1. Gustafson, Kristin DO

Article Content

Pregnancy is a risk factor for a variety of opportunistic infections, including the H1N1 virus. The Centers for Disease Control and Prevention recently reported deaths of several women with pregnancy-related H1N1 infections. Although we are learning more about the symptoms and prevalence of the H1N1 virus, related wounds are not a prominent feature of communication about H1N1.


This editorial presents the case of a 29-year-old pregnant woman with a history of asthma and worsening cough. She was evaluated and treated by her physician on July 22, 2009, for bronchitis and treated with antibiotics. A few days later, her condition worsened. She was admitted to a community hospital with rapidly worsening symptoms and was diagnosed with severe H1N1 infection, requiring intubation for respiratory support. Simultaneously, the patient gave birth to a healthy boy at 38 weeks by cesarean delivery (wound 1).


Intensive Care Unit Course

Following childbirth, the patient subsequently developed adult respiratory distress syndrome, thus requiring ventilatory support. She was then transferred to a quaternary hospital medical intensive care unit and continued treatment with intravenously administered antibiotics and an antiviral drug. On August 3, 2009, the patient had a cardiac arrest secondary to an expanding pneumothorax. After a successful advanced cardiac life support, chest tubes were inserted to treat the pneumothorax (wounds 2 and 3). The patient's cardiorespiratory status worsened, and she was emergently administered extracorporeal membrane oxygenation (ECMO), using her left femoral artery and vein (wounds 4 and 5). Consequently, she was then transferred to the cardiothoracic surgical intensive care unit (SICU).


In the intervening period, the patient's left leg became ischemic, requiring emergent reperfusion. On August 4, 2009, she was taken to the operating room for superficial femoral artery cannulation with left femoral artery repairs and bypass graft to maintain reperfusion of her left leg. The patient's cardiac function improved, and there was greater shunting to the lungs. Therefore, she was transferred from arteriovenous to venovenous ECMO on August 4, 2009, by cannulating her right inferior jugular vein (wound 6). On August 9, 2009, the patient had revision of her ECMO circuit secondary to hypoperfusion and bradycardic arrest, thus requiring another cannulation to her right femoral artery (wound 7). Wounds 8 to 10 resulted from areas used for central access.


By August 18, 2009, the patient showed improvement, and ECMO was removed. She underwent a tracheotomy with placement with a no. 8 Shiley tube and removal of an endotracheal tube on August 20, 2009. She rapidly decompensated and had an emergent venoarterial and venovenous ECMO initiated again. Candida cultures were positive, and she was prescribed fluconazole.


The patient ultimately stabilized and was transferred to the SICU on September 4, 2009. Recurrent fevers were successfully treated with broad-spectrum antibiotics. ECMO was discontinued, and her respiratory status subsequently improved. Physical therapy (PT) and occupational therapy (OT) were initiated for mobilization and enhancement of her cardiopulmonary function and mobility.


A physical medicine consult demonstrated the patient's ability to ambulate with a rolling walker with moderate assistance for 20 feet. Next, she was weaned from the ventilator. Her tracheal tube was downsized to a no. 6 cuffless model. The patient's speech and swallowing skills were cleared for her to initiate a regular diet. On September 17, 2009, she was transferred to the acute rehabilitation department.


Rehabilitation Course

Respiratory, nutrition, speech, PT/OT, neuropsychiatry, and wound care team members were immediately consulted. On admission, the patient required 28% humidified O2 via a tracheal collar. A Passy-Muir valve was initiated on September 18, 2009, and used only during the day.


The patient was very anxious and required frequent reassurance and comfort. She was very hesitant to progress to a smaller tracheal tube. By September 22, 2009, she was weaned to room air. For activities, however, she required 28% O2 to maintain adequate oxygenation during the activity. Her tracheal tube was downsized to a no. 4 Shiley cuffless, and capping trials were initiated on September 24, 2009. The patient had difficulty, secondary to anxiety, with capping. This was addressed, and she was finally decannulated on September 28, 2009, and was able to breathe normally. The patient's tracheal tube site was covered with adhesive skin closures and an occlusive dressing. During her stay, cardiology was consulted for recurring elevated blood pressure, and low-dose amlodipine was administered.


Wound Course

Initial wound assessment showed 10 nondecubitus wounds and 2 Stage II heel ulcers. The patient was placed on a low-air-loss mattress, and appropriate skin care was initiated. Her nutritional status was evaluated, and her prior albumin was 1.9 g/dL; albumin level taken a second time was 2.9 g/dL; and prealbumin was 21.7 mg/dL. (Normal serum albumin in adults is 3.5-4.8 g/dL; normal serum prealbumin is 19-38 mg/dL.) Of her 10 nonpressure wounds, 4 were of immediate concern. Her cesarean section wound was partially dehisced; her left groin wound was draining; her right groin wound had some serosanguineous discharge; and her right inferior jugular wound was draining with copious slough visible.


Both the patient's nutritional status and wounds were comprehensively evaluated, treated, and monitored. She required frequent dressing changes with chemical debridement and calcium alginate dressings on her cesarean section wound and her groin wounds. Her left groin wound continued to drain, and a fluctuant mass developed. Infectious disease staff was consulted, and an ultrasound demonstrated a subcutaneous collection several centimeters away from the patient's arterial repair. Incision and drainage was recommended. The fluid collection was opened and drained and sent for cultures, which returned only mixed flora. The wound was then packed with frequent changes and closed quickly. The patient's right inferior jugular wound and left arm access wound required chemical debridement and hydrocolloid dressings. Her Stage II foot pressure ulcers resolved with skin care, nutrition, and ambulation boots.


With supplemental O2 for activity, the patient progressed well in therapies and was independent in activities of daily living, ambulated 250 ft with supervision, and took 15 steps up the stairs using 1 handrail with supervision on discharge. She was discharged home on September 30, 2009, with a manual wheelchair for long distances, 2 L of O2 via nasal cannula as needed, wound care services, and in-home PT and OT.


Home Wound Care Prescription

The patient's discharge wound regimen was as follows:


* Tracheal tube care: Cover old tracheal tube site/neck with an adhesive bandage. Change daily, after bathing or if it comes loose. This may be discontinued when the tracheal tube site completely closes, and there is no drainage.


* General wound care: Cleanse all wounds with a wound cleanser and gently wipe around wound to dry the surrounding skin.


* Left forearm: Apply collagenase ointment to dead tissue (black, yellow, or white-looking tissue). Place a piece of 4 x 4 gauze on top of the ointment. Wrap with gauze roll. Change daily.


* Right groin: Apply collagenase ointment to dead tissue in the wound (yellow/white loose tissue). Cover with island dressing. Change daily and as needed.


* Left groin: Lightly pack wound with gauze-packing strips. Cover with island dressing. Change daily and as needed.


* Right Neck: Place a small piece of calcium alginate on the wound. Cover with an adhesive bandage. Change daily and as needed.




Although this is a dramatic case to illustrate the ravages of the H1N1 virus in a particular case, most people who are infected with this virus have a mild to moderate, transient acute viral illness lasting from a few days to weeks with spontaneous recovery and resultant active immunity to the virus. In a complex scenario as presented in this case, however, the patient is at risk for complications, including the development of wounds of intention, wounds of pressure, and the impairment of normal wound healing secondary to bed rest, immobility, and ischemia to the limbs. Moreover, the patient's wound healing trajectory can be altered by concomitant secondary comorbidities, such as compartment syndromes of the abdomen and limbs, necrotizing fasciitis, and infections, such as Staphylococcus, Streptococcus, methicillin-resistant Staphylococcus aureus, and Candida. In this case, the wound specialist provided a high quality of care and follow-up, which contributed to the positive patient outcome of this dramatic case.


Selected References


Fischbach F, Dunning MB III. A Manual of Laboratory and Diagnostic Tests. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2008.


H1N1 Pregnancy Death Risk. CBS News video. Last accessed November 10, 2009.


Jamison DJ, Honein MA, Rasmussen SA, et al; the Novel Influenza A (H1N1) Pregnancy Working Group. H1N1 2009 influenza virus infection during pregnancy in the USA. The Lancet 2009;374:451-8.


'Miracle' Mom: Swine Flu Almost Killed Pregnant Woman. ABC News video. Last accessed November 10, 2009.


White DB, Angus DC. Preparing for the sickest patients with 2009 influenza A (H1N1). JAMA 2009;302:1905-6.