DO SECONDARY SURVEY AS NEEDED

ADMIT TO HOSPITAL

YES

NO

YES

NOYES

NO