Dengue hemorrhagic fever and Dengue shock syndrome- Severe Dengue Fever

Outlines

Clinical presentationsLaboratory examinationsDiagnosisManagement

Clinical Presentations

Before admissionFever Vomiting, watery diarrhea with blood in stool Periumbillical abdominal pain for 1 dayAfter admissionCold peripheral perfusion, mottled skin, shortness of breathFresh blood from NG tube, mouth, endotracheal tube, anal tube Diffuse petechiae over trunk

Laboratory Examinations (1)

WBC (/uL)5800 D127700 D25band (%)15 D1Platelet (/uL)14000 D1CRP (mg/ml) 88.8 D1 146.9 D8PCT (ng/ml)2.73 D1 23.15 D12Dengue NS1 Ag rapid test (+) D1

Laboratory Examinations (2)

Hb (g/dL)18.9 D1 7.9 D4Hct (%)51.6 D127.9 D5PT/APTT (Sec)14.4 /48.0 D115.1 /59.6 D3D-Dimer (ng/ml)7463.4 D1FDP (ug/ml)27.6 D1Fibrinogen (mg/dL)231 D1

Laboratory Examinations (3)

Lactate (mmol/L)4.1 /7.9 D1/D3PO2/FiO2 (mmHg)76.6 /66.3 D2/D4(Day 4) CPPV mode, Vt: 360 ml, PEEP: 18 cmH2O, FiO2: 100%, PIP: 42 cmH2O, Pplateau: 40 cmH2O, Fetanyl + Ativan + NimbexGOT/GPT (U/L)4319 /1366 D17718 /1257 D2Bil-T/D (mg/dL)4.45 /3.17 D118.54 /13.78 D19Ammonia (umol/L)135 D2

Laboratory Examinations (4)

BUN/Cr. (mg/dL)50 /4.14 D1194 /12.46 D21Amylase (IU/L)225 D2931 D7Lipase (IU/L)594 D21359 D7Abdominal CT: diffuse mild swelling of pancreas D11Albumin (g/dL)3.7 D11.8 D3

Diagnosis

Severe Dengue fever (Dengue hemorrhagic fever and Dengue shock syndrome) withacute hepatitis, acute kidney injury, disseminated intravascular coagulation, gastrointestinal bleeding, acute pancreatitis,probable coexisting bacterial infection and severe sepsisacute respiratory failure s/p mechanical ventilation

Management

Treat underlying diseasesDengue & coexisting bacterial infection: inflammation, bleedingHospital acquired infection: VAP, catheter related sepsisHemodynamic support and Fluid status managementPerfusion pressure, perfusion, O2 delivery, intravascular volumeInternal and external fluid statusMechanical ventilationLung protective ventilatory strategy

Underlying diseases (1)

BleedingDiffuse bleedingPlatelet PT/APTT Hb Hb (g/dL) D1:18.9 - D4:10.5Plt: (/uL) D1:14K - D4:55KPT (Sec) D1:14.4 - D4:12APTT (Sec) D1: 48 - D4:46.7PRBC:10U FFP:38UPlt:7U Cryo.:20UCNSPain, agitation, deliriumSedation withdrawalFetanyl + Ativan + Nimbex

PIP < 35 cmH2O, FiO250%,PPEP 10cmH2O, GI work

Tramadol, Zyprexa zydis, Haldol,Ativan, Etumine, Mesyrel, Inderal

Underlying diseases (2)

CirculationCold peripheral perfusionElevated lactate levelD2:cold D4: warmLac.(mmol/L) D3: 7.9 D5: 2.0D1-3: + 22600 mlD2:GEDI/CI (626/4.27)D3:GEDI/CI (787/5.64)D4:GEDI/CI (766/3.89)LungAcute pulmonary edema, mixed typePO2/FiO2D2:76.6D3:119D4:66.3

Underlying diseases (3)

GIUGI bleedingIleusGastroparesisPPIProkinetics: promeran, moprideNJ tubeLiverAcute hepatitisJaundiceHyperammonemiaNutrition support (parenteral and enteral)Urso

Underlying diseases (4)

KidneyAcute oliguric renal failureFluid (Crystalloid firstly, colloid)DiureticsCVVHH/DRecirculation problemPancreasAcute pancreatitisSupportive carePain control + Nutrition support

Underlying diseases (5)

InfectionCommunity acquiredHospital acquiredAntibiotics ???Fever (adrenal insufficiency?)WBC/band%PltCRP/PCTEndocrineType 2 DMRelative adrenal insuffiiciencyInsulinSteroid

Hemodynamic support

&

Fluid status management

Everyday in ICU

Hemodynamic StatusFluid Status Evaluationhydrostatic pressure/permeability/oncotic pressurePerfusion pressure

Perfusion (Flow, Cardiac output)

Oxygen delivery (C.O, Hb, SaO2) Int. human bodyExt. human bodyPulmonary edemaPul. congestionPleural effusionAscitesBowel edemaScleraScalpTrunkLimbsInner side of thighGenital area

Fluid choice: Crystalloid or Colloid?

Hydrated status

Dehydrated

Normal hydrated

EdematousAlbumin level

Chemosis

Peripheral edema

PermeabilityNa+

K+

Cl-Crystalloid

0.9% N/S

Lactated Ringers

Colloid

Hemodynamic Status on Day 4

Adequate perfusion pressureBP: 113/75 mmHgMAP: 89 mmHg Adequate perfusion (cardiac output)Cold to Warm PerfusionSVI: 23 to 41 ml/m2CI: 2.72 to 3.81 L/min/m2Adequate O2 delivery (Q, Hb, SaO2)Lactate: 7.9 to 2.4 mmol/L(Lactate: 2.0 mmol/L D5)Adequate Intravascular VolumeGEDI: 569 to 766 ml/m2

Fluid Status Management (1)

Fluid Status Management (2)

Day 4

Day 15