DENGUE MANAGEMENT

Course of illness

Dengue classification

Diagnosis of dengueVirus isolation in cell culture More

accurateNucleic acid detection by PCRViral Ag detection(e.g., NS1)-day 1, 60-80%

in 2° infec.Specific antibodies (IgM, IgG)- after D5IgM-persists 30-90 days IgG-Remains detectable for 60 yrs.

Diagnostic if >4 fold rise in titer in samples collected 14 days apart.

Management of dengueNo specific antiviralsSymptomatic, supportiveFever- tepid sponging/ ParacetamolMaintain proper fluid balance. Oral/i.v.i.v. hydration usually needed for 24-48 hrsTitrate fluids according to urine output, vitals

and hct.Early blood transfusion in patients with

unstable vitals in the face of decreasing hematocrit.

Approach to the Management

Groups A• may be

sent home• tolerate

adequate volumes of oral fluids and pass urine at least once every 6 hours

• no warn signs

Groups B• referred for

in-hospital management

• with warning signs, co-existing conditions,

• with certain social circumstances

Groups C• require

emergency treatment and urgent referral

• severe dengue (in critical phase)

Management Decisions

Group A Action Plan• Encourage intake of ORS, fruit juice and other

fluids• Paracetamol for fever• Advise to come back if warning signs develop

no clinical improvement severe abdominal pain persistent vomiting cold and clammy extremities,lethargy or irritability or restlessness, bleeding

not passing urine for more than 4–6 hours.monitor:

temperature , volume of fluid intake and losses, warning signs, signs of plasma leakage and bleeding, haematocrit, and white blood cell and platelet counts

Group B (without warning signs) Action Plan

• If not tolerating oral fluids, start intravenous fluid therapy of 0.9% saline or Ringer’s lactate with or without dextrose at maintenance rate

Patients may be able to take oral fluids after a

few hours of intravenous fluid therapy.

• Close monitoring

Group B (with warning signs) Action Plan

• reference hematocrit before fluid therapy• isotonic solutions

5–7 ml/kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response

reassess:• haematocrit remains the same or rises only minimally 2–3

ml/kg/hr for another 2–4 hours • worsening vital signs and rising haematocrit rising 5–10

ml/kg/hour for 1–2 hours

Group B (with warning signs) Action Plan

Give minimum intravenous fluid volume: maintain good perfusion and urine output of about 0.5 ml/kg/hr• Intravenous fluids are usually needed for only

24–48 hours.

monitor: • vital signs and peripheral perfusion (1–4 hourly until

the patient is out of the critical phase)• urine output (4–6 hourly)• hematocrit (before and after fluid replacement, then 6–

12 hourly) • blood glucose • organ functions (renal profile, liver profile, coagulation

profile)

Group C Action Plan

• admit in ICU

• plasma losses should be replaced immediately and rapidly with isotonic crystalloid solution or, in the case of hypotensive shock, colloid solutions

• blood transfusion: with suspected/severe bleeding

• judicious intravenous fluid resuscitation: sole intervention required

Parameters Stable circulation

Compensated shock

Hypotensive shock

Conciousnes level Clear & lucid Clear & Lucid Restless,combative

CRT Brisk<2 s Prolonged >2 s prolonged,mottled

Extremities Warm & pink Cool peripherals Cold, clammy

Periph pulse vol Good volume Weak & thready Feeble or absent

Heart rate Normal for age Tachycardia for age

Severe tachycardia or bradycardia in late shock

Blood pressure N B.P. or pulse pressure for age

N sys. But rising dias. Psr ,Narrowing pulse psrPostural hypotension

Narrow pulse psr(<20 m hg)HypotensionUnrecordable

RR N Tachypnea Hyperpnea/ kussu

Urine output N Reduced trend Oliguria/Anuria

When to stop i.v. fluidsSigns of cessation of plasma leakageStable B.P., pulse and peripheral perfusionHematocrit decreases in the presence of

good pulse volApyrexia(without antipyretics)for more

than24-48 hrResolving bowel/abdominal symptomsImproving urine output

Indications of platelet Tx in DenguePlatelet count- <20,000/cmm21-40,000- only if hemorrhagic symptoms

Treatment of Hemorrhagic Complications

• Do not wait for the haematocrit to drop too low before deciding on blood transfusion• 5-10 ml/kg of PRBC or 10-20 ml/kg FWB• little evidence to support transfusion of platelet concentrate and FFP

Management of Complications•Fluid OverloadCauses:– excessive / too rapid i.v. fluids;– hypotonic rather than isotonic crystalloid solutions;– inappropriate use of large volumes of i.v. fluids in patients with

unrecognized severe bleeding;– inappropriate transfusion of FFP, platelets, cryoprecipitates– continuation of IVF after plasma leakage has resolved

TREATMENT OF FLUID OVERLOADOxygenStop i.v. fluidsDiuretics

Monitoring – Critical Phase Vitals - hourly

Fluid balance chart - 3 hourly

HCT - 6 hourly

Monitoring During Shock15 minute monitoring of vital signs.

HCT immediately before and after each fluid bolus and then at least two to four hourly

DISCHARGE CRITERIA1.Afebrile for 24 hrs without antipyretics2.Good appetite, clinically improved condition3.Adequate urine output4.At least 48 hrs sice recovery from shock5.No respiratory distress6.Platelet count>50000 and stable hematocrit without i.v. fluids

SUMMARYDO‘s and DON’Ts ManagementDon’t use corticosteroidsDon’t give platelet transfusion for low

plateletsDon’t give half (o.45%) salineDon’t assume that IV fluids are necessary

Do tell outpatients when to returnDo recognize the critical periodDo closely monitor fluid intake and output,

vital signs, and hematocrit levels

Contd…..Do recognize and treat early shockDo administer colloids for refractory shockDo give PRBCs or whole blood for clinically

significant bleeding.