qr management of dengue infection in adults (revised 2nd edition)

8/6/2019 QR Management of Dengue Infection in Adults (Revised 2nd Edition)

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MANAGEMENT OF DENGUE INFECTION IN ADULTS (Revised 2nd Edition) QUICK REFERENCE FOR HEALTHCARE PROVIDERS


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DISEASE NOTIFICATION

SuSpECT A CASE OF DENguE

KEY MESSAgES

Dengueisadnamicdiseaseandpresentedinthreephases-febrilephase,criticalphaseandrecoverphase.

Clinicaldeteriorationoftenoccursinthecriticalphaseandismarkedbplasmaleakageandrisinghaemotocrit(HCT).

Lookoutforwarningsignswhichmaindicateseveredengueorhighpossibilitofrapidprogressionorshock.

Recognitionofshockinits earlstageand promptuidresuscitationwithclosemonitoringofuidadjustmentwillgiveagoodclinicaloutcome.

Thereisnoevidencetosupportprophlacticuseofplatelettransfusion.

Apatienthasanacutefebrileillnesswithtwo or more features:RashMalgiaHeadacheArthralagia

OR Dengueendemic/hotspot/outbreakarea

LeucopeniaRetro-orbitalpainHaemorrhagicmanifestations

SuSpECT A CASE OF DENguE

DISEASE NOTIFICATIONAllsuspecteddenguecases*mustbenotiedbtelephonetothenearesthealthofcewithin24hoursofdiagnosis,followedbwrittennoticationwithinoneweekusingthestandardnoticationform.

LABORATORY INTERpRETATION In theabsenceof baselineHCT,aHCTvalueof>40% in adult femaleand

>46%inadultmaleshouldraisethesuspicionofplasmaleakage.

DENguE SEROLOgY TESTS IfthedengueIgMisnegativebeforeda7,arepeatsamplemustbetakeninthe

recoverphase.

Denguenon-structuralprotein-1(NS1Antigen)canbehelpfulinearlphase(


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WARN IN g S Ig NS

Abdominal ain or tenderness

Persistent vomiting Clinical uid accumulation (pleural effusion/ascites)

Mucosal bleed

Restlessness or lethargy

Liver enlargement >2 cm Laboratory : Increase in HCT concurrent with

rapid decrease in platelet

Step 2 : Diagnosis, disease staging and severity assessmentBasedontheabove,theclinicianshouldbeabletodetermine:

1.Denguediagnosis(provisional)2.Phaseofdengueillnessifdengueissuspected(febrile/critical/recover)

3.Hdrationandhaemodnamicstatusofpatient(inshockornot)4.Whetherthepatientrequiresadmission

Step 3 : Plan of management1.Noticationisrequired2.Ifadmissionisindicated,refertoprerequisitesfortransfer3.Ifadmissionisnotindicated:

Dailormorefrequentfollowupisnecessarespeciallfromda3onwardsuntilthepatientbecomesafebrileforatleast24-48hourswithoutantipretics

SerialFBC/HCTmustbemonitoredasdiseaseprogresses(Table3)

Table1:

STEPWISE APPROACH IN OUT PATIENT MANAGEMENT

WARN IN g S Ig NS Abdominal ain or tenderness Persistent vomiting

Clinical fluid accumulation (pleural effusion/ascites) Mucosal bleed Restlessness or lethargy Tender enlarged liver Laboratory : Increase in HCT concurrent with rapid decrease in platelet

Step 1: Overall assessment

1. HistoryDateofonsetoffever/illnessOralintakeAssessforwarningsignsDiarrhoea

BleedingChangeinmentalstate/seizure/dizzinessUrineoutput(frequenc,volumeandtimeoflastvoiding)Pregnancorotherco-morbidities

2. Physical examinationRefertoclinicalparametersfordiseasemonitoring(Table3)

3. Investigations

i.FBCanddengueserologshouldbetaken(assoonaspossible)ii.IfnofacilitforHCT,referpatienttothenearesthospital


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Table2:

WHEN TO REFER FORADMISSION

1. Symptoms: Warningsigns Bleedingmanifestations Inabilittotolerateoraluids Reducedurineoutput Seizure

2. Signs: Dehdration Shock Bleeding

Anorganfailure

3. Special Situations: Patientswithco-morbidite.g.diabetes,hpertension,ischaemic

heartdisease,morbidobesit,renalfailure,chronicliverdisease Elderl(>65earsold)

Pregnanc

Socialfactorsthatlimitfollow-upe.g.livingfarfromhealthfacilit,patientlivingalone

4. Laboratory Criteria:

RisingHCTaccompaniedbreducingplateletcount

Prerequisites for transfer to hospital1. Alleffortsmustbetakentooptimisethepatientsconditionbeforeandduring

transfer.2. TheEmergenc& Trauma Departmentand/or Medical Departmentof the

receivinghospitalmust be informed prior to transfer.3. Adequateandessentialinformationmustbesenttogetherwiththepatientandthis

includestheuidchart,monitoringchartandinvestigationresults.

Itisrecommendedtotriageallsuspectedcasesofdengueinordertoavoidcriticallillpatientsbeingmisseduponarrival.Triage Checklist:1.Historoffever2.AbdominalPain3.Vomiting

4.Dizziness/fainting5.Bleeding

Vital parameters to be taken:Mentalstate,bloodpressure,pulse,temperature,coldorwarmperipheries

PATIENT TRIAGING AT EMERGENCY AND TRAUMA /OuTpATIENT DEpARTMENT


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Table3:DISEASE MONITORING FOR DIFFERENT PHASESOF DENguE ILLNESS

ParametersformonitoringFrequencofmonitoring

Febrilephase Criticalphase

Recoverphase

CLINICALPARAMETERS

GeneralwellbeingAppetite/oralintakeWarningsigns

SmptomsofbleedingNeurological/mentalstate

Dailormorefrequentltowardslatefebrilephase

Atleasttwiceadaandmorefrequentl

asindicated

Dailormorefrequentlasindicated

Haemodnamicstatus Pink/canosis Extremities(cold/warm) Capillarrelltime Pulsevolume Pulserate Bloodpressure Pulsepressure

RespiratorstatusRespiratorrateSpO

2

4-6hourldepending

onclinicalstatus

2-4hourldependingonclinicalstatus

In shock-Ever15-30minutestillstablethen1-2hourl

4-6hourl

Signsofbleeding,abdominaltenderness,ascitesandpleuraleffusion

Dailormorefrequentl

towardslatefebrilephase

Atleasttwiceadaandmorefrequentlasindicated

Dailormore

frequentlasindicated

Urineoutput 4hourl2-4hourlIn shock-Hourl

4-6hourl

LABORATORyPARAMETERS

FBCDailormorefrequentlifindicated

4-12hourl

dependingonclinicalstatusIn shock-Repeatbeforeandaftereachattemptofuidresuscitationandasindicated

Dail

BUSE/CreatinineLiverfunctiontestRandombloodsugarCoagulationproleHCO

3/TCO

2/Lactate

Asindicated

Atleastdailormore

frequentlasindicatedIn shock-Crucialtomonitoracid-basebalance/ABGclosel

Asindicated


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ObtainabaselineHCTbeforeuidtherap

Givecrstalloidssolution(suchas0.9%saline) Startwith5-7ml/kg/hourfor1-2hours,thenreduceto3-5ml/kg/hrfor2-4hours,and

thenreduceto2-3ml/kg/hrorlessaccordingtotheclinicalresponse

IftheclinicalparametersareworseningandHCTisrising,increasetherateofinfusion

Reassesstheclinicalstatus,repeattheHCTandreviewuidinfusionratesaccordingl

FLuID MANAgEMENTDengue with warning signsAll patients with warning signs should be considered for monitoring in hospitals:

Non-shock patient Encourageadequateoralintake Intravenous f luids are indicated in patients who are vomiting, unable to

tolerate oral f luids or an increasing HCT despite increasing oral intake. Crstalloidisthefluidofchoice.

Estimated ideal body weight or IBW (kg) Normal maintenance uid (ml/hour)based on Holiday Segar formula5 1010 2015 3020 6025 6530 7035 7540 8050 9060 10070 11080 120

Notes:ForadultswithIBW>50kg,1.5-2ml/kgcanbeusedforquickcalculationofhourlmaintenanceuidregime.ForadultswithIBW


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HCT = haematocrit

1GXM: require first stage cross match or emergency O

2fresh blood: less than 5 days

IV crystalloid 5 - 7ml/kg/hr for

1 - 2 hours, then:

oreduce to 3 - 5 ml/kg/hr for

2 - 4 hours;

o reduce to 2 - 3 ml/kg/hr for

2 - 4 hours

If patient continues to improve,

fluid can be further reduced

Monitor HCT 4 - 6 hourly

If the patient is not stable,

act according to HCT levels:

o if HCT increases, consider

bolus fluid administration or

increase fluid administration

o if HCT decreases, consider

transfusion with fresh whole

blood

Consider to stop IV fluid at48 hours of plasma leakage / defervescence

COMPENSATED SHOCK(systolic pressure maintained but has signs of reduced perfusion)

Fluid resuscitation with isotonic crystalloid 5 - 10 ml/kg/hr over 1 hour FBC, HCT, before and after fluid resuscitation, BUSEC, LFT, RBS, PT/APTT, Lactate/HCO

3, GXM1

Check HCT

Administer 2nd bolus

of fluid

10-20 ml/kg/hr for 1 hr

Consider significant

occult/overt bleed

Initiate transfusion with

fresh blood2(whole blood/packed cell)

If patient improves,

reduce to 7-10 ml/kg/hrfor 1 - 2 hours

Then reduce further

IMPROVEMENT

IMPROVEMENT

YES

YES NO

NO

or high

ALGORITHM A - FLUID MANAGEMENT IN COMPENSATED SHOCK


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HCT = haematocrit GXM: require first stage cross match or emergency O fresh blood: less than 5 days

ALGORITHM B - FLUID MANAGEMENT IN DECOMPENSATED SHOCK

Consider to stop IV fluid at

48 hours of plasma leakage

/ defervescence

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qr management of dengue infection in adults (revised 2nd edition)

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