DENGUE: WHO GUIDELINES FOR DIAGNOSIS AND TREATMENT

DENGUE:

PAHO/WHO GUIDELINES FOR DIAGNOSIS

AND TREATMENT

PRESENTED BY HSPI BRANCH

MINISTRY OF HEALTH, JAMAICA

JANUARY 2019

OBJECTIVES

• DISCUSS THE CLINICAL MANIFESTATION

• DISCUSS THE CLINICAL CLASSIFICATION

• DISCUSS THE CLINICAL COURSE

• DISCUSS THE SEVERITY RISK ASSESSMENT

• DISCUSS THE CLINICAL MANAGEMENT

DENGUE CLINICAL SYMPTOMS

• EPIDEMIOLOGICAL LINK

• FEVER +2 OR MORE OF

• NAUSEA, VOMITING

• MYALGIA , ARTHALGIA

• RASH

• RETRO-ORBITAL PAIN

• SORE THROAT

• COUGH

DIFFERENTIAL DIAGNOSIS

• LEPTOSPIROSIS

• ARBOVIRUSES –CHIK V, ZIKA, YELLOW FEVER

• RESPIRATORY INFECTIONS

• MEASLES

• RUBELLA (GERMAN MEASLES)

• MALARIA

• MENINGOENCEPHALITIS

• PYELONEPHRITIS

• SEPTICEMIA

DENGUE FEVER

• WIDE SPECTRUM OF CLINICAL

PRESENTATION,

• WITH UNPREDICTABLE CLINICAL

COURSE

CLINICAL CLASSIFICATION

• PREVIOUSLY CLASSIFIED INTO:-

• UNDIFFERENTIATED FEVER

• DENGUE FEVER

• DHF- GRADE 1-IV

DENGUE HAEMORRHAGIC FEVER

• GRADE 1: FEVER, NON SPECIFIC CONSTITUTIONAL

SYMPTOMS; (+) TT- ONLY HAEMORRHAGIC

MANIFESTATION

• GRADE 2: GRADE 1 MANIFESTATION +

SPONTANEOUS BLEEDING

• GRADE 3: SIGNS OF CIRCULATORY FAILURE (RAPID

WEAK PULSE, NARROW PULSE PRESSURE,

HYPOTENSION, COLD CLAMMY SKIN)

• GRADE 4: PROFOUND SHOCK WITH

UNDETECTABLE PULSE AND BP

PATHOPHYSIOLOGY

• IMMUNE MEDIATED

• CYTOKINES GENERATED

• ENDOTHELIAL INJURY

• GLYCOCALYX INTEGRITY COMPROMISED

• PLATELETTES CONSUMED

• INCREASED CAPILLARY PERMEABILITY

• PLASMA LEAKAGE


Severity Classification

DNWS DWWS SD

DENGUE CLINICAL SYMPTOMS

• EPIDEMIOLOGICAL LINK

• FEVER +2 OR MORE OF

• NAUSEA, VOMITING

• MYALGIA , ARTHALGIA

• RASH

• HEADACHE/ RETRO-ORBITAL PAIN

• PETECHIAE/HAEMORRHAGIC MANIFESTATIONS

• (SORE THROAT/COUGH - NOT CRITERIA BUT FREQUENT SYMPTOMS)

WARNING SIGNS• 1. INTENSE ABDOMINAL PAIN OR TENDERNESS

• 2. PERSISTENT VOMITING

• 3. FLUID ACCUMULATION (ASCITES, PLEURAL EFFUSION, PERICARDIAL

EFFUSION, PERIPHERAL EDEMA)

• 4. MUCOSAL BLEED

• 5. LETHARGY/RESTLESSNESS

• 6. POSTURAL HYPOTENSION (SYSTOLIC BP FALLS BY 20MMHG)

• 7. LIVER ENLARGEMENT >2 CM

• 8. PROGRESSIVE INCREASE IN HEMATOCRIT

• 9. INCREASED VASCULAR PERMEABILITY AS EVIDENCED BY

HEMOCONCENTRATION, ≥ 20% RISE IN HEMATOCRIT ABOVE DESCRIBED

AS PLASMA LEAKAGE SYNDROME.



DNWS DWWS SD

SEVERE DENGUE

• SEVERE PLASMA LEAKAGE

• SEVERE HAEMORRHAGE

• SEVERE ORGAN IMPAIRMENT

CLINICAL COURSE

• THREE PHASES

• FEBRILE PHASE

• CRITICAL PHASE

• RECOVERY PHASE

THE CLINICAL PHASES

Febrile Phase

Critical Phase

Recovery Phase

FEBRILE PHASE

facial flushing

skin erythema

generalized body ache

myalgia and arthralgia

headache

sorethroat, injected pharynx,

and conjunctival injection

anorexia, nausea and

vomiting

• Sudden onset of

high-grade fever

• Lasts for 2-7 days

FEBRILE PHASE

• (+) TT increases the

probability of dengue• Tourniquet test

• (+) hemorrhagic

manifestations

• enlarged and tender

liver

earliest abnormality: progressive decrease in total

wbc

LAB CHANGES IN FEBRILE PHASE

• DECREASE INN WBC

• LYMPHOCYTOSIS

• INCREASE IN HAEMATOCRIT (PCV) DUE TO HAEMOCONCENTRATION

• THROMBOCYTOPENIA (FALL IN PLATELETS)

CRITICAL PHASE

• temperature drops to 37.5-38 (days 3-7)

• (+) increase in capillary permeability with increasing hematocrit levels

• significant plasma leakage lasts for 24-48 hours

• progressive leukopenia followed by rapid decrease in platelet precedes plasma leakage

CRITICAL PHASE

• if (-) increase in capillary permeability →

improve

• if (+) increase in capillary permeability →

pleural , pericardial effusion and ascites

• degree of increase above the baseline

hematocrit reflects the severity of plasma

leakage

CRITICAL PHASE

• shock: critical volume of plasma is lost

• temperature may be subnormal

• prolonged shock → organ hypoperfusion → organ

impairment, metabolic acidosis, and DIC → severe

hemorrhage

• severe hepatitis, encephalitis or myocarditis

RECOVERY PHASE

• gradual reabsorption of extravascular compartment

fluid (48-72 hours)

• general well-being improves, appetite returns, GI

symptoms abate, hemodynamic status stabilizes and

diuresis ensues

• (+) rash: “isles of white in the sea of red”

RECOVERY PHASE

• hematocrit stabilizes or may be lower due to dilutional

effect of reabsorbed fluid

• wbc starts to rise

• recovery of platelet count occurs later


DNWS DWWS SD

DENGUE WITHOUT WARNING SIGNS• TRAVELED TO AREAS WITH DENGUE TRANSMISSION IN <14 DAYS, A

FEVER 2 - 7 DAYS +

• 2 OR MORE OF THE FOLLOWING CRITERIA:

• 1. NAUSEA/ VOMITING

• 2. EXANTHEMA

• 3. HEADACHE/ RETRO-ORBITAL PAIN

• 4. MYALGIA AND ARTHRALGIA

• 5. PETECHIAE OR POSITIVE TOURNIQUET TEST

• 6. LEUKOPENIA

DENGUE WITHOUT WARNING SIGNS

• INCLUDE ANY CHILD COMING FROM OR LIVING IN AN AREA WITH

DENGUE

• FEVER 2-7 DAYS

• NO APPARENT FOCUS

DENGUE WITH WARNING SIGNS• EVERY DENGUE CASE THAT, NEAR AND PREFERABLY AT DEFERVESCENCE,

WITH ONE OR MORE OF :

• 1. INTENSE ABDOMINAL PAIN OR TENDERNESS

• 2. PERSISTENT VOMITING

• 3. FLUID ACCUMULATION (ASCITES, PLEURAL EFFUSION, PERICARDIAL

EFFUSION)

• 4. MUCOSAL BLEED

• 5. LETHARGY/RESTLESSNESS 6. POSTURAL HYPOTENSION (LIPOTHYMIA)

• 7. LIVER ENLARGEMENT >2 CM

• 8. PROGRESSIVE INCREASE IN HEMATOCRIT

SEVERE DENGUE

• EVERY DENGUE CASE THAT HAS ONE OR MORE OF THE

• 1. SHOCK OR RESPIRATORY DISTRESS DUE TO SEVERE PLASMA LEAKAGE.

• WEAK OR UNDETECTABLE PULSE, TACHYCARDIA, COLD EXTREMITIES

• CAPILLARY PERFUSION >2 SECONDS

• PULSE PRESSURE ≤ 20 MMHG: HYPOTENSION IN LATE PHASE.

• ACIDOSIS MAY COMPLICATE

SEVERE DENGUE

• 2.SEVERE BLEEDING: BASED ON EVALUATION BY THE ATTENDING

PHYSICIAN

• E.G. HEMATEMESIS (VOMITING BLOOD), MELENA ( BLACK TARRY

STOOL)

• AMPLE METRORRHAGIA (HEAVY VAGINAL BLEEDING)

• CENTRAL NERVOUS SYSTEM [CNS] BLEEDING – PRESENTS WITH

STROKE, COMA, SEIZURES

SEVERE DENGUE

3. SEVERE ORGAN INVOLVEMENT

• LIVER IMPAIRMENT (AST OR ALT ≥1000 IU),

• CNS (IMPAIRED MENTAL STATE),

• HEART (MYOCARDITIS),

• PANCREATITIS

• OTHER ORGANS

REQUIRING STRICT OBSERVATION AND MEDICAL INTERVENTION

APPROACH TO THE MANAGEMENT

• AT PRIMARY AND SECONDARY LEVELS, HEALTH CARE FACILITIES ARE RESPONSIBLE

FOR EMERGENCY/ AMBULATORY TRIAGE ASSESSMENT AND TREATMENT

• TRIAGE IS THE PROCESS OF RAPIDLY SCREENING PATIENTS

SOON AFTER THEIR ARRIVAL IN THE HOSPITAL OR HEALTH

FACILITY IN ORDER TO IDENTIFY THOSE

– SEVERE DENGUE

– WITH WARNING SIGNS

– NON-URGENT CASES

HISTORY• DATE OF ONSET OF FEVER, RASH

• FAMILY OR COMMUNITY DENGUE, TRAVEL TO DENGUE ENDEMIC AREAS

• QUANTITY OF ORAL INTAKE

• NAUSEA, VOMITING OR DIARRHEA

• ASSESSMENT FOR WARNING SIGNS

• CHANGE IN MENTAL STATUS/SEIZURES

• URINE OUTPUT (FREQUENCY, VOLUME, TIME OF LAST VOIDING)

• CO-EXISTING CONDITIONS – PREGNANCY, DIABETES MELLITUS,

CARDIOVASCULAR DISEASE, SICKLE CELL DISEASE

• OCCUPATIONAL HISTORY

• OTHER KEY FEATURES IN HISTORY TO EXCLUDE DIFFERENTIALS

PHYSICAL EXAM• ASSESSMENT OF MENTAL STATUS – ALERT VS LETHARGIC

• ASSESSMENT OF HYDRATION STATUS – DRY VS MOIST MUCOSA

• HEMODYNAMIC STATUS - PULSE, BP, CAPILLLARY REFILL

• ASSESSING FOR RASH, BLEEDING MANIFESTATIONS

• ASSESSING FOR PLEURAL EFFUSION

• ASSESSING FOR ABDOMINAL PAIN, ASCITES, HEPATOMEGALY

• TOURNIQUET TEST

• INVESTIGATIONS : CBC, NS1,PCR, IGM (PER PROTOCOL) FOR ALL

SEVERE CASES, CASES WITH WARNING SIGNS OR RETURN CASES

INVESTIGATIONS :CBC, NS1,PCR, IGM (PER PROTOCOL)

FOR ALL SEVERE CASES, CASES WITH WARNING SIGNS OR RETURN CASES

PT, PTT, LFT’S, UAND E’S, GRP & XMATCH


DISEASE NOTIFICATION

• IN DENGUE-ENDEMIC COUNTRIES, CASES OF SUSPECTED, PROBABLE

AND CONFIRMED DENGUE SHOULD BE NOTIFIED

• PUBLIC HEALTH MEASURES

– SUSPECTED CASES

• CLINICAL CRITERIA OF DENGUE

• LIVES IN OR HAS TRAVELLED TO A DENGUE-ENDEMIC AREA

• FEVER FOR THREE DAYS OR MORE

• LOW OR DECREASING WHITE CELL COUNTS

• THROMBOCYTOPAENIA ± POSITIVE TOURNIQUET TEST


Groups A• may be sent

home• tolerate

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

• no warning signs

Groups B• stabilise

• refer if doesn’t settle

• with warning signs, co-morbidities

• with social risk

Groups C• Emergency

intervention and refer to tertiary centrewhere possible.

• severe dengue (in critical phase)

Management Decisions

SPECIAL RISK- SOCIAL

• LIVES ALONE

• NO TRANSPORTATION

• NO ACCESS TO HEALTH CENTRE

• LIVES AFAR OFF

• INDIGENT

GROUP A ACTION PLAN

• Encourage intake of ORS, fruit juice and other fluids

• Paracetamol and tepid sponge for fever

• OBSERVE Drinking, Ensure stable

• Advise to come back if with

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 pattern, volume of fluid intake and losses, urine output, warning signs, signs of plasma

leakage and bleeding, rising haematocrit, and white blood cell and platelet counts every 48 hours if

possible

ADVICE ON DISCHARGE

• CLOSE OBSERVATION FOR WARNING SIGNS

• IMMEDIATE RETURN IF WARNING SIGNS OCCUR

• ABSOLUTE AVOIDANCE OF NSAIDS

• CONTINUED REST

• USE OF NETS AND MOSQUITO REPELLANT

• DRINK FLUIDS

• SHOULD HAVE SOMEONE TO MONITOR PROGRESS

• GIVE ALERT CARD/FLYER/INSTRUCTIONS

FOLLOW UP WILL MAKE A DIFFERENCE

• CALL TO ASK ABOUT RESOLUTION OF SYMPTOMS OR NEW

SYMPTOMS

• CALL TO ASK ABOUT WARNING SIGNS

• VISIT BY CHA/HEALTH TEAM

• HAVE THE PATIENT RETURN IN 48 HOURS

• REPEAT CBC :- LOOK FOR INCREASE HAEMATOCRIT, DECREASE

PLATELETS, DECREASE WHITE CELLS


• REFERRAL CENTRES RECEIVING SEVERELY ILL DENGUE PATIENTS

MUST BE ABLE TO

• GIVE PROMPT ATTENTION

• BEDS SHOULD BE AVAILABLE TO THOSE PATIENTS WHO MEET

THE ADMISSION CRITERIA

• THERE SHOULD BE A DESIGNATED AREA TO COHORT DENGUE

PATIENTS

• HIGH-DEPENDENCY UNIT FOR THOSE WITH SHOCK/SEVERE

DISEASE.

• STAFFED BY DOCTORS AND NURSES

GROUP B (WITHOUT WARNING SIGNS)ACTION PLAN

• Encourage oral fluids

• If not tolerated, 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.

• Give the minimum volume required to maintain good

perfusion and urine output.

• Intravenous fluids are usually needed only for 24–48

hours.

• Close monitoring

CLOSE MONITORING IS CRITICAL

GENERAL STATUSNEUROLOGICAL STATUS

RESPIRATORY STATUSVITAL SIGNS

URINE OUTPUT

GROUP B (WITH WARNING SIGNS)ACTION PLAN

• reference hematocrit before fluid therapy

• isotonic solutions Lactated Ringers/Normal Saline

5–7 ml/kg/hour for 1–2 hours,

then reduce to 3–5 ml/kg/hr for 2–4 hours,

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.

• Reduce intravenous fluids gradually when the rate of plasma

leakage decreases towards the end of the critical phase.

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)


CRITERIA FOR TRANSFER:

• EARLY PRESENTATION WITH SHOCK (ON DAYS 2 OR 3 OF

ILLNESS);

• SEVERE PLASMA LEAKAGE AND/OR SHOCK;

• UNDETECTABLE PULSE AND BLOOD PRESSURE;

• SEVERE BLEEDING;

• FLUID OVERLOAD;

• ORGAN IMPAIRMENT (SUCH AS HEPATIC DAMAGE,

CARDIOMYOPATHY, ENCEPHALOPATHY,

• ENCEPHALITIS AND OTHER UNUSUAL COMPLICATIONS).

GROUP C ACTION PLAN

• admit to a hospital with access to intensive care facilities and blood transfusion

• 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

GROUP C ACTION PLAN

Goals of fluid resuscitation:• improving central and peripheral circulation

(decreasing tachycardia, improving BP, warm and pink

extremities, and capillary refill time <2 seconds)

• improving end-organ perfusion

– i.e. stable conscious level (more alert or less restless),

urine output ≥ 0.5 ml/kg/hour,

decreasing metabolic acidosis.

TREATMENT OF HEMORRHAGIC COMPLICATIONS

Patients at risk of major bleeding are those who:

• prolonged/refractory shock;

• hypotensive shock and renal or liver failure

and/or severe and persistent metabolic acidosis

• given non-steroidal anti-inflammatory agents

• pre-existing peptic ulcer disease

• anticoagulant therapy

• any form of trauma


• Blood transfusion is life-saving and should be given as soon

as severe bleeding is suspected or recognized

• Do not wait for the haematocrit to drop too low before

deciding on blood transfusion

• There is a Risk of fluid overload. Give what is needed

LAB INVESTIGATION IN HOSPITAL

• CBC AND HAEMATOCRIT

• PT, PTT

• UREA AND ELECTROLYTES’S

• GLUCOSE

• LIVER FUNCTION TESTS ALT/AST

• SERUM AMYLASE ( DEPENDING ON PRESENTATION

• GROUP AND CROSS MATCH

• CXRAY, ECHOCARDIOGRAM

• ABDOMINAL ULTRASOUND


•blood transfusion if with bleeding• 5-10 ml/kg of PRBC or 10-20 ml/kg FreshWBlood• repeat if with further blood loss or no rise in hematocrit

after transfusion

• Transfuse platelets if <10,000/mm3 • (Consult Haematologist)

• Massive bleeding not managed by FWB/PRBC• may exacerbate fluid overload

MANAGEMENT OF COMPLICATIONS

• Fluid OverloadCauses:

– excessive and/or too rapid intravenous fluids;

– incorrect use of hypotonic rather than isotonic crystalloid solutions;

– inappropriate use of large volumes of intravenous fluids in patients with

unrecognized severe bleeding;

– inappropriate transfusion of FFP, platelet concentrates and Cryo

– continuation of IVF after plasma leakage has resolved

– co-morbid conditions such as congenital or ischaemic heart disease,

chronic lung and renal diseases


Clinical Features:

– respiratory distress, difficulty

in breathing;

– rapid breathing;

– chest wall in-drawing;

– wheezing (rather than

crepitations);

– large pleural effusions;

– tense ascites;

Other investigations:

• CXR

• ECG

• ABG


• Oxygen therapy• Stop IVF

• When to discontinue IVF:

– stable blood pressure, pulse and peripheral perfusion;

– haematocrit decreases in the presence of a good pulse volume;

– afebrile for more than 24–48 days (without the use of antipyretics);

– resolving bowel/abdominal symptoms;

– improving urine output

• If necessary, give oral or intravenous furosemide 0.1–0.5 mg/kg/dose once or

twice daily, or continuous infusion of furosemide 0.1 mg/kg/hour.


• If the patient has stable haemodynamic status but is still within the critical phase,

reduce the intravenous fluid accordingly. Avoid diuretics during the plasma

leakage phase

• Patients who remain in shock with low or normal haematocrit levels but show signs

of fluid overload may have occult haemorrhage.

• Careful fresh whole blood transfusion

• repeated small boluses of a colloid solution

OTHER CONSIDERATIONS

• NOTIFY PUBLIC HEALTH.. CLASS ONE DISEASE

• REPELLANT USE 5-7.5% DEET CHILDREN, 15% DEET ADULTS

• BED NETS

• CLOSE MONITORING

• SERIAL LABS

• MANAGE SYMPTOMATICALLY

• MITIGATE RISK. IDENTIFY THOSE AT GREATER RISK

CO MORBIDITIES INCREASE RISK FOR SEVERE DENGUE

• SICKLE CELL DISEASE.. RISK OF MISDIAGNOSIS

• HTN.. NOTE EFFECTS OF MEDS. RISK OF CARDIOVASCULAR DISEASE

• DM… GLUCOSE HIGH/LOW, RISK OF ACIDOSIS, CARDIOVASCULAR

DISEASE

• OBESE… FLUIDS SHOULD BE DEPENDENT ON IDEAL BODY WEIGHT

• RENAL FAILURE .. RISK OF OVERLOAD

• HEART DISEASE.. RISK OF OVERLOAD

• COAGULOPATHY… ON ANTICOAGULANTS, LIVER DISEASE

OBSTETRIC MANAGEMENT

• FOR PATIENTS WITH A PLATELET COUNT OF <50,000 PER MM3 WHO ARE

IN LABOUR AND WILL UNDERGO A CAESAREAN SECTION, PLATELET

CONCENTRATE SHOULD BE GIVEN AS CLOSE TO SURGERY AS POSSIBLE

• THE TIMING AND ROUTE OF DELIVERY OF THE BABY WILL DEPEND ON

THE OBSTETRIC CONDITION.

• IF A CAESAREAN SECTION IS NEEDED, GENERAL ANESTHESIA IS

RECOMMENDED. SPINAL AND EPIDURAL ANESTHESIA ARE NOT

RECOMMENDED BECAUSE THEY REQUIRE PUNCTURE

• UTERINE BLEEDING CAN BE A MAJOR COMPLICATION DURING DELIVERY IF

THE PREGNANT WOMAN HAS DENGUE, PARTICULARLY IF SURGICAL

PROCEDURES THAT CAN BE ASSOCIATED WITH SEVERE BLEEDING ARE

PERFORMED.

OBSTETRIC MANAGEMENT

• NOTIFY THE PAEDIATRIC SERVICE OF EVERY BABY BORN TO A MOTHER

WITH DENGUE AT THE TIME OF DELIVERY, AS THE CHILD MAY BECOME

ILL UP TO 12 DAYS AFTER BIRTH.

• BREASTFEEDING SHOULD BE CONTINUOUS AND ENCOURAGED.

• NEWBORNS OF MOTHERS WITH DENGUE (OR A MOTHER WHO HAD

THE INFECTION UP TO ONE WEEK BEFORE DELIVERY) WHO DEVELOP

THROMBOCYTOPENIA, FEVER, HEPATOMEGALY, OR VARYING DEGREES

OF CIRCULATORY FAILURE DURING THE FIRST WEEK OF LIFE MAY BE

MISDIAGNOSED WITH NEONATAL SEPSIS.

• TO PREVENT THIS, THE EPIDEMIOLOGICAL LINK MUST BE CONSIDERED

MOTHER TO CHILD TRANSMISSION

• NEWBORNS WHO DEVELOP SEVERE SYMPTOMS MAY CLINICALLY

RESEMBLE SEPSIS SUCH AS WITH HYPOTHERMIA INSTEAD OF FEVER,

PLEURAL EFFUSION, GASTROINTESTINAL BLEEDING, CIRCULATORY

FAILURE, INTRACRANIAL HEMORRHAGE, AND DEATH

• TREATMENT OF THESE SEVERE CASES CONSISTS OF ADMINISTRATION

OF BALANCED ELECTROLYTE SOLUTIONS (RINGER’S ACETATE, ETC.)

FOR THE PURPOSE OF MAINTAINING MAP WITHIN NORMAL RANGES

FOR AGE AND SEX

SPECIAL NOTE ON THE PAEDIATRIC PATIENT

• MORTALITY IS HIGHER IN THE < 1 YEAR GROUP

• SYMPTOMS IN YOUNGER CHILDREN MAY NOT FIT THE CASE

DEFINITION

• MAY BE OLIGOSYMPTOMATIC, OR MANIFEST AS A NONSPECIFIC

FEBRILE SYNDROME ,UPPER RESPIRATORY TRACT MANIFESTATIONS ,

DIARRHEA, OR SEIZURES

PAEDIATRIC SIGNS

• PLASMA LEAKAGE FROM THE INTRAVASCULAR COMPARTMENT

INITIALLY MANIFESTS AS PALPEBRAL AND PERIPHERAL OEDEMA

• HEPATOMEGALY AND SPLENOMEGALY ARE UP TO SEVEN TIMES MORE

FREQUENT IN CHILDREN UNDER ONE YEAR OF AGE THAN IN OLDER

CHILDREN

• SHOCK MAY MANIFEST AS HYPOTHERMIA, RESTLESSNESS OR

LETHARGY, COLD EXTREMITIES, AND TACHYCARDIA

PAEDIATRIC DENGUE SIGNS

• VITAL SIGNS IN THE PAEDIATRIC PATIENT ARE AGE DEPENDENT

• HAVE A REFERENCE CHART ON HAND TO IDENTIFY CLINICAL SIGNS

OF HEMODYNAMIC INSTABILITY

• CAREFULLY EVALUATE FOR WARNING SIGNS EVEN WHEN

NONSPECIFIC SYMPTOMS ARE PRESENT ESPECIALLY IN THE YOUNGER

AGE GROUP. FEVER IS USUALLY PRESENT IN ALL CASES

DISCHARGE CRITERIA

CLINICAL:–

• NO FEVER FOR 48 HOURS

• IMPROVEMENT IN CLINICAL STATUS:- GENERAL BEING, APPETITE, URINE

OUTPUT, HAEMODYNAMIC STATUS, NO RESPIRATORY DISTRESS.

LAB:-

• HAEMATOCRIT NORMALIZING WITHOUT IV FLUIDS

• PLATELET COUNTS INCREASING

CRITERIA FOR DISCHARGE

DENGUE: WHO GUIDELINES FOR DIAGNOSIS AND TREATMENT

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Transcript of DENGUE: WHO GUIDELINES FOR DIAGNOSIS AND TREATMENT