management of dengue fever & dengue h'gic fever in adult
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MANAGEMENT OF DENGUE
FEVER & DENGUE
HAEMORRHAGIC FEVER IN
ADULTSDr. R.A.N.S. Rajapakshe
SHO- Medicine
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Dengue viruses & Disease
y Arbovirus Aedes aegypti
Aedes albopictusy Four serotypes (DEN-1, DEN-2, DEN-3 e DEN-4)
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Dengue Viral Infection(10,000 patients)
Asymptomatic(9,000)
Symptomatic(1,000)
Viral Syndrome(500)
Dengue Fever(400)
DHF(100)
Plasma leakage
DHF-Nonshock
(98-99)
DSS(1-2)
Unusual
ComplicationsProlonged shockLiver failureEncephalopathyRenal failureCo-infection
Co-morbidities
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Difference between DF & DHF
y Key factor in guiding the Management.
y Two different clinical conditions from the beginning
but look very similar in first two days.
Badly managed DFwill never become DHF
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Dengue Fever
y NO PLASMA LEAKAGE
y Platelet Count may drop < 100,000 /mm3
y Leucopenia ( WBC< 5,000/mm3 )
Clinical Features :-
y Headache ( Retro orbital pain)
yArthralgia / Myalgia Sometimes
y Erythomatous or Macula- papular rash more in DF
y Positive Tourniquet test than DHF
y Skin heamorrhages
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Haemorrhagic manifestations of DF
y Skin haemorrhages:
Petichiae,Purpura,Ecchymoses
y Gum/ nasal bleeding
y GI bleeding:
Hematemesis,Malena,Hematochezia
y Haematuria
y Menorrhagia
Still not DHF
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ClinicalCase Definition for DHF
Four Necessary Criteria: All Four Needed
y Fever / recent history of Acute fever
y Hemorrhagic manifestations
y Low Platlet count ( < 100,000 /mm3 )y Objective evidence of LEAKYCAPILLARIES
Elevated Hematocrit ( 20% or more over base line)
Low Albumin ( < 3.5 g/dl)
Low Cholesterol ( < 100 mg/dl)
Pleural effusion/ Ascites
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NaturalCourse of DHFDHF is a dynamic disease & It has three phases.
FebrilePhase :-
o High grade fever 2 7 days
o
Clinical features- Facial puffiness, Erythema, Myalgia,Arthralgia, Headache, Anorexia, Nausea & vomiting
Tender Hepatomegally- Favours DHF
Critical Phase :-
o Often after 3 rd day, usually 4th
to 5th
dayo Last for 24 to 48 hrs
o Plasma leakage - rising Haematocrit 20%
o Low Serum Albumin & Cholesterol
o Pleural effusion/ Ascites
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Recovery(Convalescent) Phase :-o Lasts 3 5 days
o Plasma leak stops & Fluid reabsorbs
o Diuresis
o Classical recovery rash/ itching
Loss of Plasma
Haematocrit
24 H 24 H
Critical Phase(48H)
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Classification of Dengue
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Criteria for Admission
y With Platlet count < 100,000/mm3
y With following Warning signs:
y Abdominal pain/Tenderness
y Persistent vomiting
y Clinical signs of plasma leakage
y Mucosal bleeding
y Lethargy & restlessness
y Liver enlargement > 2cm
y Increase in Haematocrit with rapid decrease in Pltcount
y Pregnant mothers, Elderly Pts, Obese pts, Pts withCo- morbid conditions & adverse social circumstances.
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y Adequate oral fluid intake
y Adequate physical rest
y Tepid sponging
y Paracetamol 2 tabs 6H
y Antiemetics & H2 receptor blockers
y Avoid all NSAIDs & Steroids
y
Withhold Aspirin, Clopidogrel & Dipyridamole if onlong term
y FBC 3rd Day
Management at OPD
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Management of Inward Pts
y Admission Goalsy Early detection of plasma leakage (onset of Critical phase)
y Rational fluid management- prevent shock & fluid overload
SYMPTOMSOFSHOCK
Sweating
Abdominal pain
Persistent vomitingRestlessness/altered conscious level
Postural dizziness
Decreased UOP (
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SIGNSOFSHOCK
Cold extremitiesProlonged CRFT ( > 2sec)
Unexplained tachycardia
Tender hepatomegaly > 2 cm
Increasing diastolic pressure
Narrowing of pulse pressure 20mmHg
Postural drop 20mmHg of SBP
Hypotension
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Monitoring DF Patientsy Stable patients
y QHT
y Bleeding manifestations(malena , bleeding PV)
y Vital signs
y FBC daily
y Platelet < 100,000/mm3 ( chart 1)y QHT
y Vital Parameters- PR, BP, RR, CRFT - 4H
y FBC dailyy HCT twice daily
y Fluid balance Intake Type & route
Output Urine/Vomitus 6H
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y Critical phase (Chart 2)y Vital parameters 1H
y Fluid balance chart 3H
y HCT 6H
y Evidence of shocky Vital parameters 15 min
y HCT 2 to 4H
y Input/ Output 1H
( UOP 0.5 1ml/kg/hr)
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FluidManagement in DF
Calculation ofIdeal bodywt
Best method Wt for Ht /Wt for age in growth chart
Emergency situation < 1 yr Age( in months) + 9
2
< 7 yrs (Age 2) + 8
>7 yrs Age 3
APLS (Age + 4) 2
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Calculation of total fluidrequirement
M(Maintenance) 100ml/kg for 1st 10kg
50ml/kg for next 10kg
20ml/kg for Balance wt
5% of Body Wt = 50ml Body Wt(Kg)
Maximum Body Wt for Fluid calculation is 50 Kg
M + 5% = Maintenance + 5% of Body Wt
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Fluid management in Febrile phase
If fever & vomiting present
Total IV + Oral fluids = M + 5% during each 24H
If no fluid loss
Total fluids = M during each 24HRecommended IV fluids 0.9% saline/Hartmanns
Oral Electrolyte solutions Eg. ORS, King coconutwater, Kanje, Fruit juice
Too much fluid during Febrile phase cancontribute to fluid overload
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Fluid management in Critical phase
y Non shock (Haemodynamically stable)y Patient is starting to leak
y M +5% spread over 48 H
y
Rate sufficient to maintain effective circulationy Start at a slower rate ( 1- 1.5ml/kg/h)
y Rate should be increased step wise pattern according to riseof HCT & reduction of UOP
(note that it is almost one days fluids that is givenover 2 days and maximum weight for which fluid iscalculated is 50kg even if the actual weight is wellabove 50kg)
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y Fluid Intake Non Shock
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y Shock statey Continued to leak before admissiony Occurs at the peak of leaking
y M + 5% spread over 24 H ( not 48H)
y Include fluid given for resuscitation
y
Initial bolus 20ml/kg fast infusion (Crystalloids)y 10ml/kg boluses when recordable BP
y Consider Colloids
y after 2 saline boluses
y shock despite of fluid overload
y direction of exceeding M+5%
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y
Fluid Intake - Shock
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yDoses of Colloids
y Dextran 40 Maximum of 30ml/kg/24H (3 boluses of10ml/kg/h over 24H = 6 doses / 48H)
y 6% Starch Maximum of 50ml/kg/24H ( 5 boluses of10ml/kg/h over 24H = 10 doses / 48H)
y Only recommended for Critical phase
y Only as boluses
y Blood sample for Gp & DAT before Dextran
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FluidManagement of Recovery
phaseDengue patients have accumulated fluid within his/her
body
y Cut down fluid
y Give oral fluid if tolerating
y Fluid will start reabsorbing
y
Dropping HCT is not bleeding
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Fluid Overload
Causes ofFluid overload
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
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Clinical features ofFluid overload
Respiratory distress
Large pleural effusion/ Tense ascites
Elevated JVP
Prevention of flui
doverloa
d
Try to manage within the fluid quota (M+5%)
y For 48 hrs for non shock patients
y 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 Dengue monitoring chart
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Indications of Blood Transfusion
y Significant overt bleeding > 6-8ml/kg Body Wt.
y Haematocrit not as high as expected for the degree ofshock to be explained by plasma leakage alone.
y A drop in HCT without clinical improvement despiteadequate fluid replacement.
y Severe metabolic acidosis & end-organ dysfunctiondespite fluid replacement.
y 5ml/kg of packed red cells to over hydrated/ Heartdisease pts OR 10ml/kg of whole blood.
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Place of Adjunctive Therapyy Platelet transfusion - Prophylactic transfusion is not
recommended excepty Thrombocytopenic pts undergoing urgent surgery.
y Active bleeding despite repeated blood transfusion.
y DIC / ICH
y FFP transfusion Prophylactic transfusion is notrecommended but may be useful in pts with Hepaticencephalopathy and has active bleeding.
y Steroids & IVImmunoglobulin Notrecommended
y Tranexamic acid Can be used in bleeding PV eithermenstrual, intermenstrual or premenopausal.
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Comp
licated DHF
y Acidosis Check Venous blood gas & correct
y Bleeding Check HCT
y Calcium & other Electrolytes Check serum levels
y Sugar Check RBS
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Causes of Death in DHF Prolonged shock
Delayed diagnosis Late presentation
Fluid overload
Use of hypotonic saline
Given excess fluids Given more than time of leakage
Massive bleeding
Not given blood transfusion
Delayed blood transfusion
Unusual manifestations
Encephalopathy
Underlying cormorbidity
Dual infection
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References
y Dengue Haemrrhagic Fever & Dengue Control in Srilanka- SLMA News; Aug 2010.
y Guidelines on Management of Dengue Fever &
Dengue Haemorrhagic Fever in Adults Ministry ofHealth Sri lanla; Dec 2010.
y Rational Management ofFluid in Dengue Pts byDr.Rasnayake M. Mudiyanse PPt.
yCase Management of Dengue by Dr. LakKumarFernando PPt.
y Wikipedia.
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THANKYOU!
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