Meningococcemia

OVERVIEW

  • Neisseria meningitidis bacteraemia -> endotoxin mediated fulminant multi-organ failure
  • mortality 10-12%

HISTORY

  • sudden onset -> sore throat, fever, vomiting, headache, myalgia
  • SIRS -> shock
  • purpuric rash
  • obtunded
  • meningitis in 85% develops

RISK FACTORS

  • asplenia
  • complement deficiency
  • contact history
  • Pacific island or Maori or Indigenous descent
  • crowded living environment
  • malnourished
  • unimmunized
  • immunosuppressed

EXAMINATION

  • haemodynamically unstable
  • multi-organ failure
  • diffuse macular rash -> discrete non-blanching petechiae -> purpura (initially in mucous membranes)
  • extensive skin and limb necrosis

INVESTIGATIONS

  • blood cultures: gram –ve diplococcus
  • lance purpuric lesion -> gram stain
  • meningococcal PCR
  • LP if not contraindicated
  • FBC: infection and anaemia and platelet count (?DIC)
  • U+E: renal function and SIADH
  • LFT’s: liver dysfunction
  • Coag’s: DIC
  • Lactate: degree of shock
  • ABG: metabolic state

MANAGEMENT

Goals

(1) early antibiotics
(2) management of refractory shock
(3) management of DIC
(4) management of cerebral oedema

Resuscitate

A – intubation often indicated because altered LOC
B – protective lung ventilation because of ARDS development
C – large bore access -> may require an intraosseous line, fluid resuscitation + titrated inotropic support, blood product replacement for DIC
D – prevention of cerebral oedema in meningitis (steroids – controversial) -> give in meningitis and shock

Electrolytes and Acid-Base abnormalities

  • Hyponatraemia – SIADH
  • Renal failure
  • Metabolic acidosis – > hyperlactaemia

Specific treatment

  • antibiotics: empiric =

-> cefotaxime 100mg/kg LD -> 50mg/kg Q6hrly
-> ceftriaxone 100mg/kg IV OD
-> high dose penicillin 2million units Q2 hourly (adults)
-> chloramphenicol
-> amoxicillin 75mg/Kg Q6hrly + cefotaxime for kids < 3 months – limb fasciotomies Underlying cause -> the place of all of these are uncertain

  • anti-endotoxin antibodies
  • cytokine therapies
  • corticosteroids
  • plasmapheresis
  • activated protein C

PUBLIC HEATH MEASURES

  • Neisseria meningitidis
    • requires droplet precautions
    • post-exposure prophylaxis needed for close contacts if <24h treatment with appropriate antibiotics
      • ciprofloxacin 500 mg (child younger than 5 years: 30 mg/kg up to 125 mg; child 5 to 12 years: 250 mg) orally, as a single dose, OR
      • ceftriaxone 250 mg (child 1 month or older: 125 mg) IM, as a single dose (preferred option for pregnant women), OR
      • rifampicin 600 mg (neonate: 5 mg/kg; child: 10 mg/kg up to 600 mg) orally, 12-hourly for 2 days
        (NB. interacts significantly with many drugs (eg with the oral contraceptive pill) and is contraindicated in pregnancy and severe liver disease.)

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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