4. Case Histories

Dengue Expert Advisory Group

CASE HISTORY 1

24 yr old male came to the OPD with H/O fever for

1 day. Had myalgia, and severe headache. No

vomiting.

O/E Flushed skin, good hydration, pulse 80/min,

BP 110/80. No abnormality was detected on

examination.

He was sent home by the OPD doctor advising

him

• to drink - the amount, type of fluid

• to take paracetamol in correct dose

• to have rest.

• He was also advised to come back on the 4th

day of the illness with CBC.

• He came back on 4th day, still febrile, had

nausea. Pulse 80/min, BP 110/80.

• CBC on D-3

• WBC – 3800 Hct – 38.8 Plt – 120,000

IN PATIENT MANAGEMENT

• FBC and Haematocrit monitored

• Fluid intake and output monitored

IV fluids – 1500 ml with 1000 ml orally per

day

given. Total – 2500 ml/d

Domperidone and PCM sos

• Vital signs monitored

CASE HISTORY 1 CONTD.

3 4 5 6 6 7 8 9

WBC 3.8 2.8 4.1 10 9.9 10 8.3 5.5

HCT 38.8 40.5 44.5 48.5 43.9 42.8 39.7 40

PLT 120 80 21 6 9 9 19 57

MANAGEMENT CONTD.

• Symptomatic management continued

• Monitoring continued.

• Fluid increased with rise of PCV

• No clinical deterioration. Had small right sided

pleural effusion. No specific management done.

• Patient improved i.e.. General condition, appetite.

Fever settled.

• Patient was discharged home once the plt count

was >50,000 & Afebrile for 48 hrs

LESSONS LEARNED:

• Doing a CBC from 3rd day is better.

• Often only symptomatic management is

adequate.

• If there is no active bleeding, there is no place

for platelet transfusion even if the platelet count

is low.

• No place for steroids or FFP.

CASE – 2: THE SHOCKED LADY

• A 33 yr old lady, a mother of a 5 month old baby,

was admitted with a H/O fever for 5 days.

• On admission – pulse 100/min, BP 100/90,

CRFT- 3 secs, R/pleural effusion +

05.09.11 07.09.11

Platelets 181,000 52,000

HCT 33.8 40.6

FLUID ALLOCATION FOR SHOCKED

PATIENT

53

105 51

104 140 49

103 47

102 120 45

101 43

100 100 41

99 39

98 80 37

35

60

1 2 3 4 5 6 7

1 23

M + 5%

24-36 hrs

10 ml/kg

7-5 ml/kg

5-3 ml/kg

3-1 ml/kg

KVO

FLUID GIVEN DURING 1ST 24 HRS

0

100

200

300

400

500

600

2p

m

3p

m

4p

pm

5p

m

pm

7p

m

8p

m

9p

m

10

pm

11

pm

12

mn

1a

m

2am

3am

4a

m

5am

6am

7a

m

8am

9am

10

am

11am 12

n

Time

Series 1

3

8

3

6

3

5

3

5

3

5

3

8

3

4

3

5

3

5

Total volume given for first 24 hrs – 3600 ml

• IV calcium gluconate given 6 hrly.

• Amount of fluid reduced to 75ml/hr and then

50ml/hr and then stopped.

• PCV remained stable

• Blood pressure, pulse, CRFT and UOP

maintained.

• No further interventions were necessary.

LESSONS LEARNED:

Treat both

impending shock (prolonged CRFT, narrow

pulse pressure, severe postural drop of BP,

hypotension)

Full blown shock (BP un-recordable)

AGRESSIVELY and PPOMPTLY.

With crystalloid bolus and gradual reduction of

fluid.

If PCV is low, give blood.

May need dextran later.

CASE 3: OVER-LOADING IS EASY !

• A 30 yr old male with DHF was referred (at a

private hospital) on 14th Sep.

• Admitted on 12th at 5 pm & transferred to ICU on

13th at 6 pm.

11.09.11 12.09.11 13.09.11

HCT 40.8 41.2 48.0

PLATELET 112,000 58,000 12,000

OVER-LOADING IS EASY !

• Fluid given for 24 hrs = 4150 ml.

• Now the patient has got B/L pleural effusions and

ascites.

OVERLOADED PATIENT:

• PCV increased to 52

• Pulse pressure narrowed to 20 with a postural drop

of 30 in SBP.

• Dextran 500 ml given over one hour with 10 mg

of frusemide

• Pulse pressure improved.

• Good UOP.

• Patient recovered without any further intervention

LESSONS LEARNED:

• Fluid overload can occur un-intentionally.

• Patients should be told how much and what to

drink

• Dextran is useful in fluid overloaded patients

• Frusemide in small doses is very effective

DEXTRAN 40

• Preferred colloid in DHF

• Mechanism of Action - Produces plasma volume

expansion by virtue of its highly colloidal starch

structure, similar to albumin

• Given as a bolus in DHF– 250 ml over 30 mins or

500 ml over 1 hr. Not as a slow infusion.

• Recommended maximum – 1500 ml for 24 hrs.

• Should not be used in a dehydrated patients who

present with shock and high HCT until the

hydration is corrected with crystalloids.

CASE HISTORY: DELAY COSTS !

Mrs. R

53 year old female

Diabetic and hypertensive

Admitted on 08/06/2011 11.05 pm

D3 of fever

On admission

Pulse 88/min, BP 120/80,(110/80)

CRFT < 2 sec, Liver 2 cm, tender.

WBC – 1600 N – 43%

Hb – 13.7 PCV – 42 platelet – 40,000

SHO seen 09/06/2011 at 4 am.

• Patient C/O dizziness

• No bleeding manifestations

• CVS - PR – 104

BP – 130/90 supine

100/80 sitting

• CRFT - < 2sec

• Tender hepatomegaly

• R/S pleural effusion

• PCV - 46

• Critical period 4.00am 09/06/2011 to

4.00 am 11/09/2011

• From 4.00 am to 9.00 am 100ml/hr

• Bolus of N. saline 500ml at9.00am

• After that 150ml/hr x 3hrs

100ml/hr x 39 hrs

PCV 46 49.7 48 46 46 47 32? 40 40

39

Pul p 40 20 30 30 30 30 30 30 30 25 30 40

0

100

200

300

400

500

600

1 5 9 13 17 21 25 29 33 37 41 45

fluid intake

CRFT <2 <2 <2 <2 <2 <2 <2 >2

• Critical period over at 4 am on 11.06.11.

• By end of critical period 5350ml fluid given

• Blood ordered at 6.30 am

• Admitted to ICU 9.25 am

• On admission to ICU

PR- 120/min BP 110/90 mmhg

Pt dyspnoec, with oxygen SPO2- 96% RR - 38

• Blood 2 pints received at 10.40am!! After 4 hrs

10 pm

10.06.11

4 am

11.06.11

5 am

11.06.11

PCV 39 33 32

1st 24 hours after critical

period

PCV 33 32 28 26 39 39 38 35 31 39

42 45 46

0

50

100

150

200

250

300

350

400

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

oral

dextran

blood

crystalloid

• Patient developed shock on 11/06/2011 evening

with impalpable peripheral pulses and cold

extremities

• Femoral CVP catheter inserted.

• Patient developed respiratory distress and was

intubated on 12/06/2011 at 6.30am

WBC PLATELET

11.06.11 9000 32,000

12.06.11 7200 40,000

2nd 24 hours after critical period

12/06/11

PCV 41 35 32 35 41 31 33 37 37 37 36 35 37 37

37 37

0

100

200

300

400

500

600

700

800

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

tetra

crys

blood

FFp

dextran

2ND 24 HOURS AFTER CRITICAL

PERIOD 12/06/11

• Inspite of blood and fluid boluses, patient was

going into shock repeatedly.

• Decided to aspirate the R pleural effusion

• Activated factor VII two vials given

• Pleural effusion aspirated.

•1600 ML OF BLOOD ASPIRATED.

PERIPHERAL CIRCULATION RETURNED

IN THE MIDWAY OF ASPIRATION.

3RD 24 HOURS AFTER CRITICAL PHASE 13/06/11

PCV 37 37 37 37 38 40 39 38 40 39 39 38 38 39 34 35 37 40 43 41 41

40 40 39

0

50

100

150

200

250

300

350

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

blood

dextran

crystalloid

• R/S pleural aspiration repeated 14/06/2011

1300ml blood aspirated

• Patient extubated on

16/06/2011

• R/S Intercostal tube inserted due to persistant

haemothorax on 17/06/2011

1070ml drained.

• Throughout clotting profile – normal

• Slight elevation of liver enzymes

• Renal functions – low K+

• Low Serum calcium – i.v calcium gluconate

given

• Good glycaemic control on insulin

• CRP – 67- 225 – 162 -16

• Patient respiratory secretions culture - MRSA

• Pleural fluid culture and blood cultures – sterile

• Treated with antibiotics + chest physiotherapy

CASE PROFOUND SHOCK

A 10 year old boy presented at E/S

C/O

•Fever ---05 days

high grade, continuous with body aches

• Melina ---01 day

two episodes and

one episode of hematochezia

• Altered conscious level --1 hour

• Unwell looking GCS 12/15 A febrile

• Pulse Feeble BP un recordable

• Cold clammy skin

• CRT>2sec

• Abdomen tender, Liver 3cm blcm and tender TT + ve

• USG abdomen pericholic fluid

• Pelvic ascites

O/E

Management

Fluid resuscitation with crystalloid

Push with N/saline 20ml /kg

Repeat with 10 ml/kg

Dextran 40 10ml/kg over 1 hour

Pulses palpable but tachycardia

Crystalloids continued

Day 5 Day 5

TLC 8,000 7,600

Platelets 10,000 9,000

Hct 28 35

Blood Transfusion

• Crystalloids

• 18 hours later developed tachycardia

• Narrowed pulse pressure

• Amount of fluids increased

Day 6 Day 7

TLC

Plt 8,000 7,000 7,000 7,500 8,000

Hct 38 39 30 36 35

Packed Cells Transfusion

Crystalloids gradually tapered

CASE

• A six year old girl presented in emergency with

C/O:

• Fever ---04 days

high grade continuous with body aches

• Epistaxis ---01 day

3 episodes

• Vomiting --- 01 day

2-3 episodes

• Fit-----half hour

1 episode, Generalized tonic / colonic

ON EXAMIANTION

Lethargic , but arouse able child SOMI -Ve

PR- 80/min, BP- 100/80mmHg, Temp- 100F,

Abdomen mildly tender

Liver palpable 2 cm below costal margin

TT +VE

No clinical and radiological evidence of pleural

effusion

Ultrasound abdomen showed no free fluid

TLC 3,500 Plts 80,000 Hct 36% BSR

20mg/dl

INITIAL MANAGEMENT

• BSR corrected

• Maintenance fluid (Oral + I/V)

• Vitals’ Monitoring 4 Hourly

ON DAY 5

•Pulse rate 95/min

•Blood pressure 100/75

•Liver palpable 3 cm BCM and tender

•Ultrasound abdomen showed gall bladder wall

edema and mild pelvis ascites

Day 5

TLC 2,000 2,500 3,000

Platelets 20,000 15,000 14,000

Hct 35 40 38

Crystalloids continued

ON DAY 6 (AFTER NOON)

• Pulse rate 120/min

• Blood pressure 100/85

Day 6

TLC 3500 3,500 4,000

Platelets 14,000 12,000 10,000

Hct 36 38 48

Crystalloid bolus with 10 ml / kg

Tapered gradually