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DENGUE EPIDEMIC:
WHAT WE KNOW SO FAR
TAN CHENG CHENG
INTENSIVIST
SULTANAH AMINAH JOHOR BAHRU
Dengue Virus Genome
−A single stranded RNA −Genome is about 11000 ribonucleotides, encoding 3 structural proteins
and 7 non-structural proteins
−Structural proteins: capsid protein (C), membrane protein (M) and envelope protein (E)
−The non structural proteins: NS1, NS2A, NS2B, NS3, NS4A, NS4B and NS5
−The proteins are involved in the various stages of the dengue viral replication
−The envelope protein (E) is involved in the initial attachment of the virus particles on host cells
2
Dengue Virus
−4 serotypes, namely DenV 1, DenV 2, DenV 3 and DenV 4
−Further Classification into genotypes is dependent on the geographically region where the virus was isolated
−The number of genotypes for each serotype are as follows: DenV 1 (5), DenV 2 (6), DenV 3 (5) and DenV 4 (3)
−Malaysia “hyperendemic” as all serotypes could be isolated at any point of time
3
4
0%
10%
20%
30%
40%
50%
60%
70%
DENV1 DENV2 DENV3 DENV4
DENGUE SEROTYPES
YEAR 2013, 2014 AND 2015
2013 2014 2015
1992-1995: DENV3
1998-2000: DENV2
2001-2002: DENV3
2004-2006: DENV1
2008-2009: DENV3
NO PREDICTABLE CYCLE FOR DEN V
INFECTION
5
• Four-year cycle outbreaks:
1974, 1978, 1982, 1986, 1990
• No predictable cycle from 1991
• Three-year cycle outbreak from 2008
• Yearly cycle outbreak from 2012
• Usually an outbreak whenever there was a
change in the dengue virus serotype as fewer
people would be immune to the serotype after
the change
• Each individual can have 4 times of Den V
infection in his/her lifetime
Serological Profile
6
ADE: ANTIBODY-DEPENDENT ENHANCEMENT OF DENV
INFECTION ADAPTED FROM TAKADA AND KAWAOKA, 2003
Virus bound to Ab, is able to enter macrophages via the Fc receptor
This makes the infection of macrophages more efficient and leads to the infection of a large number of macrophages, leading in turn to a more severe clinical presentation
According to this hypothesis, DHF/DSS should occur only when there is more than one serotype of DV circulating in a specific area
7
8 microbewiki.kenyon.edu
DENGUE INCIDENCE RATE & CASE FATALITY RATE
FOR YEAR 2000-2014, MALAYSIA
9
DENGUE CASES 1995 – 2015 (TILL 18 JULY), MALAYSIA
10
65
43
14
25
5
19
42
9
27
38
1
10
14
6
71
03
16
36
8 32
76
7
31
54
5
33
89
5
39
65
4
38
55
6
48
84
6
49
33
5
41
48
6
46
17
1
19
88
4
21
90
0
43
34
6
10
86
98
65
39
6
0
20000
40000
60000
80000
100000
1200001
99
5
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
(till
18 J
uly
)
Num
ber
of C
ases
Year
DENGUE DEATHS 1997 – 2015 (TILL 18 JULY) MALAYSIA
11
Jan-18 July 2015 – 65,396 cases with 174 deaths
(compared 48,845 cases with 91 deaths in 2014)
Increase of cases 34% and deaths 91%
CFR 0.26% (target < 0.2%)
DISTRIBUTION OF DENGUE CASES
BY URBAN AND RURAL AREA (1998 – 2014)
13
DENGUE MORTALITY ANALYSIS 2014
(N = 197 DEATHS)
Male
31% : ≥ 50 years old
50% : 25 to 49 years
19% : < 25 years old
DENGUE MORTALITY ANALYSIS 2014
(N = 197 DEATHS)
Patients did seek
early treatment:
62% within 48h
after onset
Duration between disease
onset and patients sought 1st
treatment
DENGUE MORTALITY ANALYSIS 2014
(N = 197 DEATHS)
Duration in days between
admission & onset of
disease
90% of patients
admitted early to
hospital within 5
days of onset
DENGUE MORTALITY ANALYSIS 2014
(N = 197 DEATHS)
Duration between admission and death
ORGAN INVOLVED IN
DENGUE DEATH
Organ involved %
2012
%
2013
%
2014
CNS: Impaired
consciousness 21 33 25
Renal failure 3 33 6
Hepatitis 71 58 59
Multi-organ failure 71 76 59
Heart 29 31 41
18
Dengue Infection
2010
n = 1643
Dengue Infection
2011
n = 798
Dengue Infection
2012
n = 906
Dengue Infection
2013
n=1550
Dengue Infection
2014
n=3261
Age, years
median (IQR) 28.8
(22.5 – 47.3)
29.5
(21.0 – 44.1)
32.8
(21.5-41.8)
31.3
(21.7-46.1)
34.6
(22.0-45.4)
Interval from hospital to
ICU admission, days
median (IQR)
Not available 0.5
(0.1 – 1.3)
0.5
(0.1-1.3)
0.5
(0.1-1.4)
0.4
(0.1-1.2)
Length of ICU stay, days
median (IQR) 1.9
(1.9 – 9.6)
2.0
(1.3 – 3.0)
1.9
(1.2-2.7)
1.9
(1.3-2.9)
2.8
(1.3-3.1)
Length of hospital stay,
days
median (IQR)
5.5
(3.4 – 17.5)
5.8
(4.1 – 8.3)
5.2
(3.9-7.2)
5.3
(3.9-7.2)
7.1
(3.8-7.2)
Length of mechanical
ventilation, days median
(IQR)
3.8
(1.4 – 7.2)
3.6
(1.6 - 7.9)
4.2
(1.0-5.0)
2.9
(1.2-6.2)
5.0
(1.5-6.5)
Total SAPS II score, mean
+/-SD
Median (IQR)
19.0 + 14.1 19.6 + 16.0 17.4 + 13.0 18.6 + 13.2 18.6 + 15.0
15.0 (10.0-23.0)
% Invasive mechanical
ventilation 18.6 13.8 9.5 11.2% 12.1
% Co-morbid diseases 18.1 22.3 18.3 25 22.9
Main organ failure %
Without organ failure 32.2 27.3 35.2 36.3 32.4
Respiratory failure 4.7 3.0 3.3 2.9 5.9
CVS failure 7.1 7.2 6.9 6.1 6.0
Neurological failure 0.6 0.4 0.1 0.7 0.4
Renal failure 0.9 0.7 0.8 1.1 1.2
Hepatic failure 0.4 0.1 0.1 0.3 0.4
Haematological
failure 54.0 40.9 53.4 52.5 53.6
SMR (95% CI) 0.75
(0.42-1.20)
0.50
(0.26- 0.86)
0.51
(0.26- 0.94)
0.50
(0.28-0.95)
0.57
(0.33-1.05)
Severe Dengue in Intensive Care:
Evaluation of Mortality Risk Factors Foong KW1, Teoh SC2, Woon YL3, Lee HS3, Abdul Rahim AH4, Ismail NI5, Kumarasamy S6, Mohd Noor
MR7, Wan Ismail WN8, Kamalul Bahrin LK9, Tong MG10, Vellayuthapillai S2, Supramaniam P3, Tan CC11
Objective: To determine the demography of severe dengue cases in Intensive
Care Unit (ICU) and identify the predictors of mortality
Methods:
• Retrospective study of all adult dengue patients admitted to the 49 MOH
ICUs in year 2013
• Patients were identified via MRIC
• Medical records were reviewed by two intensivists independently to
identify SD patients and determine its onset of critical phase
• Demographic, clinical and intervention data were extracted
• For patients with missing medical record, we assumed those who died
were SD, and relevant data were extracted for mortality patients who
appeared in both MRIC and National Dengue Mortality Enquiry
Report
1531 cases coded as dengue identified from Malaysian Registry of Intensive Care (MRIC)
1436 patients’ medical record traced and screened by 2 intensivists
independently
520 severe dengue
patients identified
95 patients’ medical record missing
916 excluded from analysis: -21 paediatric -188 not dengue -707 not severe dengue
84 patients survived and excluded from analysis
11 patients died (data from MRIC)
527 severe dengue cases analyzed
7 patients with partial data from MRIC and National Dengue Mortality Enquiry Report
4 patients not found in National Dengue
Mortality Enquiry Report and excluded
The flow of patient selection / recruitment
1531 cases coded as dengue identified from Malaysian Registry of Intensive Care (MRIC)
1436 patients’ medical record traced and screened by 2 intensivists
independently
520 severe dengue
patients identified
95 patients’ medical record missing
916 excluded from analysis: -21 paediatric -188 not dengue -707 not severe dengue
84 patients survived and excluded from analysis
11 patients died (data from MRIC)
527 severe dengue cases analyzed
7 patients with partial data from MRIC and National Dengue Mortality Enquiry Report
4 patients not found in National Dengue
Mortality Enquiry Report and excluded
The flow of patient selection / recruitment
34.4% of
all dengue
admitted to
ICU
1531 cases coded as dengue identified from Malaysian Registry of Intensive Care (MRIC)
1436 patients’ medical record traced and screened by 2 intensivists
independently
520 severe dengue
patients identified
95 patients’ medical record missing
916 excluded from analysis: -21 paediatric -188 not dengue -707 not severe dengue
84 patients survived and excluded from analysis
11 patients died (data from MRIC)
527 severe dengue cases analyzed
7 patients with partial data from MRIC and National Dengue Mortality Enquiry Report
4 patients not found in National Dengue
Mortality Enquiry Report and excluded
The flow of patient selection / recruitment
34.4% of
all dengue
admitted to
ICU
12.7% ie
67 deaths
Table 4: Laboratory results at onset of critical phase / organ dysfunction*
Variables* Estimate Adjusted OR 95% CI
SAPS 0.129 1.137 1.099 – 1.176
Tachycardia 1.111 3.038 1.202 – 7.680
Lethargy 0.988 2.687 1.008 – 7.165
Liver dysfunction 1.173 3.231 1.278 – 8.189
Plasma leakage 1.251 3.493 1.294 – 9.431
Table 5 : Independent risk factors for predicting mortality in severe dengue identified by multivariate logistic regression model
* The variables input in the models are diabetes mellitus, hypertension, breathlessness, dehydration, tachypnoe, oliguria, encephalitis, overbleeding, hematocrit on critical phase, platelet count on critical phase, SAPS II, tachycardia, lethargy, liver dysfunction and plasma leakage. The final model has a R-square of 0.658
Unusual Presentations
of Severe Dengue Fever
Encephalopathy
Hepatic damage
Cardiomyopathy
Severe gastrointestinal
hemorrhage
Unusual Presentations
of Severe Dengue Fever
Encephalopathy
Hepatic damage
Cardiomyopathy
Severe gastrointestinal
hemorrhage
Unusual Presentations
of Severe Dengue Fever
Encephalopathy
Hepatic damage
Cardiomyopathy
Severe gastrointestinal
hemorrhage
8 cases
Unusual Presentations
of Severe Dengue Fever
Encephalopathy
Hepatic damage
Cardiomyopathy
Severe gastrointestinal
hemorrhage
NATURE REVIEWS CARDIOLOGY | REVIEW
Cardiovascular manifestations of the emerging dengue pandemic
Sophie Yacoub, Heiman Wertheim, Cameron P. Simmons, Gavin Screaton
& Bridget Wills
Nature Reviews Cardiology 11,
335–345 (2014) doi:10.1038/nrcardio.2014.40
Published online 08 April 2014
Evidence is increasing that dengue can also cause myocardial impairment, arrhythmias and, occasionally, fulminant myocarditis. Defining the role of cardiac dysfunction in the haemodynamic compromise of severe dengue has potentially important management implications.
Unusual Presentations
of Severe Dengue Fever
Encephalopathy
Hepatic damage
Cardiomyopathy
Severe gastrointestinal
hemorrhage
REVISED 2ND EDITION OF 2010 CPG –
2015
THE CHANGES
Calculating weight
Fluid management
Electrolytes and acid-base balance
ECG and ECHO monitoring
Haemophagocytic syndrome
Non-obese and non-overweight patients
Maintenance fluid can be calculated based on the following formula :
- 1.2 - 1.5 ml/kg/hour
Obese and overweight patients
Maintenance fluid can be calculated based on adjusted body weight
Adjusted bodyweight (ABW) can be calculated using this formula. o ABW = IBW + 0.4(actual weight - IBW)* o Ideal bodyweight (IBW) can be estimated based on the following
formula. 72, level III Female: 45.5 kg + 0.91(height -152.4) cm Male: 50.0 kg + 0.91(height -152.4) cm
*Adapted : GlobalRPH 2015, calculator adjusted body weight (available at http://www.globalrph.com/ibw_calc.htm)
REVISED 2ND EDITION OF 2010 CPG –
2015
THE CHANGES
Calculating weight
Fluid management
Electrolytes and acid-base balance
ECG and ECHO monitoring
Haemophagocytic syndrome
ALGORITHM A – FLUID MANAGEMENT IN COMPENSATED SHOCK
COMPENSATED SHOCK (systolic pressure maintained but has signs of reduced perfusion) •Fluid resuscitation with isotonic crystalloid 5 – 10ml/kg/h over 1h •FBC, HCT, before and after fluid resuscitation, BUSEC, LFT, RBS, PT/APTT, Lactate/HCO3, GXM
IMPROVEMENT*
Check HCT
Administer 2nd bolus
of fluid (colloid)**
10 – 20 ml/kg/h for 1h
Consider significant
occult/over bleed
Initiate transfusion with
fresh blood2 (whole
blood/packed cell)
•If patient improves, reduce
to 7-10 ml/kg/h for 1 – 2h
•Then reduce further
•IV crystalloid 5–7ml/kg/h x 1–2h, then:
reduce to 3 – 5 ml/kg/h for 2 – 4h
reduce to 2 – 3 ml/kg/h for 2 – 4h
•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:
If HCT ↑, consider bolus fluid adminis-
tration or ↑ fluid administration
If HCT decreases, consider
transfusion with fresh whole blood
• Consider to stop IV fluid at 48h of
plasma leakage / defervescence.
* Reassess the patient’s clinical condition, vital signs, pulse volume, capillary refill time, urine output and temperature of extremities.
** Colloid is preferable if the patient has already received previous boluses of crystalloid
IMPROVEMENT*
HCT ↑ or high HCT ↓
NO
NO
YES
YES
•Fluid resuscitation with 20 ml/kg/h colloid 15-30 minutes •Try to obtain a HCT level before fluid resuscitation •FBC, HCT, before and after fluid resuscitation, BUSEC, LFT, RBS, PT/APTT, Lactate/HCO3, GXM
IMPROVEMENT*
Review 1st HCT
Administer 2nd bolus
of fluid (colloid)**
10–20ml/kg ½ to 1h
Consider significant
occult/overt bleed
Initiate transfusion with
fresh blood2 (whole
blood/packed cell)
•Crystalloid/colloid 10ml/kg/hx1h, then
continue with:
IV crystalloid 5 – 7 ml/kg/h for 1 – 2h
reduce to 3 - 5 ml/kg/h for 2 – 4h
reduce to 2 – 3 ml/kg/h for 2 – 4h
•If patient continues to improve, fluid can be
further reduced.
•Monitor HCT q4h or more frequent as
indicated
•If the patient is not stable, act according
to HCT levels :
If HCT ↑, consider bolus fluid adminis-
tration or ↑ fluid administration
If HCT decreases, consider
transfusion with fresh whole blood
Consider to stop IV fluid at 48h of plasma
leakage / defervescence
* Reassess the patient’s clinical condition, vital signs, pulse volume, capillary refill time, urine output and temperature of extremities.
˄ Colloid is preferable if the patient has already received previous boluses of crystalloid
** In absence of colloid, crystalloid can be used
IMPROVEMENT*
HCT ↑ or high HCT ↓
NO
YES
YES
ALGORITHM B – FLUID MANAGEMENT IN DECOMPENSATED SHOCK
HCT Unchanged
REFER
ALGORITHM
C
NO
Repeat 2nd HCT
HCT ↓ HCT ↑ or high
Administer 3rd bolus of fluid
(colloid) 10 – 20 ml/kg over 1h
IMPROVEMENT*
Repeat
3rd HCT NO
YES
ALGORITHM C – FLUID MANAGEMENT IN DECOMPENSATED SHOCK
(WITH PRESENCE OF BLEEDING & LEAKING AND OTHER CAUSES SHOCK)
HAEMATOCRIT REMAIN UNCHANGED AFTER
FIRST FLUID RESUSCITATION
• Bleeding and leaking at same time
• Look for source of bleeding (eg.OGDS)
• Evidence of leaking (USG)
• Correct coagulopathy
• Transfused blood and blood products
Consider other causes of
shock
Cardiac
dysfunction Septic shock Liver failure with
severe metabolic
acidosis from lactate
accumulation
Cytokine
storm
Low CO:
Inotrope
(eg. dobutamine)
High CO:
• Vasodilated shock with
myocardia; dysfunction
• Inotropes + vasopressor
(eg. Noradrenaline +
dobutamine)
• Vasodilated state
• Noradrenaline titrated
to MAP 65 mmHg Vasopressor
+
Supportive care
+
Continuous renal
replacement
therapy (CRRT)
Noradrenaline
and fluids
All the above types of shocks need to be supported by echocardiography and non-invasive cardiac
output monitoring and treatments tailor to each patient.
REVISED 2ND EDITION OF 2010 CPG –
2015
THE CHANGES
Calculating weight
Fluid management
Electrolytes and acid-base balance
ECG and ECHO monitoring
Haemophagocytic syndrome
ELECTROLYTES AND ACID-BASE
BALANCE
Hyponatraemia – common observation in severe dengue
- a marker of disease severity
- underlying mechanism not fully understood
- ? GI loss or ? use of hypotonic solution
Metabolic acidosis - ? Leakage and shock
- consider severe bleeding, liver
failure, sepsis, or cardiac dysfunction
REVISED 2ND EDITION OF 2010 CPG –
2015
THE CHANGES
Calculating weight
Fluid management
Electrolytes and acid-base balance
ECG and ECHO monitoring
Haemophagocytic syndrome
79 patients (adult and children) with dengue infection with 3 severity grades
ECHO exam of intravascular volume + myocardial tissue Doppler Imaging – preload independent of cardiac function parameters
after immediate resus, at 24h and at hospital discharge
Systolic and diastolic impairment with segmental wall abnormalities of the septum and right ventricular wall Least severe dengue – transient More severe dengue – more frequently to have
RECOMMENDATION
• All cases of severe dengue in shock should have Echocardiography to look for evidence of cardiac dysfunction and to guide in fluid management.
• Adequate fluid resuscitation is a pre-requisite before myocardial dysfunction can be diagnosed.
Cautious volume resuscitation is required in those with myocardial dysfunction to avoid risk of iatrogenic fluid overload.
REVISED 2ND EDITION OF 2010 CPG –
2015
THE CHANGES
Calculating weight
Fluid management
Electrolytes and acid-base balance
ECG and ECHO monitoring
Haemophagocytic syndrome
HEMOPHAGOCYTIC SYNDROME
• A potentially fatal hyperinflammatory condition caused by highly stimulated but dysregulated and often ineffective immune responses
• Cardinal features: fever, hepato-splenomegaly, pancytopenia, and widespread histiocytic tissue infiltration
• 2 major forms:
i. primary (hereditary) form - in early childhood ii. secondary (reactive) form - at any age - may be related to infection, malignancy, or autoimmune disease
• Dengue associated haemophagocytic syndrome increasingly reported in case reports and case series in past few years in both primary and secondary dengue infections - South East Asia & among returned travelers from tropical countries.
• Often missed or delayed as its presentation mimics sepsis
DIAGNOSIS
OF HLH Table 2. Proposed HLH diagnostic
criteria, 2009.
1. Molecular diagnosis of hemophagocytic
lymphohistiocytosis
(HLH) or X-linked lymphoproliferative
syndrome (XLP).
2. Or at least 3 of 4:
a. Fever
b. Splenomegaly
c. Cytopenias (minimum 2 cell lines
reduced)
d. Hepatitis
3. And at least 1 of 4:
a. Hemophagocytosis
b. ↑ Ferritin
c. ↑ sIL2Rα (age based)
d. Absent or very decreased NK function
4. Other results supportive of HLH
diagnosis:
a. Hypertriglyceridemia
b. Hypofibrinogenemia
c. Hyponatremia
Limitation:
Retrospective sample – selection bias – medical records, results of bone marrow aspirate, ICD-10 classification
Classification of patients – 4
investigators, independent
Small validation sample – 27 patients compared to 312 patients in development sample
Validated mainly among population
with autoimmune diseases - used with caution in infection associated HS
aROC - 0.97
aROC – 0.95
Goodness of fit 0.93
Goodness of fit 0.76
MANAGEMENT OF HS
Mainly supportive
Not so severe cases can recover spontaneously
Sometimes, short course dexamethasone (10mg/m2 BSA) could be adequate
Due to the transient nature of HS in dengue, full HLH 2004 treatment protocol which includes chemotherapy is not necessary
For severe cases, HS specific therapy i.e IV methylprednisolone + IV Ig – to be tapered off rapidly as patients improve clinically and biochemically
In patients with co-existing sepsis and/or GIT bleeding, risks and benefits on use of steroids need to be weighed
TAKE HOME MESSAGE
Do not forget the basics ie history, physical examination, investigations and diagnosis
Look at the BIG picture – do not fix your mind on one or two parameter
Make a diagnosis after knowing the parameters – more fluids, less fluids, on the right track, other diagnosis, further investigations
Monitor response and medical condition
Remember if you are on the right track, patient should get better
TAKE HOME MESSAGE
Do not forget the basics ie history, physical examination, investigations and diagnosis
Look at the BIG picture – do not fix your mind on one or two parameter/s
Make a diagnosis after knowing the parameters – more fluids, less fluids, on the right track, other diagnosis, further investigations
Monitor response and medical condition
Remember if you are on the right track, patient should get better
TAKE HOME MESSAGE
Do not forget the basics ie history, physical examination, investigations and diagnosis
Look at the BIG picture – do not fix your mind on one or two parameter
Make a diagnosis after knowing the parameters – more fluids, less fluids, on the right track, other diagnosis, further investigations
Monitor response and medical condition
Remember if you are on the right track, patient should get better
TAKE HOME MESSAGE
Do not forget the basics ie history, physical examination, investigations and diagnosis
Look at the BIG picture – do not fix your mind on one or two parameter
Make a diagnosis after knowing the parameters – more fluids, less fluids, on the right track, other diagnosis, further investigations
Monitor response and medical condition
Remember if you are on the right track, patient should get better
TAKE HOME MESSAGE
Do not forget the basics ie history, physical examination, investigations and diagnosis
Look at the BIG picture – do not fix your mind on one or two parameter
Make a diagnosis after knowing the parameters – more fluids, less fluids, on the right track, other diagnosis, further investigations
Monitor response and medical condition
Remember if you are on the right track, patient should get better
ACKNOWLEDGEMENTS
Dr Rose Nani Mudin Public Health Physician (Epidemiologist)
Head of Vector Borne Disease Sector,
Disease Control Division, Ministry of Health Malaysia
Dr Shaharom Nor Azian Che Mat Pengarah, Makmal Kesihatan Awam
Dr Shanthi Ratnam Consultant Intensivist, Hospital Sungai Buloh
Dr Kan Foong Kee Consultant ID, Hospital Sultanah Aminah
THANKS
PEARLS ON SEVERE DENGUE INFECTION
Patient will not have plasma leakage before 72h of
fever. Rise in hematocrit likely means dehydration. Oral rehydration
usually suffices
Transition from febrile phase to critical phase
could be as early as day 3 or as late as day 7 or 8
Critical phase usually 24-48h
Total white cell count (instead of leukopenia) may
increase in patients with severe disease at critical
phase
Liver enzymes are frequently elevated during the
critical and recovery phases
PEARLS ON SEVERE DENGUE INFECTION
Warning sign of severe abdominal pain can be
mistaken as a surgical condition – fever
precedes pain, tender but not guarded, pain
improves with fluid resuscitation
Tense abdomen after IV fluid therapy - due to
ascites + liver congestion can cause abdominal pain -
consider fluid overload instead!
If IV fluid therapy increases, this can cause acute
pulmonary oedema
MANAGEMENT PEARLS OF SEVERE DENGUE
INFECTION
History: Ask open-ended questions • 3 golden questions to ask:
How much oral fluid intake: quantity and quality?
How much urine output: frequency, volume and time of most recent voiding?
What activities can the patient do during the febrile illness?
Examination: “5-in-1 maneuver” magic touch – CCTV-R
Investigations: NS1, IgM, IgG and or PCR
Diagnosis, phase of disease and severity: Does the patient have dengue or other illnesses?
Which phase of dengue (febrile/critical/recovery)?
How severe the disease is? -hydration state? warning signs present? haemodynamic state?
Best medical plan: monitoring
PEARLS ON IV FLUID THERAPY
IV fluid therapy is a Careful Budget of in and out with only one priority ie to maintain tissue perfusion
In outpatient setting, patient should drink enough fluids to pass urine about 4 to 6 times a day
A patient with dengue shock should pass at least 0.5 ml/kg/h urine. If urine volume exceeds 0.5ml/kg/h, consider reducing IV fluid therapy
Remember uncontrolled diabetes or hyperglycemia - shock becomes worse because of glycosuria
Remember changes in haematocrit may be masked by IV fluid therapy
PEARLS ON MONITORING
Monitoring CCTV-R + investigations – Big picture
Make a diagnosis after knowing the parameters – more fluids, less fluids, on the right track, other diagnosis, further investigations
Remember if you are on the right track, patient should get better
For severe disease with multi-organ involvement, consider hemophagocytic syndrome