Post on 26-Mar-2015
transcript
Fluid Management in DHF Patients
Dr Rasnayaka M MudiyanseSenior Lecturer in Paediatrics
Faculty of Medicine Peradeniya
Short Duration Fever - OPD
1. Treat Fever 2. Rest3. Fluid4. Specific drugs5. Warning signs
DDDengue ( group A)( No warning signs ) Viral feversOther D
1. Immediate attention
2. Fluid3. Oxygen 4. Observation
DDDengue (group B)( with warning signs)Other infections
Other D
1. Evaluate & ABC care2. Fluid boluses 3. Oxygen4. Hand over MO-MODDDengue ( group C)(Sever dengue ) SepticemiaDiarrhea Anaphylaxis
Treat and send home
AdmitNo resuscitation
NeedResuscitation
Classification of DengueOld WHO classification New WHO classification
Classical Dengue Fever Probable dengue ( group A - OPD management)
Dengue Fever with hemorrhagic manifestations
Dengue with warning signs ( Group B - inward observation and management) ( patients are admitted for social reasons and when they are in high risk category)
DHF grade one
DHF grade two
DHF grade three Severe Dengue ( Group C - resuscitation and management) 1.With compensated shock2.With hypotensive shock3.With severe organ impairment
DHF grade four
DHF with unusual manifestations
Dengue Hemorrhagic Fever or Dengue Leaking Fever
Essential Feature In DHF is LeakingDF may have bleeding but not leaking
The Cause of Shock in Dengue
• Plasma leakage• Bleeding – external and internal • Hypocalcaemia • Vascular involvement • Inadequate fluid intake• Myocarditis
What is the cause of Plasma Leakage
Endothelial cell dysfunction rather than destruction
Evidence of Plasma Leakage
• Rise in HCT – 20% = children 35 42 adults 40 48
• Circulatory failure• Fluid accumulation – Ascites, Pleural
effusions• Albumin < 3.5 gr/dl • Cholesterol < 100 mg%
A. Rising hematocrit ~ 50%
Evidences Evidences of of
plasma plasma leakage leakage
in in DHFDHF (Rt. lateral decubitus position)
Rt pleural effusion Ascites
Plasma Leakage Shock Prolonged shock
• Prolonged shock – Organ hypo perfusion & Organ impairment– Metabolic acidosis + DIC – Severe Hemorrhage ( Drop HCT & rise of
WBC )
All these complications may develop without obvious plasma leakage or shock
Rising HCT indicate plasma leakage
• 20-30% rise GIT ischemia including liver • 30-40 % rise Renal and brain ischemia
Patients at risk of major bleeding
• Prolonged/refractory shock;• Hypotensive shock & renal or liver failure • Severe and persistent metabolic acidosis;• Receiving NSAID agents;• Pre-existing peptic ulcer disease;• On anticoagulant therapy;• Any form of trauma( IM injection)
Flushing
Tourquet test
Leucopenia
Liver enzymes
1st day 73% 53% 70% within 24 hrs pt will enter critical phase
AST rise 90%
AST > 60 – PPV 80%
AST > ALT (2-3 times)
2nd day 90% 90%
3rd day 85% 98%
Dengue is a Dynamic Disease
Febrile, Critical and Recovery Phase
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60
1 2 3 4 5 6 7 8
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Incubation period 5-8 days ( 3-14 days)
2-7 days 1-2 days
Rate of Fluid Leakage
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60
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Optimum volume of
fluid …
M + 5%
Calculation of M +5%
• Calculation of M– 1st 10 kg – 100 ml/kg/day ( 4 ml/kg/hr)– 2nd 10 kg – 50 ml/kg/day ( 2 ml/kg/hr)– Subsequent ..kg – 20 ml/kg/day ( 1ml/kg/hr)
• Calculation of 5%– 5% = 50ml/kg/day ( 2ml/kg/hr)
Maximum Fluid for adult ( 50kg) = 4600
M+ 5% for boy 60kg (IBW 50kg ) = ?
Fluid Management in DHF patients
Rational Use of Fluid = Management of Dengue
Avoid Fluid Overload
Spectrum of Dengue
• DHF Grade 4 ( SD with hypotnsive shock ) – No pulse – 20ml/kg rapid bolus– Drop SBP (Pulse + ) – 10 ml/kg rapid bolus, Rpt sos
• DHF Grade 3 ( SD with compensated shock)– 10 ml/kg/hr
• No circulatory failure ( D warning signs)– DF +/- Bleeding ( oral fluid ? M+5%)– DHF in Febrile phase (1.5 ml/kg/hr)
DF & DHF in Febrile Phase
DF & DHF in Febrile Phase
• Parcetamole 15mg/kg 6 hrly • Physical methods of controlling fever• Don’t use Aspirin and NSAID• Fluid to maintain nutrition and hydration
– Oral – between M and M+5% ( 5ml/kg/hr)
1
Too much fluid during febrile phase can contribute
to fluid over load
Recognize the Time of Entry to the Critical Phase
( when blood vessels become leaky)
• Dropping platelet count below 100 000/dl• Rising HCT & Evidence of plasma leakage
Fluid management during Critical Phase not in shock
( when blood vessels become leaky)
• Establish IV line & IV fluid to KVO • Limit total ( IV + Oral) fluid to 1.5 ml/kg/hr• Monitor UOP ( 0.5ml/kg/hr is OK) • Rising HCT - Increase fluid- 3-5-7-10 ml/kg/hr• Monitor for circulatory failure – Fluid boluses
HCT monitoring 4-6 hrly initially then hrly
Fluid Allocation for Non Shock Patient
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M + 5%48 hrs
20-10 ml/kg
10-5 ml/kg
5-3 ml/kg
3-1 ml/kg
KVO
10-20 ml/kg
5-10 ml/kg
3-5 ml/kg
1-3 ml/kg
1.5 ml/kg
Fluid Allocation for Non Shock Patient
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M + 5%48 hrs
20-10 ml/kg
10-5 ml/kg
5-3 ml/kg
3-1 ml/kg
KVO
10-20 ml/kg
5-10 ml/kg
3-5 ml/kg
1-3 ml/kg
1.5 ml/kg
Fluid over load and shock
Fluid Allocation for Non Shock Patient
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60
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M + 5%48 hrs
20-10 ml/kg
10-5 ml/kg
5-3 ml/kg
3-1 ml/kg
KVO
10-20 ml/kg
5-10 ml/kg
3-5 ml/kg
1-3 ml/kg
1.5 ml/kg
Shock and Fluid Over Load
Prolonged shock
Prolonged Shock
• Detecting absent pulse is too late• Drop in SBP is too late• Drop in pulse pressure, CRFT, Cold
extremities .. can detect early shock• We can prevent shock !
Rise in HCT = loss of IV compartment 20% - compromise GIT blood supply40% - compromise renal and brain
Prevent Shock – Manage PCV
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M + 5%48 hrs
20-10 ml/kg
10-5 ml/kg
5-3 ml/kg
3-1 ml/kg
KVO
10-20 ml/kg
5-10 ml/kg
3-5 ml/kg
1-3 ml/kg
1.5 ml/kg
Cause of Prolonged Shock in Dengue
• Failure to detect shock is rare in SL• Clinicians thought prolonged shock is due to bleeding
as a result of low platelets • Clinicians did not appreciate that shock precipitate
bleeding and other organ damage • Clinicians did not monitor/manage PCV ( instead they
managed platelet count ) personal opinion
WHY ?Lack of knowledge and training WHY ?Failures in teaching/training programs
(DHF grade 4) Severe Dengue with Hypotensive shock
5 year old boy; fever 5 days, cold extremities and prolonged CRFT. HCT 48, Plt 45 000/dl SBP 60/40.
Adults SBP <90 mm Hg or MAP <70 mm Hg or Drop of SBP >40 mm Hg
1-10 yrs - 5th Centile SBP = 70+ (agex2)
Management of DHF Grade 4Severe Dengue with Hypotensive shock
• Oxygen,Keep flat +/- Head low• IV canula – Blood samples • Rapid Fluid bolus + Rpt SOS • Monitoring ABCS• Consider other possibilities • Record keeping & Communication
Investigations for DHF patients
• FBC• Blood grouping and cross matching• Blood sugar• Blood electrolytes ( Na,Ca,K,HCo2)• Liver Function tests• Renal Function tests• Blood gases• Coagulation profile ( PTT,PT,TT)
Management of DHF Grade 4Severe Dengue with Hypotensive shock
• Slow bolus – 10 ml/kg Crystalloid/colloids over one hour• Infusion 5- 7 ml/kg/hr for 1-2 hrs ( Hartmann)• Infusion rate 3- 5ml/kg/hr for 2-4 hrs• Infusion rate 3ml/kg/hr for 2-4 hrs• Stop fluid in 48 hrs
Fluid bolus 10-20 ml/kg Normal Saline / 15 mt
Improving , HCT coming down gradually , good UOP
No improvement HCT dropping – Blood transfusion
No improvement HCT Rising – Colloid transfusion
Management of DHF Grade 4(Severe Dengue with Hypotensive shock )
Fluid bolus 10- 20 ml/kg Normal Saline / 15 mt Rpt fluid boluses – 2 crystalloids' colloids
NO IMPROVEMENT
If HCT is dropping< 40 for Children and female
< 45 for adult male
Blood transfusion whole blood 10 -20 ml/kgPacked RBC 5-10 ml/kg
Rising HCT
2ndBolus - Colloids1.10 – 20 ml/kg/ ½-1 hr
Check HCT before fluid bolus or after fluid bolus
3rd bolus - Colloids 1.10 – 20 ml/kg/1 hr
DHF Grade 3Dengue with Compensated Shock
10 year old boy; fever 5 days. Cold extremities. Tender Hepatomegaly. PCV
52, Platelets 50 000/dl CRFT 5 sec. SBP 100/85.
5th Centile SBP = 70+ (agex2)
Management of DHF grade 3(Severe Dengue with Compensated shock)
• Hartmann - 5- 7 ml/kg/hr for 1-2 hrs• Hartmann - 3- 5ml/kg/hr for 2-4 hrs• Hartmann - 2-3 ml/kg/hr for 2-4 hrs• Stop fluid in 48 hrs
Fluid bolus 5-10 ml/kg Normal Saline / 1hrImproving , HCT coming down gradually , good UOP
Management of DHF grade 3(Severe Dengue with Compensated Shock)
Fluid bolus 5-10 ml/kg Normal Saline / 1hr
HCT rising
Fluid bolus saline /colloids10 -20 ml/kg for 1hr
If HCT is dropping
Blood transfusion Packed RBC 5-10 ml/kg
Whole blood 10-20 ml/kg
NO IMPROVEMENT
However, a rising or persistently high HCT together with stable haemodynamic status and adequate urine output
does not require extra intravenous fluid.
< 40 for Children and female < 45 for adult male
Rpt fuid bolus 5-10 ml/kg Normal Saline / 1hr
Patients not responding to usual fluid boluses
• Massive plasma leakage – rising PCV• Concealed hemorrhage – Drop of PCV• Hypocalceamia • Hypoglycaemia • Hyponatremia• Acidosis
Fluid Management During Critical Phase DON’T OVER LOAD LEAKING VESSELES
• Manage PCV and shock; use monitoring chart• Fluid quota for leaking phase is M+5%
– Pre shock in 48 hours , Grade 3& 4 in 24 hours
• Use colloids to retain longer • UOP – 0.5 ml/kg /hr is OK (Void volume chart)• Cut down fluid at recovery phase
– Eg - 10ml/kg/hr 1.5 ml/kg/hr
• Give blood when indicated
Fluid Allocation for shocked Patient
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M + 5%24 hrs
20-10 ml/kg
10-5 ml/kg
5-3 ml/kg
3-1 ml/kg
KVO
Fluid Allocation for Non Shock Patient
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35
60
1 2 3 4 5 6 7 8
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M + 5%48 hrs
20-10 ml/kg
10-5 ml/kg
5-3 ml/kg
3-1 ml/kg
KVO
10-20 ml/kg
5-10 ml/kg
3-5 ml/kg
1-3 ml/kg
1.5 ml/kg
What is M+5% in management of DHF (MCQ)
• Fluid volume to be given during critical period after excluding boluses
• Fluid volume to be given during critical period after including boluses
• Upper limit of fluid volume for critical period• Upper limit that should never be exceeded
M + 5% is only a guide to understand the risk for fluid over load
Fluid Management in Recovery Phase
Fluid Management in Recovery Phase
Dengue patients have accumulated fluid within his/her body
• Cut down fluid • Give oral fluid if tolerating• Dropping HCT is not bleeding• Rising HCT in stable child manage with oral
fluidDHF grade 3 recovery phase; nurse inform that child has massive
meleana HCT dropped to 35 !Don’t panic if the child is stable, hematocrit 35 is because he is recovering
child is passing what he bled yesterday
6 yr old boy DHF grade 4 recovered after 3 fluid boluses. His HCT dropped from 48 to 39.
However he again developed circulatory failure with reduced pulse pressure.
Management of severe bleeding
• Probably he has internal bleeding• Manage with
–10 ml/kg whole blood–5 ml/kg Packed RBC
Indications for Blood Transfusions
• Overt bleeding ( more than 10% or 6-8ml/kg)• Significant drop of HCT < 40 ( < 45 for males)
after fluid resuscitation • Hypotensive shock + low/normal HCT • Persistent or worsening metabolic acidosis• Refractory shock after fluid 40-60 ml/kg
only 10-15% patients need blood
Circulatory failure with high HCT should be managed with colloids ( + Lasix if fluid overloaded) before blood
• To decide on platelet transfusion • To recognize the beginning of critical
stage -• As a prognostic indicator-
Why do you do platelet counts ? (Answer this MCQ)
• To decide on platelet transfusion - X• To recognize the beginning of critical
stage -• As a prognostic indicator-
Why do you do platelet counts ?
Fluid Over Load
Causes of Fluid Over Load • Too much fluids in febrile phase• Excessive and/or too rapid IV fluids• Use of hypotonic crystalloid solutions• Inappropriate IV fluids for “severe bleeding”• Inappropriate - FFP, platelet & cryo• Continuation of IV fluids after Critical phase • Co-morbid conditions
– congenital or ischaemic heart disease– chronic lung and renal diseases– Obesity – Fluid not calculated for IBW
Early Clinical Features of Fluid Overload
• Respiratory distress– Difficulty in breathing– Rapid breathing– Chest wall in-drawing– Wheezing (rather than crepitations)
• Large pleural effusions &/or Tense ascites• Increased jugular venous pressure (JVP)
• Minimize fluid– Stop if in recovery phase – Minimize in critical phase
• Nurse in the R lateral position• Maintain oxygen saturation above 95%• IV Furosemide +10% Dextran (40) 10 ml/kg ?• Correct hypokalaemia• Assess ABCS
Management of Fluid over load
How to prevent fluid over load
• Try to manage within the fluid quota (M+5%)– For 48 hrs for non shock patients– For 24 hrs for shocked patients
• Expected Urine out put is only 0.5 ml/kg/hr• Calculate oral fluid also• Monitor fluid intake regularly during critical
period – Use a fluid monitor
Leaking Blood vessels ! – Give only minimal & essential
What to do in practice
3 yr old mucus diarrhea mild dehydration had HCT 55%
8 year old 30 kg girl Fluid for 48 hrs
30 kg IBW - 25 kg
M 1700 1600
M+5% 3200 2850
5 ml/kg 7200 6000
3 ml/kg 4320 3600
1.5 ml/kg 2160 1800
Fluid balance in health and dengueHealth
Ml/kg/hrDengue
Ml/kg/hr
Total intake 3 3
UOP 2 1
Insensible loss 1 1
Leaking (+ ve balance)
0 1
Water for growth was not taken in to consideration
Fluid balance in health and dengueHealth
Ml/kg/hrDengue
Ml/kg/hr
Total intake 3 5
UOP 2 2
Insensible loss 1 1
Leaking (+ ve balance)
0 2
Water for growth was not taken in to consideration
Fluid balance in health and dengueHealth
Ml/kg/hrDengue
Ml/kg/hr
Total intake 3 1.5
UOP 2 0.5
Insensible loss 1 1
Leaking(+ ve balance)
0 0.25
Water for growth was not taken in to consideration
Monitoring Charts
22 kg HCT/plt
HR BP RR UOP CRFT Coldness
FluidMl/kg
11.00 am
38 146 90/80 47 5 ml 8 Mid calf
10 ml/kg bld
12.00 noon
48 100 110/80
49SOB
10 2 ankle 10 ml/kgHS + Laxis 20 mg
1.00 pm 41 100 100/70
40Acitiseffusions
100 2 - 3 ml/kgNS
2.00 pm 110 100/70
38Effusions
60 2 - 1.5 ml/kg
2222/26401 2 3 4 5 6 7 8 9 1
011
12
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20
21
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25
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29
30
31
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39
40
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47
3 ml/kg NS /one hr
?
Fluid over load
Why?
Causes of fluid over load
• Clinicians gave too much fluid - eg 3-5 ml/kg/hr• Clinicians thought that extra fluid in the febrile
can prevent shock• Clinicians thought giving blood can be dangerous
Personal opinion with no proof
WHY ?
Lack of knowledge and training
Condition of the patient HCT Rising HCT Dropping
Deteriorating Colloids Blood transfusion
ImprovingObserve
Increase fluid rate during early critical
phase
Improving !Encourage
normal feeding
Use Void Volume Chart
7 year old (20 kg ) boy passed 100 ml of urine at 12 MN. He passed
urine at 5 pm soon after coming to the ward. Interpret his UOP
• UOP is 0.74 ml/kg/hr
He was given 100 ml/hr of Hartmann solution from MN up 6
am when he passed 400 ml of urine.
• UOP is 3.3 ml/kg/hr• ?
His blood counts done on admission total 5.6 , Platelets 50 000/dl, PCV 45
Same fluid rate was continued. At 12 noon he passed 40 ml of urine.
• UOP is 0.3 ml/kg/hr• ?
Blood counts done at 6 am – Platelets 50 , HCT 42
Circulation – HR 120, cold limbs CRFT 5 sec
Patient develop massive fluid over load. After 30 hours in critical
phase, he is on fluid 15 ml/kg/hr. He passed 300 ml of urine in 4 hrs.
• UOP is 3.75 ml/kg/hr• ?
Blood counts done at 6 am – Platelets 60 , HCT 36
Circulation – HR 98, no cold limbs CRFT 3 sec
Use monitoring chart
• Chart one – Suspected dengue patient not in critical stage
• Chart two – Start once patient enter the critical stage
Knowing the stage of the illness by everybody in the team is very important
in management of dengue patients
Unusual Manifestations of Dengue
• Encephalopathy• Hepatic failure• Renal Failure• Dual infections• Underline conditions
Ward round presentation by ho/sho• This 7 yr old IBW 20 kg child came to the
ward 3 days ago, entered the critical phase yesterday morning. Now 24 hrs in critical phase. On 5 ml/kg/hr of Hartmann.
• Stable circulation. Warm limbs, CRFT 2 sec, BP 100/60
• UOP for last six hours 0.8 ml/kg/hr• Last HCT 48 ( it has gone up from 42)• So far We have given 1200 ml out of 2500
ml 48 hr fluid quota • We thought of increasing fluid to 7
ml/kg/hr
Diagnosis Card of DHF Patient Diagnosis
Dengue Hemorrhagic Fever Grade 4(Severe Dengue with hypotensive shock)
• Patient entered critical phase 24 hrs after admission to ward• HCT - Maximu – 52, minimum – 32• Platelets – Max – 120, Mini – 40• Blood pressure – min – 40/ ?
Management • Total fluid during critical period 1850 / 1900• Crystalloid boluses – 3• Colloid boluses – 1• Blood – 10ml/kg x1
Complications – • Fluid over load – Wheezing, Pleural effusions and ascites. Lasix 20 mg x2 • Bleeding ( HCT 32, need blood 10ml/kg)• Hypocalcaemia – Serum Ca – 1.8 ( treated with 10 ml 10% ca Gluconate)
Initial fluid for following DHF patients
• DHF with no palpable pulse – 10-20 ml/kg/15 mt normal saline
• DHF palpable pulse but low BP– 10ml/kg/15 mt NSS or colloids
• DHF normal BP, cold limbs+ CRFT 4 sec– 10ml/kg/hr NSS + 10% Dextrose
• DHF no shock just entered the critical phase– 1.5 ml/kg/hr
• DF/DHF in febrile phase – Oral fluid ?5 ml/kg/hr
Thank You