2018 FSA Posters

P042: THE CASE OF THE FLU: CASE REPORT AND MANAGEMENT CONSIDERATIONS FOR A PATIENT WITH ACTIVE INFLUENZA AND NEED FOR EMERGENT SURGERY
Geoffrey D Panjeton, MD, Patricia Nwajuaku, MD, MPH, Joszef J Endredi, MD, Christopher Goldstein, MD; UF College of Medicine Department of Anesthesiology

Introduction: Influenza is an acute viral infection that can lead to severe illness or death in high risk patients.  Worldwide, annual infections result in 3-5 million cases of severe illness, and approximately 290 to 650 thousand deaths [1].  Most deaths occur among those aged 65 and older [2].  According to the CDC, the 2017-2018 influenza season will be one of the worst in the history of the United States [3].  The increasing prevalence of severe forms of influenza may translate to more patients presenting for emergent surgical intervention who may also have influenza. For Anesthesiologists, this constitutes a heightened management challenge due to the notable risk for perioperative complications in severely compromised patients.  Here we present a case of a patient with an active influenza A infection in need of emergency vascular surgery for which regional anesthesia and minimal sedation were utilized as the primary anesthetic.

Case: The patient was a 71-year-old male with a past medical history of insulin dependent type 2 diabetes mellitus complicated by peripheral neuropathy, coronary artery disease with 5 stents placed (most recent 3 years prior), mild chronic obstructive pulmonary disease, prostate cancer s/p chemoradiation, hypertension, hyperlipidemia, depression and post-traumatic stress disorder. The patient presented to the emergency department with recently diagnosed and worsening influenza A, currently treated with Tamiflu, as well as purulent drainage from an open wound on the dorsum of his right foot that was concerning for wet gangrene. He was determined to be septic with a temperature of 39.1º C, a heart rate of 101 beats per minute, and a respiratory rate of 22 breaths per minute. On further workup, the patient had an elevated lactic acid level of 3.2mmol/L, an acute elevation in creatinine to 2.5mg/dl from 1.1mg/dl, an elevated blood glucose of 585mg/dl, and white blood cell count was 9.65k/cm2. Our service was consulted for anesthetic management during an emergent ankle disarticulation to provide source control. The intraoperative anesthetic plan included the use of combined single injection ultrasound guided sciatic nerve block at the popliteal level and an infrapatellar level saphenous nerve field block and MAC. The patient tolerated the surgery well and was returned to the ICU in stable condition.

Discussion: Individuals at greater risk for severe influenza related disease include the elderly and those with chronic illnesses like those of our patient. Important anesthetic considerations included maintaining natural airway to avoid endotracheal intubation and mechanical ventilation in a patient with an active influenza infection, managing nausea and active vomiting, preventing viral contamination of anesthesia equipment, and minimizing spread of the influenza virus while providing appropriate anesthesia. 

References:

1. World Health Organization. Influenza Factsheet. http://www.who.int/mediacentre/factsheets/fs211/en/  (accessed 1/25/18)

2. Estimates of US influenza-associated deaths made using four different methods.
Thompson WW, Weintraub E, Dhankhar P, Cheng OY, Brammer L, Meltzer MI, et al. Influenza Other Respi Viruses. 2009;3:37-49
3. Centers for Disease Control and Prevention (CDC). Situation Update: Summary of Weekly FluView Report. https://www.cdc.gov/flu/weekly/summary.htm (accessed 1/25/2018).