pakistan dengue management 14.9.11
TRANSCRIPT
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Overview & Management of Dengue
Kolitha SellahewaMBBS.MD.FCCP.FRACP(Hon.)
Consultant Physician
Epidemiology Unit
SRI LANKA
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Dengue Viral Infection
Asymptomatic - 75% Symptomatic – 25% Dengue fever – 99% DHF – 1% (10,000 infected only 25
DHF) Dengue with severe & often life
threatening complications Shock Bleeding - DIC
Dr. Kolitha Sellahewa
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Clinical CourseDHF
Febrile phase 2 – 7 days
Critical phase 3-7 days Lasts only for 24 – 48 hours
Convalescent phase Begins after the critical phase & lasts for
5 - 7 days
Dr. Kolitha Sellahewa
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Febrile Phase
High continued fever Skin erythema Myalgia Arthralgia Headache Leucopenia < 5000 cells/c.mm Thrombocytopenia Tender hepatomegaly – DHF > DF
Dr. Kolitha Sellahewa
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Febrile Phase DF? Or DHF? DF
Skin rash Arthralgia Bone pain
DHF Tender hepatomegaly
Common Leucopaenia < 5000 Thrombocytopaenia Bleeding manifestations
Dr. Kolitha Sellahewa
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Critical PhasePlasma Leakage 24-48Hrs
Tachycardia Narrowing of pulse pressure < 20
mm CRFT > 2 secs HCT 20% increase from base line Pleural effusions Ascitis Ser albumin < 3.5 g/dl Non fasting ser cholesterol < 100
mg/dlDr. Kolitha Sellahewa
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Dynamics of Plasma Leakage
Dr. Kolitha Sellahewa
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R0 Hr
24 Hr
48 Hr
F C6 Hr
36 Hr
Rapid SlowModerate
Dr. Kolitha Sellahewa
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0 Hr
24 Hr
48 Hr
Time of Presentation and Management
F C RDr. Kolitha Sellahewa
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Early Recognition of Entry into Critical Phase WBC 5000 or less + TT +ve & PLT
< 100,000 entering CP next 24 Haemoconcentration
HCT progressive rise HCT 20% rise from baseline
Radiology CXR – right lateral decubitus US scan
Oedematous gall bladder wall Ascitis Pleural effusions Dr. Kolitha Sellahewa
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Confirm Entry into the Critical Phase Evidence of plasma leakage
Pleural and/or peritoneal cavities
Radiology CXR – right lateral decubitus US scan
Oedematous gall bladder wall Ascitis Pleural effusions
Biochemistry Ser albumin < 3.5 g/dl Non fasting ser cholesterol < 100 mg/dl
Dr. Kolitha Sellahewa
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How to time the onset of critical phase and predict end ....
Have serial FBCs done during the illness , ideally from the same reliable lab
Beyond Day 3...when WBC is dropping below(or close to) 5000 and platelets are <150,000 and dropping do more than once/day
DO FBC – Not PCV & Platelets!!!Dr. Kolitha Sellahewa
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How to time the onset of critical phase?
17th 8 am
D3
18th
8 am
D4
18th 8 pm
D4
19th
8 am
D5
19th
8 pm
D5
20th 8 am
D6
20th 8Pm
D6
21st
8 am
D7
21st
8 pm
D7
WBC 3200 2800 1900 2900 3700 4500 6000 7000 7300
N % 53 41 31 26 25 31 33 43 58
L % 44 56 68 71 73 67 66 55 41
PCV %
39 36 39 42 43 39 44 43 38
Plt 252000
121000
110000
61000
22000
18000
12000
8000 19000Onset End
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How to time the onset of critical phase?
17th 8 am
18th
8 am18th 8 pm
D4
19th
8 am19th
8 pm20th 8 am
20th 8 pm
21st
8 am21st
8 pm
WBC
3200 2800 1900 2900 3700 4500 6000 7000 7300
N %
53 41 31 26 25 31 33 43 58
L % 44 56 68 71 73 67 66 55 41
PCV %
39 36 39 42 43 39 44 43 38
Plt 121000 96000 94000
41000
22000
18000
12000 8000 19000
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Timing the onset of critical period
17th 8 am
18th
8 am18th 8 pm
19th
8 am19th
8 pm20th 8 am
20th 8 pm
21st
8 am21st
8 pm
7500
7000
6500
6000
5500
5000
4500
4000
3500
3000
2500
2000
1500
260,000
240,000
220,000
200,000
180,000
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
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Timing the onset of critical period
17th 8 am
18th
8 am18th 8 pm
19th
8 am19th
8 pm20th 8 am
20th 8 pm
21st
8 am21st
8 pm
7500
7000
6500
6000
5500
5000
4500
4000
3500
3000
2500
2000
1500
260,000
240,000
220,000
200,000
180,000
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
platelets
WBC
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Convalescent Phase
Good appetite Convalescent rash Pruritus
Palms & soles Heamodynamic stability Bradycardia Diuresis Stabilization of HCT Rise in WBC rise in platelet count
Dr. Kolitha Sellahewa
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Convalescent Rash
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ManagementOut Patient
Restricted Physical Activity Diet & fluid Antipyretics
Paracetamol Do NOT give NSAIDs NOT even
suppositories Advice on review & admission
Dr. Kolitha Sellahewa
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Criteria for AdmissionEssential
Warning signs Abdominal pain or tenderness Persistent vomiting Lethargy & restlessness Hepatomegaly Mucosal bleeding Evidence of plasma leakage
Platelet count < 100,000 cells/c.mm
Dr. Kolitha Sellahewa
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Criteria for AdmissionEssential
Pregnancy Elderly patients & infants Obese Co morbidity
Diabetes IHD Chronic renal failure
Dr. Kolitha Sellahewa
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Criteria for Admission
Looks ill Social reasons
Poor home support Poor access to hospital facility Living alone
Individual discretion
Dr. Kolitha Sellahewa
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ManagementInward
Diagnosis – Dengue infection Recognize the clinical type – DF or
DHF? DHF – phase of the illness ? Fluid therapy Monitoring & documentation Adjuvant therapy
Dr. Kolitha Sellahewa
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Diagnosis
Hyper-endemic setting Think of dengue – all with fever with in 8 days
Clinical Laboratory data – not essential Features of a viral infection
Acute onset of fever Myalgia Arthralgia Retro-orbital pain Usually corhyza is abscent Rash - Diffuse blanching erythema
WBC < 5000 cells / c. mm Positive tourniquet test (PPV >85%)Dr. Kolitha Sellahewa
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Differential Diagnosis Leptospirosis
Occupational history Muscle tenderness - calves Icterus Conjunctival injection Polymorphonuclear leucocytosis Thrombocytopenia
Other viral fevers Leucopaenia Normal platelet count
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Diffuse blanching erythema
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Rash in Dengue
Diffuse erythematous macules Maculo-papular Petechial Diffuse blanching erythema Blanching papular erythema
Dr. Kolitha Sellahewa
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Dengue fever
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Identify the Clinical Type
DF No plasma leakage
DHF Plasma leakage Platelet count < 100,000
With or without shock With or without bleeding
Patient with unusual or uncommon complications – Exceedingly rare
Dr. Kolitha Sellahewa
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Risk Stratification
Patient - stable but has predictors of developing severe disease
Abdominal pain Persistent vomiting Mucosal bleeding Lethargy & restlessness Tender hepatomegaly Ascitis, pleural effusions Increase HCT with rapid decrease in platelet
count WBC,5000 with relative lymphocytosis & an
increase in atypical lymphocytes Elderly, Pregnancy & co-morbid states
Dr. Kolitha Sellahewa
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Recognize the Stage of the Disease
Febrile phase Critical phase Convalescent phase
Day of the illness ? Evidence of plasma leakage ?
Convalescent rash ?
HOW
Dr. Kolitha Sellahewa
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Fluid Therapy“No Fixed Regime”
Cornerstone of management Dynamic approach Be fully aware of the dynamics of
the disease Mode of intervention depends on:
Phase Clinical type
Type of fluid Oral fluids Crystalloid Colloid Dr. Kolitha Sellahewa
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Fluid Shifts
N.Saline – 1 hour Colloids – 4 to 6 hours
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Febrile Phase
Oral fluids only Electrolyte solutions
IV fluids are not mandatory Undue vomiting or diarrhea Oral fluids not tolerated
Quantity: 1500ml – 2500ml/24Hrs Both oral & IV
Type: N.Saline
Dr. Kolitha Sellahewa
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Critical Phase of DHF Without Shock
Objective: Prevent progression to shock Avoid fluid overloading
Judicious fluid therapy- Fluid restriction Quantity – calculated
M+5% = 4600 ml / 48 hrs (50Kg) Full quota for entire critical phase 48 hrs Approximately 90 ml/hr Adjust infusion rate to match the dynamics of
plasma leakage Type:
N.Saline
MonitorHRPP > 20 mm HgCRFT < 2 secsU.O.P. 0.5-1ml/kg/hrHCTRR <20/mt
Dr. Kolitha Sellahewa
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Dr. Kolitha Sellahewa
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Calculation of Total Fluid Quota for the Critical Period
M = 5 % = M + 5% =
Dr. Kolitha Sellahewa
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Guide to rate of fluid intake in Critical Phase
PulseBPPulse PressureCRFTWarmth / ColdnessUOP – ml/kg/hrEvidence of Bleeding
Dr. Kolitha Sellahewa
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DHF with ShockAggressive Fluid Therapy
Objective Resuscitate Prevent further shock Anticipate & prevent complications of shock
GIT bleeding & DIC Intervention depends on: Compensated shock
Systolic pressure maintained but signs of reduced perfusion
Narrow Pulse Pressure Cold extremities Low volume pulse
Hypotensive shock Unrecordable BP & Pulse Dr. Kolitha Sellahewa
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Compensated Shock
N.Saline 10ml/kg (approx 500 ml) IV – 1Hr No improvement
Collect blood venous BGA Calcium HCT before & after fluid
bolus Sugar Sodium Grouping & DT
Colloid bolus 10ml/kg IV over 1 hr Colloid boluses
Haemodynamically unstable HCT drops
Blood transfusion
Dr. Kolitha Sellahewa
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Hypotensive Shock HCT before & after fluid bolus
N.Saline 10ml/kg IV bolus over 15 mts
2nd bolus 10 ml/kg over 60 mts Collect blood
Blood gas analysis Calcium Electrolytes Sugar Grouping & cross matching
Colloid 10 ml/kg IV bolus over 1 hr
Dr. Kolitha Sellahewa
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Choice of ColloidBoluses NOT infusions
Dextran 40 3 boluses over 24 hours 6 boluses over 48 hours
6% starch-Heta starch(Voluven) 5 boluses over 24 hours 10 boluses over 48 hours
Fresh Frozen Plasma 1 bolus 3 units approximately 450 – 600 ml
Dr. Kolitha Sellahewa
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Monitoring & Documentation Early detection of shock
Pulse pressure < 20 mm Hg CRFT > 2 secs HCT increase of 20% or more from baseline
Judge the efficacy of IV fluid therapy PP , CRFT, No postural hypotension Hourly UOP 0.5 – 1.0 ml/kg/hr
Early detection of complications of fluid therapy
Respiratory rate > 20/mt Lung bases SaO2 < 92% CXR
Dr. Kolitha Sellahewa
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0 Hr
24 Hr
48 Hr
Time of Presentation and Management
F C R
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DHF
Date/TimeFebrile
Date/TimeCritical
Date/TimeConvalesce
nt
Dr. Kolitha Sellahewa
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Basic MonitoringAll Patients
Pulse rate Pulse pressure CRFT Respiratory rate FBC - HCT Intensity of monitoring depends on
Phase of the illness Severity Aggressiveness of fluid therapy
Accurate fluid balance chartsDr. Kolitha Sellahewa
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Monitoring Platelet Count Drops Below 100,000
FBC- twice daily Vital parameters- four hourly
Pulse rate Blood pressure (both systolic and diastolic), Respiratory rate, Capillary refill time
Detailed fluid balance chart- Type and route of fluid hourly, Urine output four hourly
Dr. Kolitha Sellahewa
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MonitoringEvidence of Plasma Leakage
Escalate Vital signs - hourly HCT - 8 hourly Fluid intake & the balance left from
the calculated quota Temporal relationship Critical phase In hours
Detailed fluid balance chart
Dr. Kolitha Sellahewa
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MonitoringIV Fluid Therapy
Phase of the illness – be fully aware Adequacy of fluid therapy
Pulse Pressure >20 mmHg CRFT <2 sec Pulse Rate <80/mt UOP > 0.5 ml/Kg/hr HCT
Early detection of fluid overloadingRespiratory rate > 20/mt
Lung bases SaO2 < 92% CXR
Shift toICU
Dr. Kolitha Sellahewa
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Monitoring Chart I - for Management of Dengue Patients – Febrile Phase
Vital Signs
Purposes:
•Differentiate DF from DHF
•To detect entry in to Critical
Phase
Purposes:
•Differentiate DF from DHF
•To detect entry in to Critical
Phase
Dr. Kolitha Sellahewa
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Monitoring Chart I - for Management of Dengue Patients – Febrile Phase
Dengue
FeverDengue
Fever D4 without Fever
D3 with FeverWBC<5000/mm3
N-40% L-58%TT + ve
Dr. Kolitha Sellahewa
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Monitoring Chart I - for Management of Dengue Patients – Febrile Phase
D4 with FeverTT + ve, WBC<5000/mm3
N-40% L-58%Tender Liver
Dr. Kolitha Sellahewa
Entry in to Critical
PhaseEntry in to Critical
Phase
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Monitoring Chart II for Management of DHF Patients during Critical Phase Patient to be monitored hourly
Name of the patient ………………………………………………………BHT……………………………….Date and time of admission ………………………………ward -…………………
Critical Phase Commencing date and time -…………………………………………………….. End date and time …………………………………
10 9 8 7 6 5 4 3 2
1.5 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
PCV
Fluids
HR
BP
Pulse Pressure
RR
CRFT extremities
UOP UOP
ml/Kg/hr Platelet count
Weight - …………………………………
Height - ……………………………
Ideal body weight - …………… M- ………………………………… M+ 5% = …………………………ml
Annexure II
Used
Remaining
Monitoring Chart II for Management of DHF Patients during Critical Phase
Purposes:
•Early detection of Shock
•Accurate Fluid
management
Purposes:
•Early detection of Shock
•Accurate Fluid
management
Dr. Kolitha Sellahewa
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0 Hr
24 Hr
48 Hr
Date/Time Scale 2 Hrs
Date/Time Scale 20 HrsDate/Time Scale 36 Hrs
Dr. Kolitha Sellahewa
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Monitoring Chart II for Management of DHF Patients during Critical Phase
Dr. Kolitha Sellahewa
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Monitoring Chart II for Management of DHF Patients during Critical Phase
Dr. Kolitha Sellahewa
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Monitoring Chart II for Management of DHF Patients during Critical Phase
Dr. Kolitha Sellahewa
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Monitoring Chart III to be used during the Peak of leakage and during the shock Patient to be monitored every 15 minis
ABW – 19 kg; IBW – 21 kg Maintenance – 1450 ml
(Maximum 3 per 24h / 6 per 48h) M + 5% = 2400 ml for 24 hours : (Maximum 5 per 24h / 10 per 48 h)
Other fluid : PRC/WB …………………………….
Fluid ml/Kg/ hr
20
10
9
8
7
6
5
4
3
2
1
time 12.30 p.m.
12.45 p.m.
1.30 p.m
1.45 p.m.
2.45 p.m.
4.15 p.m.
6.00 p.m.
7.00 p.m.
8.00 p.m.
10.00 p.m.
PCV – 49% 56% 51% 41% 46% 51%
Fluids
HR NR Stable Weak Good
BP NR 75/65 92/56 Stable Good
Pulse Pressure
CRFT UOP
ml/Kg/hr No No No
Platelet count - 92000 29000 General
Condition well Stable
90 min.
1h 45min
3 hours
Used
Remaining
1002.25 ml 1195.25 ml 1477.25 ml
922.75 ml 1207.75 ml 1397.75 ml
902.5 ml
1497.5 ml
760 ml
1640 ml
570 ml
1830 ml
Dr. Kolitha Sellahewa
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Full Blood Count
DENGUE INVESTIGATION SUMMARY
Name: -------------------------- Age: -------------------------- Hospital: ----------------------- Ward: ---------------
BHT: ------------------------------------
Hb
PCV
Platelet
WBC
N
L
Se.Creatinine
Blood Urea
Se. Na+
Se. K+
Se.Ca2+(Ionized)
SGPT
SGOT
PT / INR
Se. Albumin
Se. Cholesterol
Urine Output-Total
UOP-ml/hour
Pulse
Blood Pressure
Pulse Pressure
CXR –R. Decubitus
US Scan
Fluid Rate (ml/kg/Hour)
Type of Fluid
Other Ix
Remarks
Date
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Summary – Febrile Patient
Dengue or not? Clinical FBC
Leucopaenia + thrombocytopaenia
DF or DHF ? Plasma leakage + or –
If DHF – what is the phase ?
Dr. Kolitha Sellahewa
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Summary In Critical phase
Time of entry Predicted time of end
Aggressive monitoring Calculate the fluid quota Dynamic approach to fluid therapy Final diagnosis – precise (DF or
DHF & grade)Dr. Kolitha Sellahewa
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COMPLICATIONS – Non?
Vigilance – detect Alert – plasma leakageActive – IV fluidAggressive - manipulate
Dr. Kolitha Sellahewa
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THANK YOU
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Complications and Adjuvant TherapyComplications and Adjuvant Therapy
Dr. Jayantha WeeramanConsultant Paediatrician
Dr. Jayantha Weeraman
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Pts with complications ....
Usually due to
• PROLONG SHOCK• FLUID OVERLOAD
Dr. Jayantha Weeraman
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Bleeding in Dengue Hemorrhagic Fever
Phase Early Pre-Shock Shock Prolong-sh Death
Severity of Mildof Bleeding Moderate
SEVERE
Mechanism Drug Vascular injury Platelet Dysfunction
Thrombocytopenia Coagulopathy-DIC
Fibrinolysis
Dr. Kolitha Sellahewa
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Fluid overload– Too much fluids in febrile phase– Calculation of fluids in obese pt-ABW vs
IBW– Use of hypotonic saline– Given excess fluids– Given more than time of leakage– Not using colloidal solution when indicates– Not giving blood when there is concealed
bleeding– Inappropriate IV Fluids for “severe
bleeding”Eg: FFP, platelets & cryo
Dr. Jayantha Weeraman
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Dr. Jayantha Weeraman
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Management of fluid overload
Frusemide 1 mg/kg
Critical Phase
Dr. Jayantha Weeraman
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Indications for IV Frusemide
Midway in the infusion of colloids when colloids are given to patients who are already fluid overloaded or who are likely to be overloaded depending on the fluids already given.
Midway between blood transfusions. In patients passing less than 0.5ml/kg/hr of urine
despite receiving adequate fluids and having stable BP, pulse, Hct to improve the UOP.
During recovery phase when there is suggestion of pulmonary oedema or fluid overload.
Dr. Jayantha Weeraman
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Prolonged shock
– Delayed diagnosis/ delayed resuscitation
– Late presentation– Fluid restriction without
monitoring
Dr. Jayantha Weeraman
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Dr. Jayantha Weeraman
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Prolonged shock in dengue – a challenge to clinicians?
> 4 hours untreated Liver failure- prognosis 50% Liver + Renal failure - prognosis10% 3 organs failure (+respiratory failure) –
Prognosis is a miracle!!!
> 10 hours untreated - Death!!!
Dr. Jayantha Weeraman
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Complicated DHF When a pt is deteriorating with no response to fluid therapy….
A: AcidosisB: BleedingC: CalciumS: Sugar
A: AcidosisB: BleedingC: CalciumS: Sugar
Dr. Jayantha Weeraman
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A : Acidosis
Acidosis is common in profound shock Prolonged acidosis makes patients
more prone to DIC Correct acidosis if pH is <7.35
together with HCO3- level <15 mmol/l One may use empirical NaHCO3
1ml/kgs slow bolus (max 10ml) diluted in equal volume
Dr. Jayantha Weeraman
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B : Bleeding
Significant overt bleeding - >6-8ml/kg BW
Concealed bleeding
Dr. Jayantha Weeraman
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When to suspect bleeding ?
• When PCV drop without clinical improvementEven with bleeding the PCV drop may take time(4-5hrs). When the pt does not show improvement important to do repeat PCVs frequently!
• Haematocrit not as high as expected for the degree of shock to be explained by plasma leakage alone. (Hypotensive shock with low or normal HCT)
• Severe metabolic acidosis and end-organ dysfunction despite adequate fluid replacement
Dr. Jayantha Weeraman
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Massive bleeding
Not given blood transfusion
Delayed blood transfusion
Remember!!!In DHF Bleeding could be concealed
Dr. Jayantha Weeraman
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How to manage bleeding Use PRC or WB If there is fluid overload(most frequently)
use PRC as 5ml/kg at once and repeat only if needed depending on the response
If there is no fluid overload use 10ml/kg of WB
Even if bleeding is likely and if PCV is >45% do not give blood without bringing down the PCV first by giving a colloid.
Dr. Jayantha Weeraman
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..how to manage bleeding
• 5ml/kg of PRC or 10ml/kg of WB will increase PCV by 5%
– Eg.10 year old girl with PCV of 26% in shock..
– Base line PCV in a 10 yr old 36% but if in shock it will be up by 20% 43%. There is 17% deficit which need 3 PRC transfusuions
Dr. Jayantha Weeraman
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C : Hypocalcaemia
Every patient with complicated DHF has hypocalcaemia.
Dengue patients who develop convulsions are likely to have hypocalcaemia.(may give them empirical calcium)
Detection of hypocalcaemia: Measure serum Ca2+ level Corrected QT interval in ECG
Dr. Jayantha Weeraman
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When to give calcium?
If the patient is complicated , and deteriorating or not showing expected improvement to fluid Rx think of hypocalcaemia.
Give empirical calcium to such pts Dose 1ml/kg of 10% Ca Gluconate slow
bolus diluted in N saline over 10-15 min(look
for bradycaria while pushing slowly) Max: 10ml. Can even give every 6Hrs if pt is not improving
Dr. Jayantha Weeraman
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Treat if blood sugar below 4 mmol/lt
Give 10% dextose 3-5ml/kg bolus followed by an infusion
S : Hypoglycaemia
Dr. Jayantha Weeraman
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Platelet transfusion- when platelets are low may need but
only in very exceptional circumstances (Thailand only in <0.4% of pts with DHF) Each platelet pack is 50-150ml
contribute to fluid overload No prophylaxis platelet transfusion
Dr. Jayantha Weeraman
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Why do you do platelet counts?
To recognize the beginning of critical stage- YES
To decide on platelet transfusion- NO As a prognostic indicator- YES
Dr. Jayantha Weeraman
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Recombinant factor VII
1 dose = 1,500 USD in a 10-kgs patient
No use in cases with prolonged shock and multiple organs failure
Consider in cases with bleeding where the cause is not prolonged shock BUT other reason: peptic ulcer, trauma etc
Dr. Jayantha Weeraman
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Place of dopamine and dobutamine...
Very limited in DHF May do harm than good by giving
a false impression about BP When using1st make sure that
there is enough intravascular volume shown by increased CVP
Dr. Jayantha Weeraman
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NO PLACE FOR STEROIDS AND IV IMMUNOGLOBULINS IN DENGUE
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Crystalloid100%
Colloid20-25%Blood
10-15%
Blood & blood component used in DHF/DSS patients
Platelet 0.4%
Dr. Jayantha Weeraman
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Myocardial involvement in Dengue
Global dysfunction of myocardial contractility seen in prolonged shock
Due to, metabolic acidosis, Hypocalcaemia
Unlikely to cause death If myocarditis is suspected fluid
should be given very carefully Rx- Symptomatic
Dr. Jayantha Weeraman
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Causes of death in DHF patients
• Prolonged shock– Delayed diagnosis/ delayed resuscitation – 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 co-morbidity– Dual infection Dr. Jayantha Weeraman
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Dr. Jayantha Weeraman
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THANK YOU