Clinical Management of Dengue in the Primary Care SettingAndre Sookdar

Objectives

• Course of Dengue Illness• Approach to Suspected Dengue Patient• Recognizing Severe Dengue• Clinical Management• Good vs Bad Practice

Course of Dengue Fever

• After incubation, Dengue Fever begins abruptly.• Three Phases; Febrile, Critical and Recovery.• Severe Dengue may occur from Day 4-5 instead of

the recovery phase. This may involve Hypovolemic/Hypotensive shock, Coagulation abnormalities or Severe Organ impairment.

• Most cases recover without hospital management.• Triage, Guidelines and management decisions at the

primary care level can help in identifying those at risk of severe Dengue and needing hospital care.

Course of Dengue Fever

At the Primary Care Level

• Recognize the Febrile patient could have Dengue.• Notify the Public Health Authorities early about suspected

cases.• Managing the early Febrile Phase of Dengue.• Recognize the Critical Phase as plasma leakage and to

initiate fluid therapy.• Recognize the Warning Signs and the need for referral.• Recognize and manage severe plasma leakage and shock,

severe bleeding and organ impairment promptly and adequately.

Approach to Suspected Dengue Patient

• Stepwise approach• Step 1 – Overall Assessment

1. History

2. Physical Examination

3. Investigations• Step 2 – Diagnosis, assessment of disease phase

and severity • Step 3 – Management

1. Group A, B or C

History

• Date of onset of fever/illness• Quantity of oral intake• Assessment of Warning Signs• Diarrhoea• Change in mental state/seizures/dizziness• Urine output• Other – neighbourhood dengue, travel to endemic

areas, co-existing conditions, risk factors for Leptospirosis, Malaria, HIV

Examination

• Mental State• Hydration Status• Hemodynamic Status• Tachypnea/Acidotic Breathing/Pleural Effusion• Abdominal Tenderness/Hepatomegaly/Ascites• Rash and Bleeding manifestations• Tourniquet Test• Temperature

• “ isles of white in the sea of red”

• Hemorrhagic Rash

Tourniquet Test

• Blood Pressure Cuff is applied and inflated midway between the systolic and diastolic pressures

• Leave on for five minutes• Positive if there are more than 10 petechiae in one

inch circle.• Dengue Hemorrhagic Fever usually results in 20 or

more petechiae.• Confounding factors include

premenstrual/postmenstrual women and sun-damaged skin

Positive Negative

Investigations

• CBC – baseline HCT, low WBC, low Platelet• Rising serial HCT – plasma leakage/critical phase• Confirmatory tests (not necessary in acute

management)• LFT’s, Glucose, Electrolytes, Urea, Creatinine,

Bicarbonate, Cardiac Enzymes, ECG, Urinalysis

Management

• Disease Notification – suspected and confirmed cases in Dengue endemic countries. Confirmation can come later for suspected cases. Early notification is key to initiate vector eradication.

• Clinical manifestations and circumstances leads to patient being sent home (Group A), referred for in-hospital management (Group B) or emergency treatment and urgent referral (Group C.)

• Education of patient and relatives on disease and vector management

Group A

• No Warning Signs• No significant co-morbid conditions or social

circumstances• Must be able to tolerate adequate oral fluids• Must be passing urine at least every six hours• May be sent home with instructions and plans for

follow-up• Bed rest; fluid intake; paracetamol• Daily review for disease progression

Group B

• Stable patients with Warning Signs or patients without the warning signs but have significant co-morbid conditions or social circumstances.

• Referral for in-hospital care• Obtain baseline CBC with HCT• Encourage oral fluids; if not tolerating for 0.9% N/S or

Ringer’s Lactate at maintenance rate.• For those with Warning signs give 0.9% N/S or Ringer’s

Lactate at 5-7ml/kg/hr for 1-2 hrs, then reduce to 3-5ml/kg/hr for 2-4 hrs, then reduce to 2-3 ml/kg/hr according to clinical response.

Group B

• Reassess, repeat HCT• If HCT is stable then continue at 2-3ml/kg/hr.• If worsening of vital signs or rising HCT increase to 5-

10 ml/kg/hr for 1-2 hrs then reassess• Observe urine output and fluid intake

Group C

• Warning signs present plus features of:Severe plasma leakage and shockFluid accumulation with respiratory distressSevere bleedingSevere Organ impairment

• For Emergency Treatment and Referral• CBC and baseline HCT• Other organ function tests• Start IV fluid resuscitation with crystalloid solutions at 5-10

ml/kg/hr for 1 hr.• Reassess patient

Group C

• If patient improves gradually reduce to 5-7 ml/kg/hr for 1-2 hrs, then 3-5 ml/kg/hr for 2-4 hrs then 2-3 ml/kg/hr for 2-4 hrs

• If patient is still unstable check HCTIf HCT increases or is still high repeat a second bolus at 10-20 ml/kg/hr for one hr. If there is improvement reduce to 7-10 lm/kg/hr for 1-2 hrs and continue to reduce as the above

• If HCT decreases this indicates bleeding and need for transfusion

Conclusion

• Course of Dengue Illness• Primary Approach to Suspected Dengue Patient• Recognizing Severe Dengue• Clinical Management of Groups A, B, C• Good vs Bad Practice

Thank You