Dengue Fever & Dengue Shock Syndrome -...

Dengue Fever & Dengue Shock Syndrome

07-May-18 PLES / SLCP 1

Objectives

Early diagnosis

Pathophysiology of DHF

Proper management

How to avoid complications

Case


Febrile Phase

• High fever 2-7 days

• Facial flushing

• +ve TT

• Haemorrhaegic diathesis

• Enlarged liver


Early diagnosis of Dengue

• High fever, No coryza

• FBC in day 3• WBC < 5000• Platelet count <150000

• Hess’s test – positive

• NS1 Ag• Day 1-3


DF Vs DHF

DF

• No plasma leakage

DHF

• Evidence of plasma leakage


Febrile

RecoveryCRITICALFebrile

Recovery

Febrile

Febrile

Recovery

Recovery


DF – Febrile phase

• Adequate rest at home

• Adequate amount of oral fluid intake

• Paracitamol only (Oral or PR)

• No NSAID drugs

• Monitor for warning signs

• Monitor with FBC 07-May-18 PLES / SLCP 7

DF – Critical Phase

• 3-5 days

• Rapid drop of temp

• ↑ Capillary leak (24-48hrs) – Pulse pressure narrowing

• Abdominal pain

• FBC – ↑ HCT & ↓Platelets • +/- Liver derangements • Hypoalbunaemia


DF – Critical Phase Identify the beginning of the capillary leak

• Platelets <100000

• PCV rise towards 10% 20%

• Pleural effusions (detected by clinically, by USS)

• Ascites (detected by clinically, by USS)

• Low albumin / Low cholesterol?


Critical phase – Capillary leak

Fluid leak in to 3rd space (pleural space & ascites)

Hypovolaemia

Shock

MODS (poor organ perfusion)

Death 07-May-18 PLES / SLCP 10

Fluids – How much ? ; How long ?

• Identify the beginning of the leak

• Predict the end

• Try to give only M+ 5% of fluids / 48hrs

• Match the leak


Rate IV Fluid : Compare adult and children


How to “Match the leak”

UOP 0.5 ml/kg/hr – Only objective parameter

PCV (every 4 – 6 hourly)

Pulse volume

Peripheral coldness

CRFT

BP


Management of leaking phase

Minimal fluids in febrile phase

Sufficient fluids in critical phase

Calculate fluid for the ideal body weight in obese children

Minimal fluids in recovery phase


Indications for urinary catheterization

•All high risk patients during the critical phase

• Patient with 1st shock

• Patient with complications

• Platelets <50,000


Case History – on Admission to Hospital @ 3 days

Clinical Scenario

• 4 years old child, weight-15kg

• WBC –3500, N-27%, L-62%

• Platelets – 98,000

• PCV – 36.3%

Commence Specific Treatment

•PCV monitoring

•Maintenance IV drip

1607-May-18 PLES / SLCP

Child developing leaking while in the hospital


Case History - 8hrs after admission

Clinical Scenario

• RR-22/min

• Extremities cold,

• Pulse thready,

• CRFT >4 seconds,

• BP was 80/65 (normal).

• Liver 4cm.

• A V P U

• PCV – 45%

Commence Specific Treatment & Monitoring

• 0.9% Saline 10ml/kg bolus over 1 hour

• Cathereterize

• Urine output (0.5-1 ml/kg/hr )

PLES / SLCP Compensated shock 07-May-18 18

How do you adjust the drip rate

• 10ml/kg/hr

• 7ml/kg/hr

• 5ml/kg/hr


When the patient is not improving

Acidosis

Bleeding

Calcium & electrolytes

Sugar


Case History – 12 hrs after admission

Clinical Scenario • RR-22/min

• pretty cold,

• pulse – very thready,

• CRFT – 5 seconds,

• BP was 40/00.

• A V P U

• Vomiting coffee ground stuff.

• PCV – 50%

• Repeat SGPT-1273,

• SGOT-1023


40% Dextran bolus 10ml/kg over an hour

Followed by 0.9% N.S 10ml/kg over 1 hour

↑ fluid to maintain urine output > 0.5ml/kg/hr – Only objective parameter)

07-May-18 PLES / SLCP 21Uncompensated shock

Simulating natural course

Natural course Admitted with shock


Case History – 26 hrs after admission

Clinical Scenario

• RR-22/min

• Cold

• pulse was moderate

• CRFT – 3 seconds,

• BP 90/65.

• A V P U

• PCV – 35% (dropped)


Pack cell transfusion 5ml/kg

↑ fluid to maintain urine output > 0.5ml/kg/hr

PLES / SLCP Acute Bleed07-May-18 23

Case History – 35 hours of leak

Clinical Scenario Received 120% fluid quota.

Responding to questions,

RR-40bpm, reduced AE on the both side, SpO2 – 94% with face mask O2,

pulse low volume with cold up to wrist.

Abdomen is distended with asicitis.

PCV is rising 40%


40% Dextran bolus 10ml/kg over an hour with frusemide infusion / Bolus

Fluid to maintain urine output > 0.5ml/kg/hr & organ perfusion

PLES / SLCP Fluid Overload 07-May-18 24


High risk patients

• Infants

•Obese patients

• Prolonged shock

•Bleeding

• Encephalopathy

•Underlying diseases

• Pregnancy

Summary

Early diagnosis

Pathophysiology of DHF

Rational fluid management

How to manage complications


Dengue Fever & Dengue Shock Syndrome -...

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