Pakistan Dengue Management 14.9.11

Overview & Management of Dengue

Kolitha SellahewaMBBS.MD.FCCP.FRACP(Hon.)

Consultant Physician

Epidemiology Unit

SRI LANKA

Dengue Viral Infection

Asymptomatic - 75% Symptomatic – 25% Dengue fever – 99% DHF – 1% (10,000 infected only 25

DHF) Dengue with severe & often life

threatening complications Shock Bleeding - DIC

Dr. Kolitha Sellahewa

Clinical CourseDHF

Febrile phase 2 – 7 days

Critical phase 3-7 days Lasts only for 24 – 48 hours

Convalescent phase Begins after the critical phase & lasts for

5 - 7 days


Febrile Phase

High continued fever Skin erythema Myalgia Arthralgia Headache Leucopenia < 5000 cells/c.mm Thrombocytopenia Tender hepatomegaly – DHF > DF


Febrile Phase DF? Or DHF? DF

Skin rash Arthralgia Bone pain

DHF Tender hepatomegaly

Common Leucopaenia < 5000 Thrombocytopaenia Bleeding manifestations


Critical PhasePlasma Leakage 24-48Hrs

Tachycardia Narrowing of pulse pressure < 20

mm CRFT > 2 secs HCT 20% increase from base line Pleural effusions Ascitis Ser albumin < 3.5 g/dl Non fasting ser cholesterol < 100

mg/dlDr. Kolitha Sellahewa

Dynamics of Plasma Leakage


R0 Hr

24 Hr

48 Hr

F C6 Hr

36 Hr

Rapid SlowModerate


0 Hr

24 Hr

48 Hr

Time of Presentation and Management

F C RDr. Kolitha Sellahewa

Early Recognition of Entry into Critical Phase WBC 5000 or less + TT +ve & PLT

< 100,000 entering CP next 24 Haemoconcentration

HCT progressive rise HCT 20% rise from baseline

Radiology CXR – right lateral decubitus US scan

Oedematous gall bladder wall Ascitis Pleural effusions Dr. Kolitha Sellahewa

Confirm Entry into the Critical Phase Evidence of plasma leakage

Pleural and/or peritoneal cavities

Radiology CXR – right lateral decubitus US scan

Oedematous gall bladder wall Ascitis Pleural effusions

Biochemistry Ser albumin < 3.5 g/dl Non fasting ser cholesterol < 100 mg/dl


How to time the onset of critical phase and predict end ....

Have serial FBCs done during the illness , ideally from the same reliable lab

Beyond Day 3...when WBC is dropping below(or close to) 5000 and platelets are <150,000 and dropping do more than once/day

DO FBC – Not PCV & Platelets!!!Dr. Kolitha Sellahewa

How to time the onset of critical phase?

17th 8 am

D3

18th

8 am

D4

18th 8 pm

D4

19th

8 am

D5

19th

8 pm

D5

20th 8 am

D6

20th 8Pm

D6

21st

8 am

D7

21st

8 pm

D7

WBC 3200 2800 1900 2900 3700 4500 6000 7000 7300

N % 53 41 31 26 25 31 33 43 58

L % 44 56 68 71 73 67 66 55 41

PCV %

39 36 39 42 43 39 44 43 38

Plt 252000

121000

110000

61000

22000

18000

12000

8000 19000Onset End

How to time the onset of critical phase?

17th 8 am

18th

8 am18th 8 pm

D4

19th

8 am19th

8 pm20th 8 am

20th 8 pm

21st

8 am21st

8 pm

WBC

3200 2800 1900 2900 3700 4500 6000 7000 7300

N %

53 41 31 26 25 31 33 43 58

L % 44 56 68 71 73 67 66 55 41

PCV %

39 36 39 42 43 39 44 43 38

Plt 121000 96000 94000

41000

22000

18000

12000 8000 19000

Timing the onset of critical period

17th 8 am

18th

8 am18th 8 pm

19th

8 am19th

8 pm20th 8 am

20th 8 pm

21st

8 am21st

8 pm

7500

7000

6500

6000

5500

5000

4500

4000

3500

3000

2500

2000

1500

260,000

240,000

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Timing the onset of critical period

17th 8 am

18th

8 am18th 8 pm

19th

8 am19th

8 pm20th 8 am

20th 8 pm

21st

8 am21st

8 pm

7500

7000

6500

6000

5500

5000

4500

4000

3500

3000

2500

2000

1500

260,000

240,000

220,000

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

platelets

WBC

Convalescent Phase

Good appetite Convalescent rash Pruritus

Palms & soles Heamodynamic stability Bradycardia Diuresis Stabilization of HCT Rise in WBC rise in platelet count


Convalescent Rash

ManagementOut Patient

Restricted Physical Activity Diet & fluid Antipyretics

Paracetamol Do NOT give NSAIDs NOT even

suppositories Advice on review & admission


Criteria for AdmissionEssential

Warning signs Abdominal pain or tenderness Persistent vomiting Lethargy & restlessness Hepatomegaly Mucosal bleeding Evidence of plasma leakage

Platelet count < 100,000 cells/c.mm


Criteria for AdmissionEssential

Pregnancy Elderly patients & infants Obese Co morbidity

Diabetes IHD Chronic renal failure


Criteria for Admission

Looks ill Social reasons

Poor home support Poor access to hospital facility Living alone

Individual discretion


ManagementInward

Diagnosis – Dengue infection Recognize the clinical type – DF or

DHF? DHF – phase of the illness ? Fluid therapy Monitoring & documentation Adjuvant therapy


Diagnosis

Hyper-endemic setting Think of dengue – all with fever with in 8 days

Clinical Laboratory data – not essential Features of a viral infection

Acute onset of fever Myalgia Arthralgia Retro-orbital pain Usually corhyza is abscent Rash - Diffuse blanching erythema

WBC < 5000 cells / c. mm Positive tourniquet test (PPV >85%)Dr. Kolitha Sellahewa

Differential Diagnosis Leptospirosis

Occupational history Muscle tenderness - calves Icterus Conjunctival injection Polymorphonuclear leucocytosis Thrombocytopenia

Other viral fevers Leucopaenia Normal platelet count


Diffuse blanching erythema

Rash in Dengue

Diffuse erythematous macules Maculo-papular Petechial Diffuse blanching erythema Blanching papular erythema


Dengue fever

Identify the Clinical Type

DF No plasma leakage

DHF Plasma leakage Platelet count < 100,000

With or without shock With or without bleeding

Patient with unusual or uncommon complications – Exceedingly rare


Risk Stratification

Patient - stable but has predictors of developing severe disease

Abdominal pain Persistent vomiting Mucosal bleeding Lethargy & restlessness Tender hepatomegaly Ascitis, pleural effusions Increase HCT with rapid decrease in platelet

count WBC,5000 with relative lymphocytosis & an

increase in atypical lymphocytes Elderly, Pregnancy & co-morbid states


Recognize the Stage of the Disease

Febrile phase Critical phase Convalescent phase

Day of the illness ? Evidence of plasma leakage ?

Convalescent rash ?

HOW


Fluid Therapy“No Fixed Regime”

Cornerstone of management Dynamic approach Be fully aware of the dynamics of

the disease Mode of intervention depends on:

Phase Clinical type

Type of fluid Oral fluids Crystalloid Colloid Dr. Kolitha Sellahewa

Fluid Shifts

N.Saline – 1 hour Colloids – 4 to 6 hours


Febrile Phase

Oral fluids only Electrolyte solutions

IV fluids are not mandatory Undue vomiting or diarrhea Oral fluids not tolerated

Quantity: 1500ml – 2500ml/24Hrs Both oral & IV

Type: N.Saline


Critical Phase of DHF Without Shock

Objective: Prevent progression to shock Avoid fluid overloading

Judicious fluid therapy- Fluid restriction Quantity – calculated

M+5% = 4600 ml / 48 hrs (50Kg) Full quota for entire critical phase 48 hrs Approximately 90 ml/hr Adjust infusion rate to match the dynamics of

plasma leakage Type:

N.Saline

MonitorHRPP > 20 mm HgCRFT < 2 secsU.O.P. 0.5-1ml/kg/hrHCTRR <20/mt


Calculation of Total Fluid Quota for the Critical Period

M = 5 % = M + 5% =


Guide to rate of fluid intake in Critical Phase

PulseBPPulse PressureCRFTWarmth / ColdnessUOP – ml/kg/hrEvidence of Bleeding


DHF with ShockAggressive Fluid Therapy

Objective Resuscitate Prevent further shock Anticipate & prevent complications of shock

GIT bleeding & DIC Intervention depends on: Compensated shock

Systolic pressure maintained but signs of reduced perfusion

Narrow Pulse Pressure Cold extremities Low volume pulse

Hypotensive shock Unrecordable BP & Pulse Dr. Kolitha Sellahewa

Compensated Shock

N.Saline 10ml/kg (approx 500 ml) IV – 1Hr No improvement

Collect blood venous BGA Calcium HCT before & after fluid

bolus Sugar Sodium Grouping & DT

Colloid bolus 10ml/kg IV over 1 hr Colloid boluses

Haemodynamically unstable HCT drops

Blood transfusion


Hypotensive Shock HCT before & after fluid bolus

N.Saline 10ml/kg IV bolus over 15 mts

2nd bolus 10 ml/kg over 60 mts Collect blood

Blood gas analysis Calcium Electrolytes Sugar Grouping & cross matching

Colloid 10 ml/kg IV bolus over 1 hr


Choice of ColloidBoluses NOT infusions

Dextran 40 3 boluses over 24 hours 6 boluses over 48 hours

6% starch-Heta starch(Voluven) 5 boluses over 24 hours 10 boluses over 48 hours

Fresh Frozen Plasma 1 bolus 3 units approximately 450 – 600 ml


Monitoring & Documentation Early detection of shock

Pulse pressure < 20 mm Hg CRFT > 2 secs HCT increase of 20% or more from baseline

Judge the efficacy of IV fluid therapy PP , CRFT, No postural hypotension Hourly UOP 0.5 – 1.0 ml/kg/hr

Early detection of complications of fluid therapy

Respiratory rate > 20/mt Lung bases SaO2 < 92% CXR


0 Hr

24 Hr

48 Hr

Time of Presentation and Management

F C R

DHF

Date/TimeFebrile

Date/TimeCritical

Date/TimeConvalesce

nt


Basic MonitoringAll Patients

Pulse rate Pulse pressure CRFT Respiratory rate FBC - HCT Intensity of monitoring depends on

Phase of the illness Severity Aggressiveness of fluid therapy

Accurate fluid balance chartsDr. Kolitha Sellahewa

Monitoring Platelet Count Drops Below 100,000

FBC- twice daily Vital parameters- four hourly

Pulse rate Blood pressure (both systolic and diastolic), Respiratory rate, Capillary refill time

Detailed fluid balance chart- Type and route of fluid hourly, Urine output four hourly


MonitoringEvidence of Plasma Leakage

Escalate Vital signs - hourly HCT - 8 hourly Fluid intake & the balance left from

the calculated quota Temporal relationship Critical phase In hours

Detailed fluid balance chart


MonitoringIV Fluid Therapy

Phase of the illness – be fully aware Adequacy of fluid therapy

Pulse Pressure >20 mmHg CRFT <2 sec Pulse Rate <80/mt UOP > 0.5 ml/Kg/hr HCT

Early detection of fluid overloadingRespiratory rate > 20/mt

Lung bases SaO2 < 92% CXR

Shift toICU


Monitoring Chart I - for Management of Dengue Patients – Febrile Phase

Vital Signs

Purposes:

•Differentiate DF from DHF

•To detect entry in to Critical

Phase

Purposes:

•Differentiate DF from DHF

•To detect entry in to Critical

Phase



Dengue

FeverDengue

Fever D4 without Fever

D3 with FeverWBC<5000/mm3

N-40% L-58%TT + ve



D4 with FeverTT + ve, WBC<5000/mm3

N-40% L-58%Tender Liver


Entry in to Critical

PhaseEntry in to Critical

Phase

Monitoring Chart II for Management of DHF Patients during Critical Phase Patient to be monitored hourly

Name of the patient ………………………………………………………BHT……………………………….Date and time of admission ………………………………ward -…………………

Critical Phase Commencing date and time -…………………………………………………….. End date and time …………………………………

10 9 8 7 6 5 4 3 2

1.5 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

PCV

Fluids

HR

BP

Pulse Pressure

RR

CRFT extremities

UOP UOP

ml/Kg/hr Platelet count

Weight - …………………………………

Height - ……………………………

Ideal body weight - …………… M- ………………………………… M+ 5% = …………………………ml

Annexure II

Used

Remaining

Monitoring Chart II for Management of DHF Patients during Critical Phase

Purposes:

•Early detection of Shock

•Accurate Fluid

management

Purposes:

•Early detection of Shock

•Accurate Fluid

management


0 Hr

24 Hr

48 Hr

Date/Time Scale 2 Hrs

Date/Time Scale 20 HrsDate/Time Scale 36 Hrs


Monitoring Chart II for Management of DHF Patients during Critical Phase


Monitoring Chart III to be used during the Peak of leakage and during the shock Patient to be monitored every 15 minis

ABW – 19 kg; IBW – 21 kg Maintenance – 1450 ml

(Maximum 3 per 24h / 6 per 48h) M + 5% = 2400 ml for 24 hours : (Maximum 5 per 24h / 10 per 48 h)

Other fluid : PRC/WB …………………………….

Fluid ml/Kg/ hr

20

10

9

8

7

6

5

4

3

2

1

time 12.30 p.m.

12.45 p.m.

1.30 p.m

1.45 p.m.

2.45 p.m.

4.15 p.m.

6.00 p.m.

7.00 p.m.

8.00 p.m.

10.00 p.m.

PCV – 49% 56% 51% 41% 46% 51%

Fluids

HR NR Stable Weak Good

BP NR 75/65 92/56 Stable Good

Pulse Pressure

CRFT UOP

ml/Kg/hr No No No

Platelet count - 92000 29000 General

Condition well Stable

90 min.

1h 45min

3 hours

Used

Remaining

1002.25 ml 1195.25 ml 1477.25 ml

922.75 ml 1207.75 ml 1397.75 ml

902.5 ml

1497.5 ml

760 ml

1640 ml

570 ml

1830 ml


Full Blood Count

DENGUE INVESTIGATION SUMMARY

Name: -------------------------- Age: -------------------------- Hospital: ----------------------- Ward: ---------------

BHT: ------------------------------------

Hb

PCV

Platelet

WBC

N

L

Se.Creatinine

Blood Urea

Se. Na+

Se. K+

Se.Ca2+(Ionized)

SGPT

SGOT

PT / INR

Se. Albumin

Se. Cholesterol

Urine Output-Total

UOP-ml/hour

Pulse

Blood Pressure

Pulse Pressure

CXR –R. Decubitus

US Scan

Fluid Rate (ml/kg/Hour)

Type of Fluid

Other Ix

Remarks

Date

Summary – Febrile Patient

Dengue or not? Clinical FBC

Leucopaenia + thrombocytopaenia

DF or DHF ? Plasma leakage + or –

If DHF – what is the phase ?


Summary In Critical phase

Time of entry Predicted time of end

Aggressive monitoring Calculate the fluid quota Dynamic approach to fluid therapy Final diagnosis – precise (DF or

DHF & grade)Dr. Kolitha Sellahewa

COMPLICATIONS – Non?

Vigilance – detect Alert – plasma leakageActive – IV fluidAggressive - manipulate


THANK YOU

Complications and Adjuvant TherapyComplications and Adjuvant Therapy

Dr. Jayantha WeeramanConsultant Paediatrician

Dr. Jayantha Weeraman

Pts with complications ....

Usually due to

• PROLONG SHOCK• FLUID OVERLOAD


Bleeding in Dengue Hemorrhagic Fever

Phase Early Pre-Shock Shock Prolong-sh Death

Severity of Mildof Bleeding Moderate

SEVERE

Mechanism Drug Vascular injury Platelet Dysfunction

Thrombocytopenia Coagulopathy-DIC

Fibrinolysis


Fluid overload– Too much fluids in febrile phase– Calculation of fluids in obese pt-ABW vs

IBW– Use of hypotonic saline– Given excess fluids– Given more than time of leakage– Not using colloidal solution when indicates– Not giving blood when there is concealed

bleeding– Inappropriate IV Fluids for “severe

bleeding”Eg: FFP, platelets & cryo


Management of fluid overload

Frusemide 1 mg/kg

Critical Phase


Indications for IV Frusemide

Midway in the infusion of colloids when colloids are given to patients who are already fluid overloaded or who are likely to be overloaded depending on the fluids already given.

Midway between blood transfusions. In patients passing less than 0.5ml/kg/hr of urine

despite receiving adequate fluids and having stable BP, pulse, Hct to improve the UOP.

During recovery phase when there is suggestion of pulmonary oedema or fluid overload.


Prolonged shock

– Delayed diagnosis/ delayed resuscitation

– Late presentation– Fluid restriction without

monitoring


Prolonged shock in dengue – a challenge to clinicians?

> 4 hours untreated Liver failure- prognosis 50% Liver + Renal failure - prognosis10% 3 organs failure (+respiratory failure) –

Prognosis is a miracle!!!

> 10 hours untreated - Death!!!


Complicated DHF When a pt is deteriorating with no response to fluid therapy….

A: AcidosisB: BleedingC: CalciumS: Sugar

A: AcidosisB: BleedingC: CalciumS: Sugar


A : Acidosis

Acidosis is common in profound shock Prolonged acidosis makes patients

more prone to DIC Correct acidosis if pH is <7.35

together with HCO3- level <15 mmol/l One may use empirical NaHCO3

1ml/kgs slow bolus (max 10ml) diluted in equal volume


B : Bleeding

Significant overt bleeding - >6-8ml/kg BW

Concealed bleeding


When to suspect bleeding ?

• When PCV drop without clinical improvementEven with bleeding the PCV drop may take time(4-5hrs). When the pt does not show improvement important to do repeat PCVs frequently!

• Haematocrit not as high as expected for the degree of shock to be explained by plasma leakage alone. (Hypotensive shock with low or normal HCT)

• Severe metabolic acidosis and end-organ dysfunction despite adequate fluid replacement


Massive bleeding

Not given blood transfusion

Delayed blood transfusion

Remember!!!In DHF Bleeding could be concealed


How to manage bleeding Use PRC or WB If there is fluid overload(most frequently)

use PRC as 5ml/kg at once and repeat only if needed depending on the response

If there is no fluid overload use 10ml/kg of WB

Even if bleeding is likely and if PCV is >45% do not give blood without bringing down the PCV first by giving a colloid.


..how to manage bleeding

• 5ml/kg of PRC or 10ml/kg of WB will increase PCV by 5%

– Eg.10 year old girl with PCV of 26% in shock..

– Base line PCV in a 10 yr old 36% but if in shock it will be up by 20% 43%. There is 17% deficit which need 3 PRC transfusuions


C : Hypocalcaemia

Every patient with complicated DHF has hypocalcaemia.

Dengue patients who develop convulsions are likely to have hypocalcaemia.(may give them empirical calcium)

Detection of hypocalcaemia: Measure serum Ca2+ level Corrected QT interval in ECG


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 bradycaria while pushing slowly) Max: 10ml. Can even give every 6Hrs if pt is not improving


Treat if blood sugar below 4 mmol/lt

Give 10% dextose 3-5ml/kg bolus followed by an infusion

S : Hypoglycaemia


Platelet transfusion- when platelets are low may need but

only in very exceptional circumstances (Thailand only in <0.4% of pts with DHF) Each platelet pack is 50-150ml

contribute to fluid overload No prophylaxis platelet transfusion


Why do you do platelet counts?

To recognize the beginning of critical stage- YES

To decide on platelet transfusion- NO As a prognostic indicator- YES


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 in cases with bleeding where the cause is not prolonged shock BUT other reason: peptic ulcer, trauma etc


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


NO PLACE FOR STEROIDS AND IV IMMUNOGLOBULINS IN DENGUE

Crystalloid100%

Colloid20-25%Blood

10-15%

Blood & blood component used in DHF/DSS patients

Platelet 0.4%


Myocardial involvement in Dengue

Global dysfunction of myocardial contractility seen in prolonged shock

Due to, metabolic acidosis, Hypocalcaemia

Unlikely to cause death If myocarditis is suspected fluid

should be given very carefully Rx- Symptomatic


Causes of death in DHF patients

• Prolonged shock– Delayed diagnosis/ delayed resuscitation – 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 co-morbidity– Dual infection Dr. Jayantha Weeraman

THANK YOU

Pakistan Dengue Management 14.9.11

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