Management of Dengue Fever & Dengue H'Gic Fever in Adult

8/3/2019 Management of Dengue Fever & Dengue H'Gic Fever in Adult

1/36

MANAGEMENT OF DENGUE

FEVER & DENGUE

HAEMORRHAGIC FEVER IN

ADULTSDr. R.A.N.S. Rajapakshe

SHO- Medicine


2/36

Dengue viruses & Disease

y Arbovirus Aedes aegypti

Aedes albopictusy Four serotypes (DEN-1, DEN-2, DEN-3 e DEN-4)


3/36

Dengue Viral Infection(10,000 patients)

Asymptomatic(9,000)

Symptomatic(1,000)

Viral Syndrome(500)

Dengue Fever(400)

DHF(100)

Plasma leakage

DHF-Nonshock

(98-99)

DSS(1-2)

Unusual

ComplicationsProlonged shockLiver failureEncephalopathyRenal failureCo-infection

Co-morbidities


4/36

Difference between DF & DHF

y Key factor in guiding the Management.

y Two different clinical conditions from the beginning

but look very similar in first two days.

Badly managed DFwill never become DHF


5/36

Dengue Fever

y NO PLASMA LEAKAGE

y Platelet Count may drop < 100,000 /mm3

y Leucopenia ( WBC< 5,000/mm3 )

Clinical Features :-

y Headache ( Retro orbital pain)

yArthralgia / Myalgia Sometimes

y Erythomatous or Macula- papular rash more in DF

y Positive Tourniquet test than DHF

y Skin heamorrhages


6/36

Haemorrhagic manifestations of DF

y Skin haemorrhages:

Petichiae,Purpura,Ecchymoses

y Gum/ nasal bleeding

y GI bleeding:

Hematemesis,Malena,Hematochezia

y Haematuria

y Menorrhagia

Still not DHF


7/36

ClinicalCase Definition for DHF

Four Necessary Criteria: All Four Needed

y Fever / recent history of Acute fever

y Hemorrhagic manifestations

y Low Platlet count ( < 100,000 /mm3 )y Objective evidence of LEAKYCAPILLARIES

Elevated Hematocrit ( 20% or more over base line)

Low Albumin ( < 3.5 g/dl)

Low Cholesterol ( < 100 mg/dl)

Pleural effusion/ Ascites


8/36

NaturalCourse of DHFDHF is a dynamic disease & It has three phases.

FebrilePhase :-

o High grade fever 2 7 days

o

Clinical features- Facial puffiness, Erythema, Myalgia,Arthralgia, Headache, Anorexia, Nausea & vomiting

Tender Hepatomegally- Favours DHF

Critical Phase :-

o Often after 3 rd day, usually 4th

to 5th

dayo Last for 24 to 48 hrs

o Plasma leakage - rising Haematocrit 20%

o Low Serum Albumin & Cholesterol

o Pleural effusion/ Ascites


9/36

Recovery(Convalescent) Phase :-o Lasts 3 5 days

o Plasma leak stops & Fluid reabsorbs

o Diuresis

o Classical recovery rash/ itching

Loss of Plasma

Haematocrit

24 H 24 H

Critical Phase(48H)


10/36


11/36

Classification of Dengue


12/36

Criteria for Admission

y With Platlet count < 100,000/mm3

y With following Warning signs:

y Abdominal pain/Tenderness

y Persistent vomiting

y Clinical signs of plasma leakage

y Mucosal bleeding

y Lethargy & restlessness

y Liver enlargement > 2cm

y Increase in Haematocrit with rapid decrease in Pltcount

y Pregnant mothers, Elderly Pts, Obese pts, Pts withCo- morbid conditions & adverse social circumstances.


13/36

y Adequate oral fluid intake

y Adequate physical rest

y Tepid sponging

y Paracetamol 2 tabs 6H

y Antiemetics & H2 receptor blockers

y Avoid all NSAIDs & Steroids

y

Withhold Aspirin, Clopidogrel & Dipyridamole if onlong term

y FBC 3rd Day

Management at OPD


14/36

Management of Inward Pts

y Admission Goalsy Early detection of plasma leakage (onset of Critical phase)

y Rational fluid management- prevent shock & fluid overload

SYMPTOMSOFSHOCK

Sweating

Abdominal pain

Persistent vomitingRestlessness/altered conscious level

Postural dizziness

Decreased UOP (


15/36

SIGNSOFSHOCK

Cold extremitiesProlonged CRFT ( > 2sec)

Unexplained tachycardia

Tender hepatomegaly > 2 cm

Increasing diastolic pressure

Narrowing of pulse pressure 20mmHg

Postural drop 20mmHg of SBP

Hypotension


16/36

Monitoring DF Patientsy Stable patients

y QHT

y Bleeding manifestations(malena , bleeding PV)

y Vital signs

y FBC daily

y Platelet < 100,000/mm3 ( chart 1)y QHT

y Vital Parameters- PR, BP, RR, CRFT - 4H

y FBC dailyy HCT twice daily

y Fluid balance Intake Type & route

Output Urine/Vomitus 6H


17/36

y Critical phase (Chart 2)y Vital parameters 1H

y Fluid balance chart 3H

y HCT 6H

y Evidence of shocky Vital parameters 15 min

y HCT 2 to 4H

y Input/ Output 1H

( UOP 0.5 1ml/kg/hr)


18/36


19/36


20/36

FluidManagement in DF

Calculation ofIdeal bodywt

Best method Wt for Ht /Wt for age in growth chart

Emergency situation < 1 yr Age( in months) + 9

2

< 7 yrs (Age 2) + 8

>7 yrs Age 3

APLS (Age + 4) 2


21/36

Calculation of total fluidrequirement

M(Maintenance) 100ml/kg for 1st 10kg

50ml/kg for next 10kg

20ml/kg for Balance wt

5% of Body Wt = 50ml Body Wt(Kg)

Maximum Body Wt for Fluid calculation is 50 Kg

M + 5% = Maintenance + 5% of Body Wt


22/36

Fluid management in Febrile phase

If fever & vomiting present

Total IV + Oral fluids = M + 5% during each 24H

If no fluid loss

Total fluids = M during each 24HRecommended IV fluids 0.9% saline/Hartmanns

Oral Electrolyte solutions Eg. ORS, King coconutwater, Kanje, Fruit juice

Too much fluid during Febrile phase cancontribute to fluid overload


23/36

Fluid management in Critical phase

y Non shock (Haemodynamically stable)y Patient is starting to leak

y M +5% spread over 48 H

y

Rate sufficient to maintain effective circulationy Start at a slower rate ( 1- 1.5ml/kg/h)

y Rate should be increased step wise pattern according to riseof HCT & reduction of UOP

(note that it is almost one days fluids that is givenover 2 days and maximum weight for which fluid iscalculated is 50kg even if the actual weight is wellabove 50kg)


24/36

y Fluid Intake Non Shock


25/36

y Shock statey Continued to leak before admissiony Occurs at the peak of leaking

y M + 5% spread over 24 H ( not 48H)

y Include fluid given for resuscitation

y

Initial bolus 20ml/kg fast infusion (Crystalloids)y 10ml/kg boluses when recordable BP

y Consider Colloids

y after 2 saline boluses

y shock despite of fluid overload

y direction of exceeding M+5%


26/36

y

Fluid Intake - Shock


27/36

yDoses of Colloids

y Dextran 40 Maximum of 30ml/kg/24H (3 boluses of10ml/kg/h over 24H = 6 doses / 48H)

y 6% Starch Maximum of 50ml/kg/24H ( 5 boluses of10ml/kg/h over 24H = 10 doses / 48H)

y Only recommended for Critical phase

y Only as boluses

y Blood sample for Gp & DAT before Dextran


28/36

FluidManagement of Recovery

phaseDengue patients have accumulated fluid within his/her

body

y Cut down fluid

y Give oral fluid if tolerating

y Fluid will start reabsorbing

y

Dropping HCT is not bleeding


29/36

Fluid Overload

Causes ofFluid overload

Too much fluids in febrile phase

Excessive and/or too rapid IV fluids

Use of hypotonic crystalloid solutions Inappropriate IV fluids for severe bleeding

Inappropriate - FFP, platelet & cryo

Continuation of IV fluids after Critical phase

Co-morbid conditions

congenital or ischaemic heart disease

chronic lung and renal diseases

Obesity Fluid not calculated for IBW


30/36

Clinical features ofFluid overload

Respiratory distress

Large pleural effusion/ Tense ascites

Elevated JVP

Prevention of flui

doverloa

d

Try to manage within the fluid quota (M+5%)

y For 48 hrs for non shock patients

y For 24 hrs for shocked patients

Expected Urine out put is only 0.5 ml/kg/hr Calculate oral fluid also

Monitor fluid intake regularly during critical period Use Dengue monitoring chart


31/36

Indications of Blood Transfusion

y Significant overt bleeding > 6-8ml/kg Body Wt.

y Haematocrit not as high as expected for the degree ofshock to be explained by plasma leakage alone.

y A drop in HCT without clinical improvement despiteadequate fluid replacement.

y Severe metabolic acidosis & end-organ dysfunctiondespite fluid replacement.

y 5ml/kg of packed red cells to over hydrated/ Heartdisease pts OR 10ml/kg of whole blood.


32/36

Place of Adjunctive Therapyy Platelet transfusion - Prophylactic transfusion is not

recommended excepty Thrombocytopenic pts undergoing urgent surgery.

y Active bleeding despite repeated blood transfusion.

y DIC / ICH

y FFP transfusion Prophylactic transfusion is notrecommended but may be useful in pts with Hepaticencephalopathy and has active bleeding.

y Steroids & IVImmunoglobulin Notrecommended

y Tranexamic acid Can be used in bleeding PV eithermenstrual, intermenstrual or premenopausal.


33/36

Comp

licated DHF

y Acidosis Check Venous blood gas & correct

y Bleeding Check HCT

y Calcium & other Electrolytes Check serum levels

y Sugar Check RBS


34/36

Causes of Death in DHF Prolonged shock

Delayed diagnosis 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 cormorbidity

Dual infection


35/36

References

y Dengue Haemrrhagic Fever & Dengue Control in Srilanka- SLMA News; Aug 2010.

y Guidelines on Management of Dengue Fever &

Dengue Haemorrhagic Fever in Adults Ministry ofHealth Sri lanla; Dec 2010.

y Rational Management ofFluid in Dengue Pts byDr.Rasnayake M. Mudiyanse PPt.

yCase Management of Dengue by Dr. LakKumarFernando PPt.

y Wikipedia.


36/36

THANKYOU!

Documents

Management of Dengue Fever & Dengue H'Gic Fever in Adult