Case Management in Dengue What is New Slma

8/3/2019 Case Management in Dengue What is New Slma

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Dr A. LakKumar FernandoMBBS, DCH, MD(Paed), MRCP(UK), MRCPCH(UK), FRCP(Lond)

10/2/2011 LAKKUMAR FERNANO 1


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Kalana

Age: 10y

Developed fever on 03rd Oct, 2009 (D1-SATURDAY)

FBC on 04th October, 2009 (D2-SUNDAY)

WBC 5.4 X 103

N 71%

Hb 10.8

Plt. 237x 103

PCV 36%


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Admitted to hospital on 6th Oct 2009 (D4- Tuesday)

Examination findings: Weight 19 kg

Ill looking, febrile

B/P - 60/50

Lungs B/L lungs clear air entry good, no added sounds

FBC on day of admission

WBC 2900

Hb 12.5

PCV 43%

Plt 57,000


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Total Fluids in 1st 24h(D4-TUESDAY)(06.10.09 10.30 am to 07.10.09 10.30 am)

N/2 Saline = 2050ml

(9h as maintenance + 15h of M + 5% )

N/ Saline bolus = 190ml x 2 = 380 ml

Hetastarch bolus = 190 ml

Oral fluids = 960 ml

1st 24 hr Fluids total = 3580 ml


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Total Fluids in 2nd 24h(D5-WEDNESDAY)(07.10.09 10.30 am to 08.10.09 10.30 am)

N/2 Saline = 2590ml

(10h of M+5%, 12 h of M + 7%, 2 h of M + 5%)

N/ Saline bolus = 190ml x 2 = 380 ml

Hetastarch bolus = 190 ml


2nd 24 hr Fluids total = 3560 ml


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Came in early shock

Received a Total of7,140 ml of fluids

(IV+Oral) over first 48 hrs


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Transferred to ICU on THURSDAY NIGHT (D6) for ventilation


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FRIDAY (D7)


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SATURDAY D8afternoon


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Dengue Viral Infection

(10,000 patients)

Asymptomatic

(9,000)

Symptomatic

(1,000)

Viral Syndrome

(500)

Dengue Fever

(400)

DHF

(100)

Plasma leakage

DHF

(98-99)

DSS

(1-2)

Unusual DHF

Liver failure

Encephalopathy

Renal failure

Co-infection

Co-morbidities10LAKKUMAR FERNANO10/2/2011


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DF or DHF?

DF vs DHF

Important to differentiate

Two different clinical conditions from thebeginning of the illness; Though they look very

similar on the first 2 days

However badly managed DF will neverbecome DHF (DF does not progress to DHF)

11LAKKUMAR FERNANO10/2/2011


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Difference between DF & DHF

Dengue Fever(DF)

No plasma leakage

Plt may be decreased to


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Hemorrhagic Manifestations of DF

Skin hemorrhages:

petechiae, purpura, ecchymoses

Gingival bleeding

Nasal bleeding

Gastrointestinal bleeding:

hematemesis, melena, hematochezia

Hematuria

Haemorrhagic Manifestations not enough to

call it DHF 13LAKKUMAR FERNANO10/2/2011


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Dengue Haemorrhagic Fever

Key feature is PLASMA LEAK

Clinical

Initially like DF

Haemorrhagic manifestations (hepatomegaly)

(Shock)

Lab

Plt < 100,000 in all DHF (when platelets drop 20%, pleural effusion,ascitis, albumin


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Albumin and cholesterol level

Both albumin and cholesterol (non fasting) are usefulto detect plasma leak

Non fasting cholesterol level is 140-150 mg/dl

Both albumin and cholesterol levels drop when plasma

leakage starts. Eg: If albumin was 4g/l and it comes down to 3.5 g/dl it

means there is plasma leakage

During the plasma leakage phase

Albumin: 3.5 g/dl

Cholesterol: 100 mg/dl



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Natural Course of DHF

Febrile phase: High fever for 2 7 days

Critical phase:

Plasma leakage

Lasts 24- 48 h

Usually on D5/ D6, but earliest on D3

Convalescent phase:

2-5 days

Longer in adults 16LAKKUMAR FERNANO10/2/2011


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Natural Course of DF

Febrile phase: High fever for 2 7 days

Convalescent phase:

2-5 days

Longer in adults 17LAKKUMAR FERNANO10/2/2011

No critical phase in DF!!!


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Detection of critical phase

Defervescence

Drowsy

Rapid pulse

Narrow pulse pressure (20 mmHg)

Hypotension

Rising Haematocrit

Low Albumin level

Low Cholesterol level



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Haematocrit

Rise of Hct by 20% over the baseline indicates

leakage

Eg: if baseline PCV 35%42% = 20% rise



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Patient is in critical phase and

confirmed to be DHF if

D 3 or beyond

Platelet < 100,000 (WBC < 5,000)

Evidence of plasma leak Effusions : pleura/ peritoneum (CXR/ USS)

Hct rise of 20% from baseline

Low albumin/ low cholesterol



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Causes of death in DHF patients

Prolonged shock Delayed diagnosis/ delayed resus..

Late presentation

Fluid overload Use of hypotonic saline Giving excess fluids

Massive bleeding Not giving or delaying blood transfusions

Unusual manifestations Encephalopathy

Underlying co-morbidity

Dual infection



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the new guidelines for the 1st time

stressed the importance of MEASURING

FLUIDS THAT WE GIVE

GIVE ONLY A CALCULATED AMOUNT OF FLUID

BOTH IV AND ORAL!


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HealthMl/kg/hrDengue

Ml/kg/hrDengue

Ml/kg/hrDengue

Ml/kg/hr

Total intake 3 3

UOP 2 1

Insensible

loss

1 1

Leaking(+ ve balance)

0 1

Fluid balance in health and dengue

10/2/2011 23LAKKUMAR FERNANO


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Ml/kg/hrDengue

Ml/kg/hrDengue

Ml/kg/hr

Total intake 3 3 5

UOP 2 1 2

Insensible

loss

1 1 1


0 1 2




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Ml/kg/hrDengue

Ml/kg/hrDengue

Ml/kg/hr

Total intake 3 3 5 2

UOP 2 1 2 0.5

Insensible

loss

1 1 1 1


0 1 2 0.5




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Fluid Management in Dengue

Has major differences according the phase of

the illness.

Even oral fluid can cause fluid overload

The critical phase is only 48 hrs (24- 50+)

Some fluid restriction is essential during the

critical phase(24-48hrs)

The final outcome/morbidity/mortality will

largely depend on the fluid management of

the critical phaseLAKKUMAR FERNANO 2610/2/2011


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Fluid Management in Dengue..

Initially (During the 1st 2 days)

dengue shock is extremely rare within 1st2 days

There is NO LEAKAGE Can give fluids freely



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After 3rd Day

May start leaking any time

DONT ASK TO DRINK PLENTY OF FLUIDS

SOME FLUID RESTRICTION IS USEFUL

LOOK FOR SIGNS OF LEAKING & platelets

dropping


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Once patient is in the critical phase (24-48hrs)

TOTAL FLUIDS=

MAINTENANCE+5% DEFICIT



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Fluid quota for critical phase...

Calculation M+5%

Maintenance

1st 10 kg 100ml/kg

2nd 10 kg 50ml/kg

Balance wt 20ml/kg

5% body wt = 50ml/kg



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Calculation M+5%

Maintenance

1st 10 kg 100ml/kg

2nd 10 kg 50ml/kg

Balance wt 20ml/kg


Eg: 22kg



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Calculation M+5%

Maintenance

1st 10 kg 100ml/kg

2nd 10 kg 50ml/kg

Balance wt 20ml/kg


Eg: 22kg (100x10 + 50x10+ 20x2) + 50x 22

1540 + 1100 = 2640ml



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Fluid Management during the critical

phase (DONT OVER LOAD LEAKING VESSELES)

Total amount of fluids = Maintainance + 5%

deficit

This includes both IV and oral fluids

This amount of fluids is given over 24-48 hours

Ideal body weight or actual body weight is

used for calculation (whichever is smaller)

BUT Maximum body weight for which fluid is

calculated is only 50kg in ALLchildren,

adults, pregnancy..LAKKUMAR FERNANO 3310/2/2011

C l l i f id l b d i h


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Calculation of ideal body weight

BESTWeight for Height from a chartother methods ..

< 1 year: Age in months + 9

2

< 7 year: [Age (y) x 2] + 8

> 7 year: Age x 3

APLS : (Age + 4) x 2



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TOTAL FLUID VOLUME IN CRITICAL

PHASE(usually 48HRS) Fluid volume equivalent to (FLUID QUOTA)

Maintenance(only one days calculated volume) + 5% of

body weight(i.e 50ml/kg) calculated for ideal body

weight (or actual body weight if it is lower than IBW;

maximum BW only 50kg) is the total fluid volume thatshould be given during the entire critical phase(leaking

phase) irrespective of its length! This is usually 24-48 hrs

and most patients it is 48 hours. Occasionally it 50 hrs or

little more. Still one should try not to exceed this volume.(*note that it is almost one days fluids that is given over 2

days and maximum weight for which fluid is calculated is

50kg even if the actual weight is well above 50kg)



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Critical Phase Fluids in DHF

The maximum recommended total criticalphase fluid volume for any given pt will not

exceed 4600ml

Maximum BWt 50 kg M+5% - (maintenance

100x10+ 50x10 + 20x 30 + (50x 50) When pt is in hospital or seen from the onset

When Mx begins with the onset of leaking total fluids

should be given over 48 hrs.

When Pt presents in SHOCK

The pt is already in the peak of leaking and has only 24

more hrs before the leaking stop. The total M+5% can here

be given over 24 hrs 36LAKKUMAR FERNANO10/2/2011


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WHAT Determine the rate of fluid?

PULSE RATE/VOLUME

BLOOD PRESSURE/PULSE PRESSURE

HCT

UOP (0.5-1.0ml/kg/hr)

If UOP is >1ml/kg/hr

too much fluidOr too fast rate of fluids



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LAKKUMAR FERNANO 3810/2/2011

40ml/hr

80-100ml/hr

100-120ml/hr

150ml/hr

Plt < 100,000 cells/cumm.

Hct increase


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LAKKUMAR FERNANO 3910/2/2011

300-500ml/hr

100-120ml/hr

40-80ml/hr

40ml/hr

DETECTION OF SHOCK


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Critical 48 hours Total Fluids 7,140 ml !

M +5% for 48 hours = 2400ml


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IV Fluids

Normal Saline/ Hartmann


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WHAT FLUIDS AND WHEN?

Initially when pt come in shock (with no fluid

overload) give N saline(crystalloids). If BP

pulse not recordable give as fast as possible

free flowor 20ml/kg but only till BP/pulsecan be felt

After this only 10ml/kg boluses

After 2 saline boluses consider colloids



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When to give colloids?

Crystalloids also leak through leaky capillaries

during leaking phase and will not hold on

volume and PCV for long(not more that 1-2

hrs)

Colloids will not leak easily and will hold on to

volume and maintain PCV for longer period (4-

5 hrs) What about FFP will also readily leak !


( )


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Plasma (FFP) transfusion

FFP almost have no place in the treatment of

DHF/DSS!

Too large amount (40-50 ml/kg) needed to correct

coagulopathy

It is not effective in holding the intravascular

volume because it iso-oncotic (the osmolarity is

about 280-300 milli-osmole readily leak!!!

**if FFP is given to provide clotting factors for pt with liver failure what is the point inallowing it to leak out of the vascular compartment by giving it during leaking phase?

If you are to keep FFP within the circulation better to give it AFTER the leaking stops!If you

give Vit K from the time you notice significant rise of LFTs even such need could be

avoided!10/2/2011 46LAKKUMAR FERNANO

Bl d & bl d t d i


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Crystalloid100%

Colloid20-25%Blood

10-15%

Blood & blood component used in

DHF/DSS patients

Platelet 0.4%

10/2/2011 47LAKKUMAR FERNANO _Prof SiripenThailand


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Use of colloids

One dose of dextran (10ml/kg/bolus) will

bring down the haematocrit by 10%

If Hct is 52% it should drop to 42%

Eg. If patients PCV is 52% and if it drops to

40% (instead of 42%)one has to think of

bleeding!

** Do not use dextran as the initial resuscitationfluid in dehydrated patients



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How much colloids to give?

Needed only during critical phase Both Dextran and hetastarch should ONLY be

given as BOLUSES (NEVER as a continuous

drip).

10ml/kg iv Dextran 40maximum 3 doses(total

30ml/kg/day) per 24 hr period (i.e 6 doses

over 48hrs) Before Dextran take blood for cross matching

Hetastarchmaximum 5 doses over 24 hrs(10

boluses over 48 hrs)49LAKKUMAR FERNANO10/2/2011


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During critical 48 hrs...

While giving fluid to maintain pulse/BP/PCV

If enough fluid left from total quota (M+5%) give

crystalloids

If only little fluid is left from quota use morecolloids. (keeping in mind the maximum)

When IV fluids are given at a rate >5ml/kg/hr

cannot go on for > 4-6 hrs (may overload) If rate is 3ml/kg/hr can go on for even for10 hrs

Be guided by UOP keep >0.5ml/kg/hr



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Furosemide..

Colloids when there is fluid overload..

When there is evidence of fluid overload use

Furosemide with starch or dextran. (0.5-

1mg/kg halfway during the bolus)

But when furosemide is given be prepared to

wait with the pt for at least 60minutes after

the injection (effects like BP drop will occur within60min)



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Platelet transfusion-

when platelets are low may need but only invery exceptional circumstances

(Thailand only in .100,000 is due to BM suppression but

later when it drops


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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 only in cases with bleeding due to a

specific reason

eg: peptic ulcer, trauma etc



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Ashani

Age 10 y

Presented with fever for 5 days and blood

stained vomiting for 1 day duration

30/07/2010 12.50 pm

Gum bleeding +

Bleeding from puncture sites+

Pulse: Very low BP 80mmHg, Diastolic BP cannot

be recorded

Tender hepatomegaly+


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Day of admission(Friday 30th July- after initial resuscitation


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Bleeding from venepuncture sites and gumbleeding


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Investigations

FBC

WBC 5600

PCV 45.6%

Plt 11,000

S. Cholesterol 100

S. Albumin 3.63


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Management Summary

IV boluses

N/S bolus on admission = 250ml

Starch bolous at 36 h of critical phase= 250ml

IV fluids =1784 ml


Total = 2739 ml

(M+ 5% for 48 hours 2850ml)


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At 24 h after hospital admission


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At 48 h after hospital admission


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3 days after hospital admission


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FBC

Platelet 8,000

WBC 3.45

Hb 11.5 g/dl

PCV 35.3

On 02nd

AUGUST 2010


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FBC

Platelet 51,000WBC 5.3

Hb 11.8 g/dl

PCV 36.3%


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Management

12.45pm (at PCU): Started on N. Saline 20ml/kg (took 30 min)

1.25pm (in ward): *Dextran40, 10ml/kg (200ml) over 1 hour started

Still Pulse not palpable. BP not manually

recordable; from machine75/ 65 mmHg

Right Lateral Decubitus Xray on


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Right Lateral Decubitus Xray on

07/12/Morning

Effusion hasbecome bigger


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Managed in theWard and recoveredWithout anycomplications


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New fluid regimen...

A form of fluid restriction during leakage

phase

Help prevent FLUID OVERLOAD

Also prevent shock give what is needed tomaintain BP, Pulse and

produce enough UOP (0.5-1ml/kg/hr)

Prevention of shock avoid organ failure, avoidDIC, coagulopathy due to Liver failure



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LAKKUMAR FERNANO 71

Pts with complications ....

Usually due toPROLONG SHOCKFLUID OVERLOAD

10/2/2011


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Prolonged shock

10 hours untreated- Death!!! > 4 hours untreated

Liver failure-prognosis 50%

Liver+ Renal failure -prognosis10%3 organs failure (+respiratory failure)

Prognosis is a miracle!!!



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Complicated DHF

When a pt is deteriorating with no response tofluid therapy.

A: AcidosisB: Bleeding

C: Calcium

S: Sugar



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Acidosis

Acidosis is common in profound shock

Prolonged acidosis makes patients more prone

to DIC

Correct acidosis if pH is


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Hypocalcaemia

Every patient with complicated DHF has

hypocalcaemia.

Dengue patients who develop convulsions are

likely to have hypocalcaemia.(may give themempirical calcium)

Detection of hypocalcaemia:

Measure serum Ca2+ level

Corrected QT interval in ECG



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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 bradycariawhile pushing slowly) Max: 10ml. Can even give every

6Hrs if pt is not improving


Factors contribute to bleeding in


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Factors contribute to bleeding in

DHF/DSS patients

Capillary fragility - only minor bleeding e.g.

skin bleeding (petechiae)

Thrombocytopenia - only with trauma, no

spontaneous bleeding in DHF/ DSS

Coagulopathy- DIC prolonged PTT, TT

(massive bleeding after prolonged shock -

advanced DIC)

Liver failure - prolonged PT (results from

prolonged shock)



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Bleeding...

When to suspect...?(when overt bleeding

absent)

1. At presentation ...

After 20 ml fast NS bolus No pulse !! Get ready

with blood in case it is needed ask for uncross

matched O-ve blood and also sent for DT

Cant sustain BP even after colloid bolus andadequate fluid resus

PCV drop without pt improving

PCV drop > 10 points after 10ml/kg dextran x 1hr

Bleeding


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Bleeding...

When to suspect...?(when overt bleedingabsent)

2. While managing the patient in the ward..

Sudden big rise in WBC with neutrophilleukocytosis

eg. WBC 5500 13,500 with a day

If a sudden rise in LFT sp AST(SGOT)

eg. AST 310 IU 1600 IU within a day

If PCV drop with dextran(colloid) is more than

expected

l id bl d f i


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Also consider blood transfusion

If blood loss visible eg H,mesis etc is > 10% of

blood volume

Even with bleeding the PCV drop may take

time(4-5hrs).

When the pt does not show improvement

important to do repeat PCVs frequently

h bl d i


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How much blood to give...

During critical phase PCV is falsely high

Eg 5 yr old pt with PCV drop to 25..

Usual PCV for age 35%, but in critical phaseof dengue with 20% rise it will be at least 42%

If it is only 25 the deficit is 42-25 = 17

Each PRC 5ml/kg will increase PCV by 5, toincrease to expected value more than 3 PRCtransfusions needed

but give one at a time looking for response!10/2/2011 LAKKUMAR FERNANO 81

H bl di


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How to manage bleeding

Use PRC or WB

PRC as 5ml/kg at a time If there is fluid

overload(most frequently)

WB-as 10ml/kg (if no fluid overload)

Even if bleeding is likely and if PCV is >45% do

not give blood without bringing down the PCV

first by giving a colloid.

Most of the time with blood give 0.5-1mg kg

of frusemide at the middle82LAKKUMAR FERNANO10/2/2011

T h di


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Tachycardia...

When ht rate is high (more than the fever)

Things to consider....

Shock/impending shock

Bleeding

Impending respiratory failure

Hypocalcaemia

Myocarditis not usually needing intervention

Not uncommon to have Troponin I or T to be positive in

pts with normal echo and EF who showed no clinical

features of cardiac involvement.

M f h l h


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Management of encephalopathy

Most of the patients with encephalopathy aredue to hepatic encephalopathy. The principle

treatment of hepatic encephalopathy is to

prevent increase in intra cranial pressure.

Mannitol not generally recommended



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MYOCARDITIS?



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Of interest, although there are thousands of DHF in

Thailand, there are only 2 reports of dengue myocarditis in

the literature. This might represent the rarity of the cases or

it might be due to the underdiagnosis and neglecting to

report. To assess the magnitude of occult myocarditis in the

severe DHF cases, the author performed further analysis on

the reported Thai fatal DHF cases with official autopsy

findings. Concerning the autopsy reports on Thai DHFCases,..................


myocarditis is very rare


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y y

and might not be fatal ...............There were 4 reports covering 51 Thai fatal

DHF cases from total 6154 DHF cases. Of the fatal cases,

none had cardiac manifestation, giving null prevalence.

Here, it might imply that dengue myocarditis is very rare

and might not be fatal


Pl f d i d d b t i


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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


BP 90/40

Pulse -

/


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z

Dobutamine

Dopamine

No

Urine

122/min

CVP= 29

Nor-adrenaline


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4.15 at the ICU on 10th February 2011

24 year old young man well built

On the ventilator

CVP line; (CVP 29)

3 infusions dopamin ; dobutamine; nor-

adrenalin UOP


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What are you going to do?

On the ventilator

UOP nil for past 4 hours

No bleeding sites or malena

Lungs B/L crepts; Abd distension ++

Age 24 years.


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Date 05/02 06/02 07/02 08/02 09/02 10/02

Time 9.35am

2.45pm

10.15am

2.31pm

6.34pm

5.16am 9.10am

(For bld

Picture)

9.27am

WBC 12.2 9.4 6.0 4.3 5.4 6.6 7.6 13.2 11.5 15.5

N 88 % 94% 80% 84% 72.5% 77% 79% 81% 87.5% 82%

L 06% 05% 12% 14% 21.6% 20% 10% 15.3% 10.3% 14%

Hb 13.9 12.6 12.7 14.2 17.6 17.9 18.8 17.1 13.6 12.7

PCV 40 37 38.2 40.8 50.3 49.2 52.2 49.3 39 36.4

Plt 204,000 164,000 113,000 25,000 8,000 7,000 7,000 9,000 7,000

With Agg

10,000

FLUID INTAKE on 10th Feb 2011 24 yrs -


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received 4710 cc fluid within 12 hrs!

Time Fluid type

Volume

given Total Volume Urine Vol:

UOP

ml/Kg/hr

Total

UOP

7.00am NL Saline 200cc 200cc 20cc 0.4 20cc

9.00am Starch 500cc 700cc - 20cc

Dextran 500cc 1200cc 20cc 0.4 40cc

10.00am R. Lactate 500cc 1700cc 35cc 0.7 75cc

11.00am Ca. Gluconate 10cc 1710cc 12cc 0.24 87cc

12.00N Dextran 500c 2210c 50cc 1.0 137c

1.00pm Plt 4 Packs 500cc 2710cc 10cc 0.2 147cc

2.00pm

3.00pm Dextran 500cc 3210cc Nil

4.00pm Nil

5.00pm 500cc 3710cc Nil

6.00pm 500cc 4210cc Nil

Blood 500cc 4710cc Nil

Ix ordered at 4.30pm (10th Feb)


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p ( )

FBC

Se Electrolytes

Se Calcium

SGOT/SGPT Se Bilirubin

DENGUE Ab IgG AND IgM

SE ALBUMIN; SE CHOLESTEROL

Age 24years.

D t 05//02 06/02 07/02 08/02 10/02


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Date 05//02 06/02 07/02 08/02 10/02

Time 9.35

am

2.45

pm

10.15

am

2.31

am

6.34

pm

5.16am 9.10

am

9.2

7am

4.30PM

OUTSIDE

WBC 12.2 9.4 6.0 4.3 5.4 6.6 7.6 13.2 11.5 15.5 19.14

N 88 % 94% 80% 84% 72.5% 77% 79% 81% 87.5% 82% 88%

L 06% 05% 12% 14% 21.6% 20% 10% 15.3% 10.3% 14% 02%

Hb 13.9 12.6 12.7 14.2 17.6 17.9 18.8 17.1 13.6 12.7 8.7

PCV 40 37 38.2 40.

8

50.

3

49.2 52.2 49.3 39 36.4 21%MANU

AL

25.0

Plt 204,000 164,000 113,000 25,000 8,000 7,000 7,000 9,000 7,000With 10,000 32,000


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Manual PCV at 4.40pm 21%

Asked to bring Blood immediately for

transfusion

While awaiting for blood BP started dropping

again..

-Dobutamine increased but still BP dropping


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Patient arrested at 4.55pm!!!

CPR

Blood Transfusion started

CPR....cont

6pm CPR failed

Pt died!


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6pm CPR failed Pt died!

WHAT WENT WRONG???


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Investigations 4 30pm (10th Feb)


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Investigations . 4.30pm (10th Feb)

S.E. sodium 143.0 mEq/L 130 - 145

pottasium 5.7 mEq/L 3.5 - 5.0

chloride 104 mEq/L 95 108

Calcium 7.6 mg /dl 8.6 10.0

SGOT 9158.7 IU/L 13 - 31

SGPT 2608 IU/L 10 - 40

S. Cholesterol - 27 mg/dl

S. Albumin 1.2 g/dl 3.4 4.8

C.R.P. 16 mg/L

T. Bilirubin 2.4 mg/dl 0.3 1.2

How could you have avoided this


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death..?

Better understanding of Mx of dengue The BASICS

THE DIFFICULT DENGUE

ASK SOME ONE OR DISCUSS WITH SOME ONEWHO KNOWS DENGUE Mx


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Deeply unconsciousNo response to pain


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Investigations (10/10/2009) WBC 16,800(N70)

Hb 8.8

Plt 107,000

PCV 25.9%

Na 143 K 3.6

Ca 6.1

BU 79 SGOT 7320

SGPT 1820

Albumin 2.7


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On 03/10/2009.

WBC 5.4 X 103

Pl. 237x 103

PCV 36%

On 06/10/2009

WBC 2900

Hb 12.5

PCV 43%

Plt 57,000

Has had both prolonged shock and

fluid overload

Kalana


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Kalana...

Management of Complications Given 3x PRC transfusions

Correction of Hypocalcaemia

Correction of acidosis

Liver failure regimen VIT K/Lactulose/Neomycin

NOT NAC

Repeated doses of furosimide



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Dengue Antibody positive


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THANK YOU


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THANK YOU!

[email protected]

mailto:[email protected]:[email protected]


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Most of the patients with encephalopathy aredue to hepatic encephalopathy. The principle

treatment of hepatic encephalopathy is to

prevent increase in intra cranial pressure.

Mannitol not generally recommended




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Prolonged shock Delayed diagnosis/ delayed resus..

Late presentation

Fluid overload Use of hypotonic saline

Giving excess fluids

Massive bleeding Not giving or delaying blood transfusions

Unusual manifestations Encephalopathy

Underlying co-morbidity

Dual infection



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Thank you!


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THANK YOU!

QUESTIONS?

lakkumar@gmail com

Documents

Case Management in Dengue What is New Slma