Dr.S. Sambath M.D D.CH
MADURAI.
DOS AND DONTS IN DENGUE FEVER
3 MANIFESTATIONS Probable dengueDengue with warning signsSevere dengue
3 PHASESFebrilecriticalRecovery
3 IMPORTANT ASPECTSAssessment - triageMonitoring - Clinical and LaboratoryTreatment - IV Fluids and Blood
3 PLANS of Mx –Plan A, B, C
Dengue Lab Diagnosis
RNA, Flaviviridae, Flavivirus Febrile phase 1 to 4 days
Genome - RT PCR - Highly sensitive
NS1 Ag – rapid test or ELISA Critical Phase 4 to 5 days
IgM mac ELISA or rapid on 5th day
IgM/IgG optical density ratio >1:2
IgG ratio >1/1280
Essential for good practicePLAN A -PROBABLE DENGUE
Patient from endemic area Fever (plus 2 of the following)
Anorexia with nausea
Rash
Aches and Pains
Leucopenia
Tourniquet test + ve no warning signs Laboratory features [hct ,platlet]
Plan A - Managed at home
Educate about warning signs Monitor urine output Administer ORS Avoid NSAID Treat fever - paracetamol 10 mg/kg Report in case of warning signs
immediately & follow up
PLAN B – DENGUE WITH WARNING SIGNS CLINICAL LABORATORY
Abdominal pain Persistent vomiting Lethargy,
Restlessness Mucosal bleed Liver enlargement >2
cm Clinical fluid
accumulation
Increased HCT Decreased platelet
count Progressive
leucopenia
Plan B -Dengue with warning signs-Mx Admit
Obtain reference HCT before IV fluids Give only NS,RL or Hartmann’s solution Start 5-7ml/kg/hr for 1-2 hrs (reassess)
3-5ml/kg/hr for 2-4 hrs(reassess)
2-3ml/kg/hr Reassess clinical status and HCT before
adjusting fluid therapy Minimum fluid to maintain urine output
0.5ml/kg/ hr
Monitoring
vitals &peripheral pulses 1-4 hrly
U/O 4-6 hrly
HCT before and after fluid therapy
Blood sugar, organ function(RFT,LFT ABG, etc)
Encourage oral fluids in high risk comorbid dengue pts
If HCT remains same or increase minimally& vitals stable
NS 2-3 ml/kg/hr for 2-4 hr then change to oral fluids
If HCT increases – vitals deteriorates
increase fluid to 5-10ml/kg for 1-2 hrs Ideally body weight is used for
calculating fluid infusion in obese patients
PLAN C Severe dengue compensated shock
Tachypnoea, mild retractions, air entry decreased HR increased, pulse volume decreased,
CRT>2sec,narrow pulse pressure<20mmHg Liver span increased Drowsy ,answers to questions
Management Administer O2 through jacksonrees circuit IV NS bolus 10ml/kg for 1 hr Check HCT , monitor U/O, Cardio-Respiratory-
Cerebral assessment
No shock with increased hematocrit
isotonic fluid 5-7ml/kg/hr for 1-2 hrs
3-5 ml/kg/hr for 2-4 hrs
2-3 ml/kg/hr for upto 48 hrs Shock with increased HCT
repeat NS bolus10-20ml/kg/hr
7-10 ml/kg/hr for 1-2 hrs Shock with decreased HCT
PRBC 5-10 ml/kg
Fresh blood 10-20 ml/kg
Plan C - Severe dengue-hypotensive shock
cold clammy skin ,pulse not felt -?,
CRT>2 sec, BP-?
Management Provide O2 through jacksonrees circuit IV bolus NS 20ml/kg over 15 min check HCT IV bolus NS 10ml/kg over 30min-1hr IV bolus NS 10ml/kg over 1hr
↑HCT with unstable vitals-bolus fluid ↑HCT with stable vitals- maintenance
fluid Severe h’ge-urgent blood transfusion No clinical signs of bleed- use colloid
solution ↓HCT with unstable signs - blood
transfusion ↓HCT with stable signs + u/o ↑ -
reduce iv fluid
Correct hypoglycemia,hyponatremia
hypocalcemia, hyperkalemia Hypovolemia with shock
metabolic acidosis
give - IV fluids alone Tissue hypoxia +lactic acidosis give
IV fluids + sodium bicarbonate Hyperchloremia- Hartmann or RL Septic screening
Shock persisting even after giving 40 to 60ml of bolus NS
BP low - Dopamine low dose Severe hypotension -Epinephrine HCT low, No CRT improvement
Blood transfusion Pedal edema + hepatomegaly, fluid
overload
minimal iv fluids+ Ionotropes
Colloids
No clear advantage Improves the cardiac index & Raises the
HCT faster( pulse pressure <10mm Hg) Dextran 40 binds with Von Willebrand factor Gelatin based – allergic reaction Hydroxy ethyl starch- Osmotic renal injury
Blood transfusion -indications
Melena with profound refractory shock Persistent metabolic acidosis with normal
BP with abdominal pain and tenderness Unstable vitals regardless of hematocrit
Decreased hematocrit inspite of 40-60 ml/kg of IV fluidDoubtful - 5 to 10 ml/kg of fresh whole blood
Defenite-10 to 20 ml/kg
Fluid overload when Prolonged higher rate of IV fluid
Hypotonic, Inappropriate Early – wt gain, large pleural effusion,
large ascites Late -- pulmonary edema, abdominal
compartment syndrome Occur both in critical &recovery phase.
Fluid overload
SignsRespiratory distressElevated JVPRhonchiPleural effusionTense ascitesPulmonary edemaIrreversible shock
Management Oxygen Strong pulse with warm extremities
Recovery phase○ Inj. frusemide 0.1 to 0.5 mg/kg bid or tid
Critical phase○ ↓ iv fluids , change to colloid
Shock+↑HCT +fluid accumulation-careful iv fluids-5ml/kg / hr- 1-2 hrs
Shock + normal HCT +excess fluid + BP↓-dopamine drip at low rate +fresh whole blood
ACUTE RESPIRATORY DISTRESS AND FAILURE
1. Kussmals breathing-severe metabolic acidosis with severe shock –prefer lying posture
2. volume overload- large pleural effusion and ascites – normal pulse & urine output
3. Acute pulmonary edema –[wheeze/rhonchi]
4. ARDS-persistent hypoxia
NON INVASIVE VENTILATION Life threatening hypoxemia Early pulmonary edema ARDS Mild metabolic acidosis
MECHANICAL VENTILATION Restlessness, confused Acute pulmonary edema + shock Fail to respond to non invasive ventilation
Agitations-Shock, Hepatic failure, Metabolic derangement, encephalopathy, cerebral edema
Occult bleeding - prolonged hypotensive shock, unexplained tachycardia, Metabolic acidosis, Decreased HCT
Death-Prolonged shock, massive bleed,
Fluid overload, Organ dysfunction
Discharge criteria No fever for 48 hrs Normal hemodynamic status and urine
output No vomiting No respiratory distress Normal HCT , Increasing platelet count
WHAT TO DO: Drop in platelet & rise in HCT are
essential for early diagnosis cases of dengue/DHF should be
observed every hr Timely IV therapy-isotonic crystalloid
solution can prevent shock/lessen its severity
The patient condition become worse despite of giving 20 ml/kg of NS for 1hr,replace crystalloid solution with colloid solution(dextran or plasma)
If improvement occurs reduce the speed from 10 ml/kg to 7ml/kg then 5ml/kg and finally 3ml/kg
In case of severe bleeding ,give Fresh blood transfusion 10-20ml/kg -2hr..then crystalloid10ml/kg- 30to60 min &reduce the rate
in case of shock give O2 For correction of lactic acidosis use
sodium bicarbonate + iv fluids
WHAT NOT TO DO Missed diagnosis at the frontline Misinterpretations of vitals signs Inadequate fluid intake &urine output Late recognition of prolonged & profound shock Too little or too much iv fluids Do not give aspirin or brufen for fever Avoid giving IV therapy before there is warning
signs Avoid giving blood transfusion unless indicated Do not change the speed of fluid so rapidly NG tube to determine concealed bleeding or to
stop bleeding is not recommended
THANKS A LOT FOR LISTENING