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Management of
Dengue in Adults
Part II : Fluid
Management
Dr Ker Hong Bee
Hospital Raja Permaisuri
Bainun
Ipoh
1Perak Dengue TOT 2012
Causes of death in DHF patients
1. Prolonged shock
� Delayed diagnosis/ delayed resuscitation
� Untreated prolonged shock > 4 hours will lead to organ
failure and prognosis is very grave
2. Fluid overload2. Fluid overload
� excess fluids or fluid given beyond the time of leakage
3. Massive bleeding
4. Unusual manifestations
� Encephalopathy
� Fulminant hepatitis
2Perak Dengue TOT 2012
Clinical Course of DHF
3Perak Dengue TOT 2012
Increased capillary
permeability
Systemic vascular
leakage becomes
apparent around the
time of defervescence
Warning signs If
Immunopathogenesis of Severe
Dengue
Simmons. Current concepts: Dengue. NEJM
2012;366:1423-32
Warning signs If
clinically significant
leakage develops
Compensated shock
Decompensated shock
4Perak Dengue TOT 2012
Warning signs :
Patients who may deteriorate into
Severe Dengue
Perak Dengue TOT 2012 5
Assessment in Dengue
• Warning signs
• Evidence of plasma leakage
• Look for defervescence
• Hours since onset of leakage Identify
phase of illness
Symptoms & signs
• BP, pulse pressure, PR
• Capillary filling
• Respiratory rate
• Most useful HCT & WBC count trend
Assess peripheral circulation
Lab parameters
6Perak Dengue TOT 2012
DIAGNOSIS
• Day of illness
• Dengue fever / severe dengue
• ± warning signs
• Febrile phase / Defervescence by hours
• Haemodynamic stable / in shock• Haemodynamic stable / in shock
D4 , Severe dengue with DHF
with warning signs
defervesence phase 6 hours
in compensated shock
Perak Dengue TOT 2012 7
Fluid Management in Dengue
Maintenance
fluid
Resuscitation
fluidfluid fluid
1. With warning signs
2. Compensated shock
3. Decompensated shock
1. Non shock patients
unable to tolerate orally
2. Patients in shock
8Perak Dengue TOT 2012
Fluid in Non shock Dengue patients
• IV fluid (0.9% saline) is indicated in those with
o increasing HCT (indicating on-going plasma leakage)
despite increased oral intake
owho are vomiting and not tolerating orally
• 1.2 - 1.5 X Maintenance in critical phase• 1.2 - 1.5 X Maintenance in critical phase
• 4-6 hourly fluid adjustment during critical phase
• Fluid resuscitation if warning signs or deterioration to shock
• Reduce and consider discontinuation of IV fluid after 24-48
hours of defervescence in stable patients
9Perak Dengue TOT 2012
Fluid management - maintenance
• Calculations for normal maintenance of intravenous fluid infusion per hour:
(Equivalent to Halliday-Segar formula)
4 mL/kg/h for first 10kg body weight
+ 2 mL/kg/h for next 10kg body weight
+ 1 mL/kg/h for subsequent kg body weight
*For overweight/obese patients calculate normal maintenance fluid based on ideal body weight
Ideal bodyweight can be estimated based on the following formula
Female: 45.5 kg + 0.91(height -152.4) cm
Male: 50.0 kg + 0.91(height -152.4) cm
Perak Dengue TOT 2012 10
If patient weighs 60kg ……..
4 mL/kg/h for first 10kg body weight
+ 2 mL/kg/h for next 10kg body weight
+ 1 mL/kg/h for subsequent kg body weight for 1x maintainance
4ml/kg/hr x 10 = 40 ml/hr4ml/kg/hr x 10 = 40 ml/hr
2ml/kg/hr x 10 = 20 ml/hr
1ml/kg/hr x 40 = 40 ml/hr
total = 100 ml/hr = 1 pint over 5 hrs
( 2400 ml/day )
Perak Dengue TOT 2012 11
Dengue with warning signs : should be monitored in
hospitals
Perak Dengue TOT 2012 12
5-7
3-5ml/kg/hr
Fluid for Dengue with Warning Signs
2-3
1 2 3 4 5 6 7 8
Hours
ml/kg/hr
1.2 – 1.5 x maintenance pending clinical parameters and
HCT
13Perak Dengue TOT 2012
Dengue Shock Syndrome – DHF Grade 3 and 4
• Dengue shock syndrome is a medical emergency
• Recognition of shock in its early stage (compensated
shock) and prompt fluid resuscitation will give a good
clinical outcomeclinical outcome
• Pulse pressure of < 20 mmHg and systolic pressure < 90
mmHg are late signs of shock in adults
14Perak Dengue TOT 2012
120
110
10090
80
Blood pressure, pulse pressure, heart rate in
hypovolemic shockPULSE PULSE
PRESSURE
( SBP-DBP )
RESPIRATORY
RATE• Narrowing pulse
HR
80
70
60
Time
LCS Lum
Compensated shock Decompensated shock
RATE
Perak Dengue TOT 2012
• Narrowing pulse
pressure
• Tachycardia
• SBP maintains
• Tachypnoeic
15
16Perak Dengue TOT 2012
Dengue Shock Syndrome
• All patients with dengue shock should be managed in
HDU/ICU
• Fluid resuscitation must be initiated promptly and should
not be delayed while waiting for admission to ICU or high
dependency unitdependency unit
• The volume of initial and subsequent fluid resuscitation
depends on the degree of shock
• Following initial resuscitation there maybe recurrent
episodes of shock because capillary leakage can continue
for 24-48 hours
17Perak Dengue TOT 2012
IV fluid in Dengue Shock Syndrome
• IV fluid therapy is the mainstay of treatment for dengue
shock
• Studies# showed no clear advantage of using any of the
colloids over crystalloids in terms of the overall outcome
• Colloids may be preferable as the fluid of choice in • Colloids may be preferable as the fluid of choice in
patients with intractable shock in the initial resuscitation
• The choice of colloids includes gelatin solution (e.g.
Gelafusine) and starch solution (e.g. Voluven)
# Dung NM, Day NP, Tam DT, et al. Fluid replacement in dengue shock syndrome: a randomized, double-blind comparison of four intravenous-fluid
regimens. Clin Infect Dis. 1999 Oct;29:787-94.
Ngo NT, Cao XT ,Kneen R, et al. Acute management of dengue shock syndrome : a randomized double-blind comparison of 4 intravenous fluid regiments in
the first hour. Clin Infect Dis. 2001. 32:(2) 204-13.
Wills BA, Nguyen MD, Ha TL, et al. Comparison of three fluid solutions for resuscitation in dengue shock syndrome. N Engl J Med. 2005 Sep 1;353(9):877-89.
18Perak Dengue TOT 2012
Assessment after each bolus of fluid
resuscitation
Clinical parameters
1.Improvement of general
well being / mental state
2.Warm peripheries
Laboratory parameters
1.Decrease in HCT
2.Improvement in
metabolic acidosis2.Warm peripheries
3.CRT < 2sec
4.BP stable
5.Improving pulse pressure
6.Less tachycardic and less
tachypnoiec
7.Increase in urine output (≥
0.5ml/kg/hr)
metabolic acidosis
19Perak Dengue TOT 2012
Dengue Shock Syndrome
• Fluid therapy has to be judiciously controlled
to avoid fluid overload, result in massive pleural
effusion, pulmonary oedema or ascites
Perak Dengue TOT 2012 20
21Perak Dengue TOT 2012
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23Perak Dengue TOT 2012
Fluid for DHF with Compensated Shock
5-
10
5-7
ml/
kg
/hr
3-5
2-3
1.2-1.5x maintenanceTo further reduce fluid if patient continues to improve
Aim
to
stop
1 2 3 4 5 6 7 8 9 10 1
1
12 1
3
14 15 1
6
1
7
1
8
1
9
2
0
2
1
2
2
2
3
2
4
24-48
ml/
kg
/hr
Hours
24Perak Dengue TOT 2012
Assessment after each bolus of fluid
resuscitation
Clinical parameters
1.Improvement of general
well being / mental state
2.Warm peripheries
Laboratory parameters
1.Decrease in HCT
2.Improvement in
metabolic acidosis2.Warm peripheries
3.CRT < 2sec
4.BP stable
5.Improving pulse pressure
6.Less tachycardic and less
tachypnoiec
7.Increase in urine output (≥
0.5ml/kg/hr)
metabolic acidosis
25Perak Dengue TOT 2012
If still unstable after fluid resuscitation ?
Patient remains in shock after the first 2 cycles
of fluid resuscitation with crystalloids
(about 40 ml/kg)
Repeat HCT remains high Repeat HCT dropsRepeat HCT remains high
Colloids should be
considered for the 3rd
cycle
Repeat HCT drops
Suspect significant bleed
(often occult) and blood
transfusion should be
instituted ASAP
26Perak Dengue TOT 2012
Persistent shock despite 60 ml/kg IV fluid
resuscitation
Consider :
• Significant occult bleeds
• Cardiogenic shock (due to myocarditis or ischaemic
heart disease)
• Sepsis
27Perak Dengue TOT 2012
28
29Perak Dengue TOT 2012
Fluid for DHF with Decompensated Shock
2
0
1
0
5-7
ml/
kg
/hr
3-5
2-3
1.2-1.5x maintenanceTo further reduce fluid if patient continues to improve
Aim to
stop
1 2 3 4 5 6 7 8 9 1
0
1
1
1
2
1
3
1
4
1
5
1
6
1
7
1
8
1
9
2
0
2
1
2
2
2
3
2
4 24-48
ml/
kg
/hr
Hours 30Perak Dengue TOT 2012
Remember
• The chart on the rate of fluid administration is only a guide
• Individual patient's rate of fluid requirement will depend on
the rate of leakage in that patient
• The rate of IV fluid administration has to be adjusted all the
time with FREQUENT MONITORING of
�vital signs ( BP, pulse pressure, periperal perfusion and urine
output ) and
�laboratory parameters ( HCT / HCO3 ± Se lactate )
Perak Dengue TOT 2012 31
Dengue hepatitis and liver failure
• Hepatitis is common in patients with DF/DHF
• Maybe mild or severe regardless of the degree of plasma
leakage
• Fulminant hepatitis with liver failure may occur
�higher propensity to bleed, especially gastrointestinal
bleeding
�Supportive therapy
�Not to fluid overload patient
� IV N-acetylcysteine (NAC) therapy may be beneficial – need further
clinical trials
Perak Dengue TOT 2012 32
Clinical Course of DHF
33Perak Dengue TOT 2012
Recovery Phase
• After 24-48 hours of defervescence, plasma leakage stops and
is followed by reabsorption of extravascular fluid
• HCT level stabilises or drops further due to haemodilution
following reabsorption of extravascular fluidfollowing reabsorption of extravascular fluid
• The recovery of white cell count (WCC) is followed by the
recovery of platelet count
• Discontinue IVD during reabsorption phase to avoid fluid
overload
34Perak Dengue TOT 2012
Common pitfalls in fluid therapy
1. Treating patient with unnecessary fluid bolus based on
raised HCT as the sole parameter without considering
other clinical parameters
2. Excessive and prolonged fixed fluid regime in stable 2. Excessive and prolonged fixed fluid regime in stable
patients
3. Infrequent monitoring and adjustment of infusion rate
4. Continuation of intravenous fluid during the recovery
phase
35Perak Dengue TOT 2012
The role of blood and blood
productsproducts
Perak Dengue TOT 2012 36
How to Recognize Significant Occult
Bleeding?
Significant bleeding or DIVC usually occurs following
prolonged shock and acidosis
37Perak Dengue TOT 2012
Management of bleeding in dengue
38Perak Dengue TOT 2012
Role of prophylactic transfusions in
dengue ?
NO !
39Perak Dengue TOT 2012
Thank You
40Perak Dengue TOT 2012