2. Fluid Management in 2. Fluid Management in Dengue Hemorrhagic FeverDengue Hemorrhagic Fever

Dengue Expert Advisory Dengue Expert Advisory GroupGroup

Dengue Virus InfectionDengue Virus Infection

• AsymptomaticAsymptomatic

• Symptomatic Symptomatic – Undifferentiated Febrile Illness – Undifferentiated Febrile Illness – Dengue – Dengue Fever Fever – Dengue Hemorrhagic Fever – Dengue Hemorrhagic Fever Non Shock Non Shock Shock Shock

Dengue Hemorrhagic FeverDengue Hemorrhagic Fever

• Febrile PhaseFebrile Phase

• Critical phase characterized by plasma Critical phase characterized by plasma leakleak

• Convalescent PhaseConvalescent Phase

Dengue “Leak” FeverDengue “Leak” Fever

• Plasma leak during critical phase is the Plasma leak during critical phase is the hall markhall mark

• Leading to 3Leading to 3rdrd space losses space losses – peritoneal cavity – peritoneal cavity – pleural cavity – pleural cavity

• Variable in magnitude and exact timingVariable in magnitude and exact timing

Pathogenesis of leakPathogenesis of leak

• Infection with a virulent dengue virus Infection with a virulent dengue virus

• Presence of antibodies that enhance Presence of antibodies that enhance dengue virus infection (ADE)dengue virus infection (ADE)

• Intense immune activationIntense immune activation

PathogenesisPathogenesis

• Rapidly elevated cytokines (TNF-a, IL-2, Rapidly elevated cytokines (TNF-a, IL-2, IL-6, IL-8, IL-10, IL-12, and IFN-g)IL-6, IL-8, IL-10, IL-12, and IFN-g)

• Malfunction of vascular endothelial cellsMalfunction of vascular endothelial cells

• Plasma leakage from intra to extravascular Plasma leakage from intra to extravascular spacespace

PathogenesisPathogenesis

• In severe DHF the loss of plasma is criticalIn severe DHF the loss of plasma is critical

• Patient becomes hypovolaemicPatient becomes hypovolaemic

• Signs of circulatory compromiseSigns of circulatory compromise

• Progress to shock, organ failure, deathProgress to shock, organ failure, death

PathogenesisPathogenesis

• Cytokine StormCytokine Storm

• Self limitedSelf limited

• Ends after 48 hoursEnds after 48 hours

Clinical ImplicationsClinical Implications

• Extravascular fluid loss at variable rate Extravascular fluid loss at variable rate that has to be matched ml for mlthat has to be matched ml for ml

• Lasting 48 hoursLasting 48 hours

• Resorption of fluid during convalescent Resorption of fluid during convalescent phasephase

Key PointsKey Points

• Manage critical phase with appropriate Manage critical phase with appropriate volume volume – Don’t under transfuse – Don’t under transfuse – Don’t over transfuse – Don’t over transfuse

• Meticulous monitoring during critical phase Meticulous monitoring during critical phase to match rate of fluid infusion with rate of to match rate of fluid infusion with rate of leak leak

Monitoring ParametersMonitoring Parameters

• Clinical Clinical – Pulse Rate – Pulse Rate – Blood and Pulse – Blood and Pulse Pressure – Pressure – Capillary Refill Time Capillary Refill Time – Urinary Output – Urinary Output

• Lab Lab – Hematocrit – Hematocrit

Fluid Management Fluid Management Critical Phase Critical Phase

Amount of Fluid?Amount of Fluid?

• Based on weight Based on weight

• Adults Adults – If less than 50kg use actual weight – If less than 50kg use actual weight – If more take weight as – If more take weight as 50 kg50 kg

• Paediatrics Paediatrics – Current OR Ideal body weight – Current OR Ideal body weight whichever is lowerwhichever is lower

Ideal Body WeightIdeal Body Weight

• Weight for height using a growth chartWeight for height using a growth chart

• Weight for ageWeight for age

• Formulae in emergencyFormulae in emergency

Growth ChartsGrowth Charts

FormulaeFormulae

• <1 year : Age (in Months)+ 9/2

• 1-7 years : (Age x 2)+ 8

• >7 years : Age x 3

• APLS : (Age in years + 4) x 2

Fluid Quota Fluid Quota

• M + 5% = Maintenance + 5% of body weight

• Over 48 hours if patient presents in the Over 48 hours if patient presents in the beginning of critical phase (without shock)beginning of critical phase (without shock)

• Over 24 hours for patients coming in Over 24 hours for patients coming in shockshock

M + 5% - AdultsM + 5% - Adults

• Maintenance Maintenance – 1 – 1stst 10 kg – 1000 mls 10 kg – 1000 mls – 2 – 2ndnd 10 kg – 10 kg – 500 mls – 500 mls – Remaining 30kgs – 600 mls Remaining 30kgs – 600 mls – Sum = 2100 mls – Sum = 2100 mls

• 5% deficit – 50 x 50 = 2500 mls5% deficit – 50 x 50 = 2500 mls

• Total = 4600 mlsTotal = 4600 mls

Child 22 kgChild 22 kg

• Maintenance Maintenance – 1000 + 500 + 40 = 1540 mls – 1000 + 500 + 40 = 1540 mls

• 5% Deficit – 50 x 22 = 1100 mls5% Deficit – 50 x 22 = 1100 mls

• Total 2640 mlsTotal 2640 mls

Types of FluidTypes of Fluid

• Crystalloids Crystalloids – 0.9% Saline – 0.9% Saline – 5%Dextrose 0.9% – 5%Dextrose 0.9% Saline Saline – 5% Dextrose ½ saline– 5% Dextrose ½ saline

Monitoring – Critical Phase Monitoring – Critical Phase

• Vital parameters - hourlyVital parameters - hourly

• Fluid balance chart - assess three hourlyFluid balance chart - assess three hourly

• HCT - six hourlyHCT - six hourly

Fluid Management in Fluid Management in Dengue Shock Dengue Shock

SyndromeSyndrome

CompensatedCompensated

• Body compensates for fluid lossBody compensates for fluid loss

• TachycardiaTachycardia

• Pulse Pressure narrowsPulse Pressure narrows

• Prolonged CRTProlonged CRT

• Fall in urine output to 0.5 mls/kg/hr Fall in urine output to 0.5 mls/kg/hr

DecompensatedDecompensated

• Pulse pressure narrows further leading to Pulse pressure narrows further leading to unrecordable pulse and BPunrecordable pulse and BP

• Urine output falls less than 0.5 mls/kg/hourUrine output falls less than 0.5 mls/kg/hour

Fluid ResuscitationFluid Resuscitation

• Crystalloids – N SalineCrystalloids – N Saline

• Colloids Colloids – Dextran 40 in N. Saline – Dextran 40 in N. Saline – 6% – 6% StarchStarch

• All boluses part of fluid quotaAll boluses part of fluid quota

Indications for Colloid Indications for Colloid

• Failure of crystalloid boluses to normalize Failure of crystalloid boluses to normalize pulse /BP pulse /BP

• Development of shock Development of shock – with fluid overload – with fluid overload – amount of fluid – amount of fluid exceeding M + 5% deficitexceeding M + 5% deficit

10 ml/kg over 1 hour10 ml/kg over 1 hour

ColloidsColloids

• Dextran may sometimes interfere with Dextran may sometimes interfere with grouping and cross matchinggrouping and cross matching

• 3 doses of Dextran 40 during a 24 hour 3 doses of Dextran 40 during a 24 hour

• 5 doses of 6% Starch during 24 hour5 doses of 6% Starch during 24 hour

• Remain in circulation for much longerRemain in circulation for much longer

Refractory Shock - ABCSRefractory Shock - ABCS

• Blood Blood – packed cells – packed cells – whole blood – whole blood

• BicarbonateBicarbonate

• GlucoseGlucose

• CalciumCalcium

Monitoring During ShockMonitoring During Shock

• 15 minute monitoring of vital signs 15 minute monitoring of vital signs

• HCT immediately before and after each HCT immediately before and after each fluid bolus and then at least two to four fluid bolus and then at least two to four hourlyhourly

Key Points – Managing DHFKey Points – Managing DHF

• Recognizing the start of critical phase of DHFRecognizing the start of critical phase of DHF

• Predicting the rate of leak which may vary from Predicting the rate of leak which may vary from patient to patient and within the same patientpatient to patient and within the same patient

• Matching the rate of infusion to rate of leakMatching the rate of infusion to rate of leak

• Being cognizant of the end of critical Being cognizant of the end of critical phasephase

Key Points – Managing DSSKey Points – Managing DSS

• Meticulous monitoringMeticulous monitoring

• Switching appropriately from crystalloids to Switching appropriately from crystalloids to colloidscolloids

• Recognizing need for blood transfusionRecognizing need for blood transfusion