dengue case histories
TRANSCRIPT
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4. Case Histories
Dengue Expert Advisory Group
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24 yr old male came to the OPD with H/O fever for 1 day. Had myalgia, and severe headache. No vomiting.
O/E Flushed skin, good hydration, pulse 80/min, BP 110/80. No abnormality was detected on examination.
He was sent home by the OPD doctor advising him • to drink - the amount, type of fluid• to take paracetamol in correct dose• to have rest.
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• He was also advised to come back on the 4th day of the illness with CBC.
• He came back on 4th day, still febrile, had nausea. Pulse 80/min, BP 110/80.
• CBC on D-3• WBC – 3800 Hct – 38.8 Plt – 120,000
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• FBC and Haematocrit monitored• Fluid intake and output monitored
IV fluids – 1500 ml with 1000 ml orally per day given. Total – 2500 ml/d Domperidone and PCM sos
• Vital signs monitored
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3 4 5 6 6 7 8 9
WBC 3.8 2.8 4.1 10 9.9 10 8.3 5.5
HCT 38.8 40.5 44.5 48.5 43.9 42.8 39.7 40
PLT 120 80 21 6 9 9 19 57
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• Symptomatic management continued• Monitoring continued.• Fluid increased with rise of PCV• No clinical deterioration. Had small right sided
pleural effusion. No specific management done.• Patient improved i.e.. General condition, appetite.
Fever settled.• Patient was discharged home once the plt count
was >50,000 & Afebrile for 48 hrs
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• Doing a CBC from 3rd day is better.• Often only symptomatic management is
adequate. • If there is no active bleeding, there is no place
for platelet transfusion even if the platelet count is low.
• No place for steroids or FFP.
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• A 33 yr old lady, a mother of a 5 month old baby, was admitted with a H/O fever for 5 days.
• On admission – pulse 100/min, BP 100/90, CRFT- 3 secs, R/pleural effusion +
05.09.11
07.09.11
Platelets 181,000 52,000
HCT 33.8 40.6
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53105 51104 140 49
103 47102 120 45
101 43100 100 41
99 3998 80 37
35
60
1 2 3 4 5 6 7
1 23
M + 5%24-36 hrs
10 ml/kg
7-5 ml/kg
5-3 ml/kg
3-1 ml/kg
KVO
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0100200300400500600
2pm
3pm
4ppm 5p
m pm 7pm
8pm
9pm
10pm
11pm
12m
n1a
m2a
m3a
m4a
m5a
m6a
m7a
m8a
m9a
m10
am11
am 12n
Time
Series 1
38
36
35
35
35
38
34
35
35
Total volume given for first 24 hrs – 3600 ml
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• IV calcium gluconate given 6 hrly.• Amount of fluid reduced to 75ml/hr and then
50ml/hr and then stopped. • PCV remained stable• Blood pressure, pulse, CRFT and UOP
maintained.• No further interventions were necessary.
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Treat both impending shock (prolonged CRFT, narrow
pulse pressure, severe postural drop of BP, hypotension)
Full blown shock (BP un-recordable) AGRESSIVELY and PPOMPTLY. With crystalloid bolus and gradual reduction of
fluid.If PCV is low, give blood. May need dextran later.
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• A 30 yr old male with DHF was referred (at a private hospital) on 14th Sep.
• Admitted on 12th at 5 pm & transferred to ICU on 13th at 6 pm.
11.09.11 12.09.11 13.09.11
HCT 40.8 41.2 48.0
PLATELET 112,000 58,000 12,000
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• Fluid given for 24 hrs = 4150 ml. • Now the patient has got B/L pleural effusions and
ascites.
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• PCV increased to 52• Pulse pressure narrowed to 20 with a postural drop
of 30 in SBP. • Dextran 500 ml given over one hour with 10 mg
of frusemide • Pulse pressure improved.• Good UOP.• Patient recovered without any further intervention
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• Fluid overload can occur un-intentionally.• Patients should be told how much and what to
drink• Dextran is useful in fluid overloaded patients• Frusemide in small doses is very effective
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• Preferred colloid in DHF• Mechanism of Action - Produces plasma volume
expansion by virtue of its highly colloidal starch structure, similar to albumin
• Given as a bolus in DHF– 250 ml over 30 mins or 500 ml over 1 hr. Not as a slow infusion.
• Recommended maximum – 1500 ml for 24 hrs.• Should not be used in a dehydrated patients who
present with shock and high HCT until the hydration is corrected with crystalloids.
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Mrs. R 53 year old female Diabetic and hypertensive Admitted on 08/06/2011 11.05 pm D3 of fever On admission Pulse 88/min, BP 120/80,(110/80) CRFT < 2 sec, Liver 2 cm, tender. WBC – 1600 N – 43%
Hb – 13.7 PCV – 42 platelet – 40,000
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SHO seen 09/06/2011 at 4 am.• Patient C/O dizziness• No bleeding manifestations• CVS - PR – 104
BP – 130/90 supine 100/80 sitting
• CRFT - < 2sec• Tender hepatomegaly• R/S pleural effusion• PCV - 46
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• Critical period 4.00am 09/06/2011 to 4.00 am 11/09/2011
• From 4.00 am to 9.00 am 100ml/hr• Bolus of N. saline 500ml at9.00am• After that 150ml/hr x 3hrs
100ml/hr x 39 hrs
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PCV 46 49.7 48 46 46 47 32? 40 40 39
Pul p 40 20 30 30 30 30 30 30 30 25 30 40
CRFT <2 <2 <2 <2 <2 <2 <2 >2
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• Critical period over at 4 am on 11.06.11.• By end of critical period 5350ml fluid given
• Blood ordered at 6.30 am• Admitted to ICU 9.25 am• On admission to ICU
PR- 120/min BP 110/90 mmhg Pt dyspnoec, with oxygen SPO2- 96% RR - 38• Blood 2 pints received at 10.40am!! After 4 hrs
10 pm 10.06.11
4 am 11.06.11
5 am11.06.11
PCV 39 33 32
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1st 24 hours after critical period
PCV 33 32 28 26 39 39 38 35 31 39 42 45 46
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• Patient developed shock on 11/06/2011 evening with impalpable peripheral pulses and cold extremities
• Femoral CVP catheter inserted.• Patient developed respiratory distress and was
intubated on 12/06/2011 at 6.30am
WBC PLATELET
11.06.11 9000 32,000
12.06.11 7200 40,000
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2nd 24 hours after critical period 12/06/11
PCV 41 35 32 35 41 31 33 37 37 37 36 35 37 37 37 37
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• Inspite of blood and fluid boluses, patient was going into shock repeatedly.
• Decided to aspirate the R pleural effusion• Activated factor VII two vials given• Pleural effusion aspirated.
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PCV 37 37 37 37 38 40 39 38 40 39 39 38 38 39 34 35 37 40 43 41 41 40 40 39
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• R/S pleural aspiration repeated 14/06/20111300ml blood aspirated
• Patient extubated on 16/06/2011
• R/S Intercostal tube inserted due to persistant haemothorax on 17/06/2011 1070ml drained.
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• Throughout clotting profile – normal• Slight elevation of liver enzymes• Renal functions – low K+• Low Serum calcium – i.v calcium gluconate
given• Good glycaemic control on insulin• CRP – 67- 225 – 162 -16• Patient respiratory secretions culture - MRSA• Pleural fluid culture and blood cultures – sterile• Treated with antibiotics + chest physiotherapy
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A 10 year old boy presented at E/S C/O•Fever ---05 days high grade, continuous with body aches• Melina ---01 day two episodes and one episode of hematochezia• Altered conscious level --1 hour
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• Unwell looking GCS 12/15 A febrile • Pulse Feeble BP un recordable • Cold clammy skin • CRT>2sec • Abdomen tender, Liver 3cm blcm and tender
TT + ve• USG abdomen pericholic fluid • Pelvic ascites
O/E
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Management
Fluid resuscitation with crystalloid Push with N/saline 20ml /kg Repeat with 10 ml/kg Dextran 40 10ml/kg over 1 hour Pulses palpable but tachycardia Crystalloids continued
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Day 5 Day 5
TLC 8,000 7,600
Platelets 10,000 9,000Hct 28 35
• Crystalloids• 18 hours later developed tachycardia • Narrowed pulse pressure• Amount of fluids increased
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Day 6 Day 7TLCPlt 8,000 7,000 7,000 7,500 8,000Hct 38 39 30 36 35
Packed Cells Transfusion Crystalloids gradually tapered
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• A six year old girl presented in emergency withC/O:• Fever ---04 days high grade continuous with body aches• Epistaxis ---01 day 3 episodes• Vomiting --- 01 day 2-3 episodes• Fit-----half hour 1 episode, Generalized tonic / colonic
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ON EXAMIANTION
Lethargic , but arouse able child SOMI -Ve PR- 80/min, BP- 100/80mmHg, Temp- 100F, Abdomen mildly tender Liver palpable 2 cm below costal margin TT +VE No clinical and radiological evidence of pleural
effusion Ultrasound abdomen showed no free fluid TLC 3,500 Plts 80,000 Hct 36% BSR
20mg/dl
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INITIAL MANAGEMENT
• BSR corrected
• Maintenance fluid (Oral + I/V)
• Vitals’ Monitoring 4 Hourly
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ON DAY 5
•Pulse rate 95/min•Blood pressure 100/75•Liver palpable 3 cm BCM and tender•Ultrasound abdomen showed gall bladder wall edema and mild pelvis ascites
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Day 5TLC 2,000 2,500 3,000
Platelets 20,000 15,000 14,000
Hct 35 40 38
Crystalloids continued
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• Pulse rate 120/min• Blood pressure 100/85
Day 6TLC 3500 3,500 4,000
Platelets 14,000 12,000 10,000
Hct 36 38 48
Crystalloid bolus with 10 ml / kg Tapered gradually