D NGUE WORKSHOP 2015

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E

CHALLENGES IN THE MANAGEMENT OF DENGUE

DR LOW LEE LEEID PHYSICIAN

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What are the warning signs?

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Fluid resuscitation is needed to sustain the intravascular pressure : Compensated or decompensated shock

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Severe Dengue :Dengue with target organ involvement

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Dengue with hepatitis

VomitingRight hypochrondriac painBaseline LFT ( if admitted)

Dengue with encephalitis

Headache, vomiting, altered sensorium, seizure Comatose ( late stage)

Dengue with perimyocarditis

Chest pain, dypsnoea, palpitation,Cardiogenic shock ( late stage)

Atypical presentations

• Diarrhoea• Myocarditis• Encephalitis• Myositis• Hepatitis• Acute abdomen • Severe bleeding without plasma leakage• Plasma leakage in febrile phase

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Dengue Clerking Sheet

Pearls of management

Fever + 2 other features .Advise patient to return to clinic/ seek medical attention• If fever does not settle after 3days• Presence of warning signsDo FBC ± Dengue rapid test (combo)Home advice leafletEarly notification

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HOME CARE ADVICE LEAFLET FOR DENGUE PATIENTS

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First step

• All fever must be considered probable dengue• Fever plus 2 symptoms: myalgia/arthralgia,

nausea vomiting, rash, bleeding tendency, leucopenia and thrombocytopenia, any warning signs

• Notify once diagnose clinically

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Ask yourself are Dengue Warning Signs present?

• Abdominal pain or tenderness

• Persistent vomiting• Clinical fluid accumulation (pleural effusion/ascites)• Mucosal bleed • Restlessness or lethargy• Liver enlargement >2 cm• Laboratory: Increase in HCT concurrent with rapid decrease in platelet

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Second step

• Disease staging and severity assessment

1. Dengue diagnosis (provisional)2. Phase of dengue illness if dengue is suspected

(febrile/critical/recovery)3. With or without warning signs4. Hydration and haemodynamic status of patient

(in shock or not)5. Whether the patient requires admission

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CRITERIA FOR HOSPITAL REFERRAL / ADMISSION

Symptoms:1. Warning signs 2. Bleeding manifestations3. Inability to tolerate oral fluids4. Reduced urine output5. Seizure

Signs:1. Dehydration2. Shock 3. Bleeding4. Any organ

failure

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CONSIDER EARLY ADMISSION

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• Co-morbidity e.g. DM, HPT, IHD, Coagulopathies, Morbid Obesity, Renal failure, Chronic Liver disease, COPD• Elderly > 65• Pregnancy• Social factors: living far, living alone etc

Lab. criteria• Rising HCT with reducing platelet count

If you are in KK/district hospital

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• Stabilise patient• Continue resuscitation and monitoring during

transportation• Patient should be accompanied by a medical

officer

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How much fluid to give

Fluid regime• Dengue with no warning signs• Dengue with warning signs• Decompensated shock• Compensated shock

Fluid Resuscitation

Dengue without warning signs :but with poor oral intake or mild

dehydrationNon-shock patient/no warning signs• Encourage adequate oral intake• Intravenous fluids are indicated in patients

who are vomiting, diarrhoea and mild dehydrated.

• 4/2/1 ( 4ml/kg for first 10 Kg + 2 mls/kg for subsequent 10 kg + 1ml/Kg for every Kg )

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Estimated ideal body weight

or IBW (kg)

Normal maintenance fluid (ml/hour) based

on Holiday Segar formula

5 1010 2015 3020 60

25 6530 7035 7540 8050 9060 10070 11080 120

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Dengue with warning signs : 5/3/2• All patients with warning signs should be considered for monitoring

in hospitals.• Obtain a baseline HCT before fluid therapy.• Give crystalloids solution (such as 0.9% saline).• Start with 5–7 ml/kg/hour for 1–2 hours, then • reduce to 3–5 ml/kg/hr for 2–4 hours, and • then reduce to 2–3 ml/kg/hr or less according to the clinical

response.• If the clinical parameters are worsening and HCT is rising, increase

the rate of infusion.(7 mls/5/3/2)

• Reassess the clinical status, repeat the HCT and review fluid infusion rates accordingly.(during critical phase, review every 4 Hly, monitoring VS 2 Hly) ID HSB 2015

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Pearls of management

Dengue patient may bleed during febrile phase.

For instance : UGIB In particularly in patient who has pre-existing PUD, is taking anti-platelet / NSAID

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Pearls of management

• Good triaging system ED & OPD • To determine whether urgent attention is required

• Triage Checklist (TO BE SEEN STAT)1. Warning signs2. Vital parameters not stable VS to be taken: Mental state, BP, pulse, temp., cold or warm peripheries

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Pearls in management

• Take good history on medical illness : eg: DM / CCF / HPT• Take BP/PR / Pulse volume / RR• Good documentation

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How to prevent deathEarly recognition of dengueIdentification of clinical problems in different phases of dengueEarly recognition of dengue warning signsEarly recognition of shockEarly recognition of occult bleedingRecognition of comorbidities and its complicationsLook out for atypical presentations of dengue Early notification

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THANK YOU

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