Hypovolemic?
Start Norepinephrine and titrate to keep MAP >65 mmHg
Assess Fluid Status
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
Furosemide 40 mg IV bolus or Bumetamide 1 mg IV
Double dose of furosemide (or Bumetanide) hourly up to a maximum of 160 mg (or 4 mg) Oliguria - <0.5 ml/kg/hr or <400ml/day or
self-report of low or no urine output in 12 hrs
R
EFERENCES1. Lomar AV, Veronesi R, Brito T, Diament D:Leptospiroses; in Veronesi R, Focaccia R (eds). Tratado de Infectologia, ed 2. São Paulo,Atheneu, 2002, pp 1007–1023.
2. Ko AI, Galvão Reis M, Ribeiro Dourado CM, et al. Urban epidemic of severe Leptospirosis in Brazil. Salvador Leptospirosis Study Group. Lancet 1999;354:820–
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report of 12 cases. Scand J Infect Dis 1996; 28: 637–639.
6. Visith S, Kearkiat P, Nephropathy in leptospirosis (Symposium). J Postgrad Med 2005; 51: 184–188.
7. Seguro AC, Lomar AV, Rocha AS: Acute renalfailure in leptospirosis: nonoliguric and hypokalemic forms. Nephron 1990; 55: 146–151
8. Cerqueira TB, Athanazio DA, Spichler AS and Seguro AC: The Brazilian J Infect Dis 2008;12(3):248-252
9. Chih-Wei Yang, Mai-Szu Wu, Ming-Jeng Pan. Nephrol Dial Transplant 2001;16(Suppl 5):73-7
10. Spichler AS, Vilaça PJ, Athanazio DA, Albuquerque JO,Buzzar M, Castro B, et al.
Predictors of lethality in severe leptospirosis in urban Brazil. Am J Trop Med Hyg 2008; 79(6): 911–914
11. Daher EF, Silva GB, Karbage NNN, Carvalho PC Jr, Kataoka RS, Silva EC, et al. Predictors of oliguric acute kidney injury in leptospirosis. Nephron Clin Pract 2009;112:c25-c30
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14. Villela G, Edmilao MI, Cordero CP, Valdez J and the Leptospirosis Study Group.
Predictors of oliguria and complications/mortality among acute renal failure leptospirosis cases admitted at the Philippine General Hospital. Phil J Intern Med 2000;38:2335-42
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Analysis of factors associated with severity in 147 confi rmed cases. Intensive Care Med 2007; 33(11):1959-66
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6. P ULMONARY C OMPLICATIONS OF L EPTOSPIROSIS
Pulmonary complications of leptospirosis have been infrequently described, but in recent years this scenario has changed. The incidence of pulmonary involvement varies, but ranges from 20-70%.1 There is a pronounced male predominance due to outdoor activity during heavy rainfall and flooding.2 However, with the increasing female social roles more cases are now reported in women.
Pulmonary involvement in leptospirosis was reported to be present in urban but unknown in rural areas. Potential explanation could include: different frequencies of exposure to pathogenic leptospirosis in urban and rural populations, differing pathogenicity of serovars present in urban and in rural environments, the focal emergence of pulmonary tropism, or varying levels of infecting leptospira in environmental water sources of infections.5
6.1 Clinical Diagnosis of Pulmonary Complications of Leptospirosis
1. When would you suspect pulmonary complications of Leptospirosis?Tachypnea (Respiratory Rate > 30/min) is the first sign of pulmonary involvement in most cases. One should consider lung involvement with the onset of cough, hemoptysis or dyspnea in a patient with a clinical diagnosis of leptospirosis. Pulmonary symptoms usually appear between the 4th and 6th day of disease.8
Leptospirosis must be suspected when there is potential exposure to rats, especially in patients with high grade fever, myalgia, hepatitis and renal abnormalities. Cough (either dry or productive of blood stained sputum), frank hemoptysis and different grades of dyspnea are the most common symptoms suggestive of pulmonary involvement.6 Some patients may present with pleuritic chest pain. Pulmonary examination maybe normal or presence of crackles at the lung bases maybe noted in some cases.
2. What are the predictors for the development of pulmonary complications in leptospirosis?
Significant risk factors for pulmonary complications are delayed antibiotic treatment and thrombocytopenia at the onset of the disease
Leptospira interrogens bataviae is the most common serotype seen in patients with pulmonary involvement.1 Patients with pulmonary complications had a longer duration of fever at presentation, delayed antibiotic treatment, platelet count < 100 x109 L, and most patients had serum creatinine > 177 μmol/L and bilirubin > 34.2 μmol/L.1 (Table 9)