Volk Charles G, Cusmano Paul M, Bower Richard J, Sanders Terrel, Maves Ryan C
Department of Pulmonary and Critical Care Medicine, Naval Medical Center, San Diego, CA.
Department of Gastroenterology, Naval Medical Center, San Diego, CA.
Crit Care Explor. 2021 May 18;3(5):e0423. doi: 10.1097/CCE.0000000000000423. eCollection 2021 May.
Shiga toxin-producing infection is associated with dysentery and the hemolytic uremic syndrome, marked by the triad of microangiopathic hemolytic anemia, acute kidney failure, and thrombocytopenia. Descriptions of Shiga toxin-producing outbreaks causing hemolytic uremic syndrome in adults are sparse, and management strategies are largely adapted from pediatric literature where aggressive fluid administration is recommended. However, these may not be ideal for adults.
We present a case series of an Shiga toxin-producing outbreak in U.S. Marine Corps recruits.
We review the clinical course, laboratory data, and fluid resuscitation used in hospitalized patients during the 2017 Shiga toxin-producing outbreak at Marine Corps Recruit Depot, San Diego.
Patients admitted to the hospital for complications from Shiga toxin-producing infection. All were previously healthy men between the ages of 17 and 20 years.
Isotonic crystalloid fluid resuscitation during the first 72 hours.
Of 244 identified cases of Shiga toxin-producing infection, 30 required hospitalization, 15 progressed to hemolytic uremic syndrome, and five required hemodialysis. Patients were admitted and given aggressive IV fluid hydration. Those who progressed to hemolytic uremic syndrome received on average 8.4 L of isotonic crystalloid over the initial 72 hours, with up to 18% of body weight delivered. The six critically ill patients received a mean 12.2 L in the first 72 hours. Those who did not progress to hemolytic uremic syndrome received a mean 3.0 L of crystalloid. If oligoanuria developed, a net-even fluid balance was maintained. The amount of volume infused was not associated with improved outcomes. The patients with the highest fluid balance totals more often required dialysis than those who received less fluid. One hemolytic uremic syndrome patient developed flash pulmonary edema.
The aggressive IV hydration protocols (as a percentage of body weight) in the pediatric literature may not be applicable to adults diagnosed with hemolytic uremic syndrome. A more conservative fluid strategy in adults with hemolytic uremic syndrome merits further investigation.
产志贺毒素感染与痢疾及溶血尿毒综合征相关，其特征为微血管病性溶血性贫血、急性肾衰竭和血小板减少三联征。关于成人产志贺毒素暴发导致溶血尿毒综合征的描述较少，治疗策略大多借鉴儿科文献，其中推荐积极补液。然而，这些策略可能对成人并不理想。
我们呈现了一组美国海军陆战队新兵中产志贺毒素暴发的病例系列。
我们回顾了2017年圣地亚哥海军陆战队新兵训练营产志贺毒素暴发期间住院患者的临床病程、实验室数据及液体复苏情况。
因产志贺毒素感染并发症入院的患者。均为年龄在17至20岁之间的既往健康男性。
最初72小时内进行等渗晶体液复苏。
在244例确诊的产志贺毒素感染病例中，30例需要住院治疗，15例进展为溶血尿毒综合征，5例需要血液透析。患者入院后接受积极的静脉补液。进展为溶血尿毒综合征的患者在最初72小时内平均接受了8.4升等渗晶体液，补液量高达体重的18%。6例危重症患者在最初72小时内平均接受了12.2升补液。未进展为溶血尿毒综合征的患者平均接受了3.0升晶体液。如果出现少尿，则维持液体净平衡。补液量与预后改善无关。补液总量最高的患者比补液量少的患者更常需要透析。1例溶血尿毒综合征患者发生了急性肺水肿。
儿科文献中的积极静脉补液方案（按体重百分比计算）可能不适用于诊断为溶血尿毒综合征的成人。对于成人溶血尿毒综合征采用更保守的补液策略值得进一步研究。
