Hantavirus infection surgery
|
Hantavirus infection Microchapters |
|
Patient Information |
|---|
|
Diagnosis |
|
Treatment |
|
Case Studies |
|
Hantavirus infection surgery On the Web |
|
American Roentgen Ray Society Images of Hantavirus infection surgery |
|
Directions to Hospitals Treating Hantavirus pulmonary syndrome |
|
Risk calculators and risk factors for Hantavirus infection surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Basir Gill, M.B.B.S, M.D.[2] Seyedmahdi Pahlavani, M.D. [3]
Overview
Surgical intervention is not recommended for the management of hantavirus infection. However, several invasive procedural interventions play a critical role in the supportive care of severe hantavirus disease, particularly in hantavirus cardiopulmonary syndrome (HCPS) and hemorrhagic fever with renal syndrome (HFRS). These include extracorporeal membrane oxygenation (ECMO) cannulation, pulmonary artery catheterization, central venous catheter placement, endotracheal intubation, and vascular access for renal replacement therapy.[1][2]
Surgery
General Principles
There is no role for traditional surgical intervention in the management of hantavirus infection. The disease is managed with supportive care, and no operative procedure is directed at the underlying viral pathology.[1] However, several invasive bedside and procedural interventions are integral to the critical care management of severe HCPS and HFRS, and are described below.
Contraindications
Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids are contraindicated in patients with hantavirus infection due to the risk of exacerbating hemorrhage and thrombocytopenia.[3]
Non-invasive positive pressure ventilation (NIPPV) such as BiPAP is generally contraindicated in HCPS due to the anticipated severity of respiratory failure and the risk of delaying definitive airway management and ECMO access.[4]
Vascular Access and ECMO Cannulation
Vascular access procedures are among the most important procedural interventions in severe HCPS. Early insertion of vascular sheaths is recommended based on a presumptive or definitive diagnosis of HCPS, even before criteria for immediate initiation of ECMO are met. This strategy allows for rapid transition to venoarterial (VA) ECMO if the patient deteriorates.[1]
The ECMO cannulation procedure involves:
Insertion of a venous drainage cannula into the femoral vein, advanced to the right atrium
Insertion of an arterial return cannula into the common femoral artery, with oxygenated blood returning to the external iliac artery
Placement of a distal perfusion cannula to supply blood flow to the ipsilateral leg and prevent ischemia
Connection to a centrifugal pump and membrane oxygenator[1]
Key procedural consideration: Intubation should be delayed when feasible until vascular access for ECMO has been established. Loss of adrenergic drive due to intubation and sedation can result in worsening of cardiac failure and cardiogenic shock in HCPS patients.[1][4]
Pulmonary Artery Catheterization
Insertion of a pulmonary artery catheter (Swan-Ganz catheter) is recommended in patients with severe HCPS to:[1][4]
Guide target-directed inotropic and vasopressor therapy
Monitor cardiac index, pulmonary artery pressures, and pulmonary capillary wedge pressure
Assess candidacy for ECMO (cardiac index <2.5 L/min/m2 despite maximal inotropic support is an indication for ECMO)
Differentiate the hemodynamic pattern of HCPS (low preload, systolic dysfunction, high systemic vascular resistance) from classic cardiogenic shock or septic shock
Alternatively, transpulmonary thermodilution (e.g., PiCCO) provides hemodynamic data including cardiac index, extravascular lung water, and pulmonary vascular permeability index, which have been used to characterize HCPS pathophysiology and guide fluid management.[5] Serial echocardiography is a less invasive alternative used in centers where trained staff are continuously available.[1]
Endotracheal Intubation and Mechanical Ventilation
Endotracheal intubation and mechanical ventilation are frequently required in the cardiopulmonary phase of HCPS. Important procedural considerations include:[1][2]
Equipment and materials for intubation should be readily available at the bedside, as onset of respiratory failure may be precipitous
Patients with HCPS may progress from room air to requiring invasive mechanical ventilation within hours
When possible, intubation should be coordinated with ECMO vascular access placement to minimize the hemodynamic consequences of sedation and positive pressure ventilation
Inotropic agents and vasopressor drugs should be immediately available in the patient room prior to intubation[4]
Renal Replacement Therapy
Renal replacement therapy (RRT), including hemodialysis and continuous renal replacement therapy (CRRT), may be required in both HFRS and HCPS:[1][6]
HFRS: Dialysis is required in approximately 15% of patients with Dobrava virus (DOBV) infection, but in less than 5% of patients with Puumala virus (PUUV) infection. In a European study, 30–50% of HFRS patients required hemodialysis.[1]
HCPS: Renal failure may occur as part of multiorgan dysfunction. Tailored high-volume hemofiltration has been used before ECMO in select patients, thereby avoiding ECMO in some cases.[1]
Vascular access for RRT requires placement of a temporary dialysis catheter, typically in the internal jugular vein or femoral vein
Infection control precautions are essential during hemodialysis of hantavirus-infected patients, including use of dedicated machines, decontamination of spent dialysate, and disposal of blood tubing as infectious waste
Central Venous Catheterization
Placement of a central venous catheter is frequently required for:[1][2]
Administration of inotropic agents (dobutamine, epinephrine) and vasopressor drugs
Hemodynamic monitoring (central venous pressure)
Reliable intravenous access for fluid and medication administration
Blood sampling
Caution: Given the thrombocytopenia and coagulopathy frequently present in hantavirus infection, procedural bleeding risk should be assessed and platelet transfusion considered prior to invasive vascular access procedures when feasible.[1]
Thoracentesis
Thoracentesis may be considered in patients with significant pleural effusions contributing to respiratory failure, particularly in HCPS where bilateral pleural effusions are a common radiographic finding. However, the primary mechanism of respiratory failure in HCPS is increased pulmonary vascular permeability with non-cardiogenic pulmonary edema, and thoracentesis alone is unlikely to provide definitive respiratory improvement.[1][2]
Summary of Procedural Interventions
| Procedure | Indication | Syndrome | Key Considerations |
|---|---|---|---|
| ECMO cannulation (VA-ECMO) | Refractory cardiogenic shock (cardiac index <2.5 L/min/m2) or inadequate gas exchange despite mechanical ventilation | HCPS | Early vascular sheath insertion recommended; delay intubation until ECMO access established |
| Pulmonary artery catheterization | Hemodynamic monitoring and ECMO candidacy assessment | HCPS | Guides inotrope titration; differentiates HCPS hemodynamics from septic/cardiogenic shock |
| Transpulmonary thermodilution | Hemodynamic and pulmonary permeability monitoring | HCPS | Provides cardiac index, extravascular lung water, and pulmonary vascular permeability data |
| Endotracheal intubation | Respiratory failure | HCPS | Coordinate with ECMO access; have inotropes/vasopressors at bedside |
| Hemodialysis / CRRT | Acute kidney injury, oliguria, renal failure | HFRS (15% DOBV, <5% PUUV); HCPS (multiorgan failure) | Dedicated machines; infection control for dialysate disposal |
| High-volume hemofiltration | Bridge therapy before ECMO | HCPS | May avoid ECMO in select patients |
| Central venous catheter | Inotrope/vasopressor administration, hemodynamic monitoring | HCPS, HFRS | Assess bleeding risk given thrombocytopenia |
| Thoracentesis | Significant pleural effusion contributing to respiratory compromise | HCPS | Unlikely to provide definitive improvement; primary pathology is capillary leak |
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Vial PA, Ferrés M, Vial C, Rabagliati R, Castillo C, Ossa G, Mertz GJ, Enria D, López R, Padula P, Pini N, Ramírez E, Godoy P, Calvo M, Valdivieso F (2023). "Hantavirus in humans: a review of clinical aspects and management". Lancet Infect Dis. 23 (9): e371–e382. doi:10.1016/S1473-3099(23)00128-7. PMID 37105214 Check
|pmid=value (help). - ↑ 2.0 2.1 2.2 2.3 Ulloa-Morrison R, Pavez N, Parra E, Medel JN, Cornejo R, Díaz R, Tomicic V, Fajardo C, Cerda J, Vial PA (2024). "Critical care management of hantavirus cardiopulmonary syndrome. A narrative review". J Crit Care. 84: 154867. doi:10.1016/j.jcrc.2024.154867. PMID 39024823 Check
|pmid=value (help). - ↑ Cooper LT, Mensah GA, Baddour LM (2007). "ACCF/AHA/CDC Conference Report on Emerging Infectious Diseases and Biological Terrorism Threats. Task Force III: Prevention and Control of Cardiovascular Complications of Emerging Infectious Diseases and Potential Biological Terrorism Agents and Diseases". J Am Coll Cardiol. 49 (12): 1398–406. doi:10.1016/j.jacc.2007.01.021. PMID 17394981.
- ↑ 4.0 4.1 4.2 4.3 Llah ST, Mir S, Sharif S, Khan S, Mir MA (2018). "Hantavirus induced cardiopulmonary syndrome: a public health concern". J Med Virol. 90 (6): 1003–1009. doi:10.1002/jmv.25054. PMID 29532890.
- ↑ López R, Pérez-Araos R, Salazar Á, Ulloa-Morrison R, Vial PA (2019). "Hemodynamic and pulmonary permeability characterization of hantavirus cardiopulmonary syndrome by transpulmonary thermodilution". Viruses. 11 (10): E900. doi:10.3390/v11100900. PMID 31569646.
- ↑ Koehler FC, Di Cristanziano V, Späth MR, Grundmann F, Stumpf J, Kluger MA, Lüth S, Becker JU, Müller RU (2022). "The kidney in hantavirus infection—epidemiology, virology, pathophysiology, clinical presentation, diagnosis and management". Clin Kidney J. 15 (7): 1231–1252. doi:10.1093/ckj/sfac008. PMID 35756741 Check
|pmid=value (help).