PROTOCOL FOR MANAGEMENT WHO 2012

COuRsE OF DENGuE ILLNEss

FEBRILE PHAsEo Typically develop high grade fever suddenly.o Lasts for 2-7 days.o Often accompanied by facial flushing, skin

erythema, generalized body ache, myalgia, retro orbital eye pain, photophobia, and headache.

o Anorexia, nausea & vomiting are common.o A positive Tourniquet test in this phase indicates an

increased probability of dengue.o Mild petechiae and mucosal bleeding may be seen.o The liver may be enlarged and tender after few days

of fever.o Progressive decrease in total white cell count

should alert to high probability of dengue

CRITICAL PHAsEo Warning signs mark the beginning of the critical phase.o These pts become worse around the time of

defervescence when temp drops to 37.5 -38 Co Day 3-8o Progressive leukopenia f/b rapid decrease in platelet

count usually precedes plasma leakage.o An increasing haematocrit may be one of the earliest

additional signs.o Period of clinically significant plasma leakage usually

lasts 24- 48 hrs.o In addition sevr organ involvement may develop- sevr

hepatitis,encephalitis,myocarditis and severe bleeding without obvious shock.

RECOVERY PHAsE As pt survives the 24-48 hour critical phase, a

gradual reabsorption of extravascular compartment fluid takes place in the following 48-72 hrs.

General well being improves,appetite returns, GI sympt. Abates, haemodynamis status stabilizes & diuresis ensues.

Some pts have a confluent erythematous or petechial rash with small areas of normal skin ISLES OF WHITE IN THE SEA OF RED .

Bradycardia & ECG changes are common. Haematocrit stabilizes or may be lower due to the

dilutional effect of reabsorbed fluid. White cell count starts to rise soon, but recovery of

platelet count is typically later.

MEDICAL COMPLICATIONs sEEN IN DIFFERENT PHAsEs OF

DENGuEFEBRILE PHASE Dehydration; high fever may cause

neurological disturbances and febrile seizures in young children

CRITICAL PHASE Shock from plasma leakage; severe haemorrhage; organ impairment

RECOVERY PHASE Hypervolaemia(only if IVF has been excessive) and acute pulmonary oedema.

sTEPwIsE APPROACH TO THE MANAGEMENT OF

DENGuEStep1 - Overall assessment

History, including symptoms, past medical and family history

Physical examination, including full physical and mental assessment

Investigation, including routine laboratory tests & Dengue specific lab tests

Step2 Diagnosis, assessment of disease phase & severity

Step3 - Management

3.1Disease notification

3.2 Depending on the clinical manifestations and other circumstances, patients may;-Be sent home(Group A)-Be referred for in-hospital management(Group B)-Require emergency treatment and urgent referral(Group C)

sTEP 1- OVERALL AssEssMENTThe history should include: Date of onset of fever/illness; Quantity of oral fluid intake; Diarrhoea; Urine output; Assessment of warning signs; Change in mental state/seizure/dizziness; Other h/o: family or neighbourhood dengue,

travel,co-existing conditions(infancy, DM, HTn)

CLINICAL

Abdominal pain or TendernessPersistent vomitingLethargy, restlessnessMucosal bleedLiver enlargement >2cm or tender enlarged liverClinical fluid accumulation

LABORATORYIncrease in haematocrit level concurrent with rapid decrease in platelet count

WARNING SIGNS

The Physical examination should include:

Assessment of mental state; Assessment of hydration status; Assessment of haemodynamic status; Checking for quiet tachypnoea / acidotic

breathing/ pleural effusion; Checking for abdominal tenderness/

hepatomegaly/ ascites; Examination for rash and bleeding

manifestations; Tourniquet test( repeat if ve or if there is no

bleeding manifestation)

Parameters sTABLECIRCuLATION

COMPENsATED sHOCk

HYPOTENsIVEsHOCk

Conscious level Clear & lucid Clear and lucid Change of mental state (restless)

Capillary refill time

Brisk(2sec) Very prolonged, mottled skin

Extremities Warm and Pink Cool peripheries Cold, clammyextremities

Peripheral pulse volume

Good volume Weak and thready Feeble or absent

Heart rate Normal for age Tachycardia Severe tachycardia

BP Normal for age Normal syst. Press, but rising diast. pressure

HypotensionUnrecordable BP

RR Normal for age Quiet tachypnoea Metab acidosis/ hyperpnoea

Urine O/P normal Reducing trend Oliguria/ anuria

THE INVEsTIGATION Full blood count(may be normal)- should be

repeated daily until the critical phase is over.

Haematocrit WBC count - makes the diag of dengue very likely. Platelet count- a rapid decrease with concomitant rise in

PCV is suggestive of progress to the Plasma leakage/ critical phase of disease.

Dengue specific lab test should be performed to confirm diag. NS1 Ag detection(a/c dengue infection) & Ig Mmarkers(recent infection)

Additional tests: LFT, glucose, S. electrolytes, urea & creatinine, ECG &urine specific gravity depending on co-morbi

sTEP 2- DIAGNOsIs, AssEssMENT OF DIsEAsE PHAsE AND

sEVERITY On basis of evaluation of history, physical

examination and/or full blood count and haematocrit.

Which phase is it(febrile/critical/recovery) Warning signs? Hydration & Haemodynamic state of pt

TREATMENT

GROuP APts who may be sent homePts are able to tolerate adequate volumes of oral fluids,

pass urine atleast once in every 6hrsDo not have warning signs Advice bed rest Frequent oral fluids(ORS/Soup/Fruit juices) Give Paracetamol for high fever. Dose:10mg/kg/dose,

not more than 3-4 times in 24 hours. Tepid sponging. ASPIRIN ,IBUPROFEN, NSAIDS

Instruct care givers, to bring pt. hosp. immed. if: no clinical improvement, sevr abd. Pain, persist vomiting, cold clammy extrem., lethargy, bleeding, shortness of breath, not passing urine for >6hrs

Daily monitoring : temp., intake /output volum, warning signs, signs of plasma leakage & bleeding, complete blood counts .

GROuP BAdmitted in hosp. for close observation as they

approach the critical phaseIncludes pts. with warning signs, co-existing

conditions &those with certain social circumstances.

If the pt. has dengue with warning signs/ signs of dehydration, judicious volume replacement by IV fluid therapy from the early stage may modify the course & severity of d/s.

ADMIssION CRITERIAWarning signs Any of the warning signs

Signs and symptoms of hypotension

Dehydrated patient, unable to tolerate oral fluidsDizziness or postural hypotensionProfuse perspiration, fainting, prostration during defervescenceHypotension or cold extremitiesDifficulty in breathing/shortness of breath

Bleeding Spontaneous bleeding,independent of the platelet count

Organ impairment Renal, hepatic, neurological or cardiac-enlarged, tender liver, although not yet in shock- chest pain or respiratory distress, cyanosis

Findings through investigation Rising haematocritPleural effusion/ascites/asymptomatic G.B. thicke

Co-existing conditions Co-morbid conditions(DM,HTN,Peptic ulcer)Overweight / obeseInfancy/old age

Social circumstances Living alone/far/without reliable means of transport

The action of plan includes:1. Obtain a reference Haematocrit before IVF

therapy begins. Give only isotonic solutions (0.9% saline, Ringers lactate).

2. Start with 5-7ml/kg/hr for 1-2hours,

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

reduce to 2-3ml/kg /hr or less (accord to clinical response.)

3. Reassess the clinical status and repeat haematocrit.

If it remains same or rises minimally, continue at same rate(2-3ml/kg/hr) for another 2-4hrs.

If the vital signs are worsening &the haematocrit is rising rapidly, increase the rate to 5-10ml/kg/hr for 1-2 hours.

Reassess the clinical status, repeat haematocrit & review fluid infusion rates accordingly.

4. Reduce IVF gradually when the rate of plasma leakage decreases towards the end of the critical phase. This is indicated by urine o/p and oral fluid intake improving, haematocritdecreasing below the baseline value in a stable patient.

5. Monitor vital signs and peripheral perfusion(1-4 hrly until pt. is out of critical phase), urine O/P(4-6hrly), haematocrit (before & after fluid replacement, then 6-12 hrly), blood glucose & other organ function(renal profile/liver profile /coagulation profile) as indicated.

If the patient has dengue with co- existing conditions but without warning signs; the

plan of action should be: Encourage oral fluids; if not tolerated start IVF

at appropriate maintenance rate Revise the fluid infusion frequently. Give

minimum volume required to maintain good perfusion & urine o/p .

Pt. should be monitored for temp. pattern, volume of intake & losses, urine o/p, warning signs, haematocrit, WBC and platelet count.

GROuP CThese are pts.with severe dengue who require

emergency treatment and urgent referral and have:

Severe plasma leakage leading to dengue shock and/or fluid accumulation with respiratory distress;

Severe haemorrhages; Severe organ impairment(hepatic damage,

renal impairment, cardiomyopathy, encephalopathy or encephalitis).

Should be admitted to hosp with access to blood transfusion facilities.

Judicious IVF resuscitation is essential and usually sole intervention required.

The crystalloid solution should be isotonic and the volume just sufficient to maintain an effective circulation during the period of plasma leakage.

If possible, obtain haematocrit levels before and after fluid resuscitation.

Continue replacement of further plasma losses to maintain effective circulation for 24-48 hours.

All shock pts.should have their blood Gp taken and a cross-match carried out.

Blood transfusion should be given only in cases with established sevr bleeding/suspected sevr bleeding in combination with unexplained hypotension.

The goal of fluid resuscitation include;

Improving central and peripheral circulation-i.e. decreasing tachycardia, improving BP and pulse volume, warm and pink extremities, a capillary refill time =0.5ml/kg/hr or decreasing metabolic acidosis.

TREATMENT OF sHOCk Obtain a reference haematocrit before

starting IVF therapy. Start IVF resuscita. with ISOTONIC crystalloid

solution at 10-20ml/kg/hr over 1hour in infants and children.

Then reassess the pts condition(vital signs, capillary refill time, haematocrit, urine output)

If the condition of infant / child improves;

IVF should be reduced to 10ml/kg/hr for 1-2 hrs

7ml/kg/hr for 2 hours 5ml/kg/hr for 4 hours 3ml/kg/hr , maintained for upto 24-48 hrs

The total duration of IVF therapy should not exceed 48hours.

If vitals are still unstable(i.e. shock persists)

Check the haematocrit after first bolus. If it increases or is still high, change to colloid

solution at 10-20ml/kg/hr. After the initial dose, reduce the rate to

10ml/kg/hr for 1hour; Then reduce to 7ml/kg/hr Change to crystalloid when pts condition

improves.

If the haematocrit decreases compared to initial reference haematocrit value and the pt still has unstable vital signs, this may indicate bleeding.

Look for severe bleeding. Cross-match fresh whole blood/fresh packed red cells and transfuse if there is overt bleeding

If there is no bleeding, give a bolus of 10-20ml/kg of Colloid over 1hour, repeat clinical assessment and determine haemotocrit level

Compensated Shock(Systolic pressure maintained + signs of reduced perfusion)

Start isotonic crystalloid 10-20 ml/kg/hr for 1hour

IMPROVEMENT

YES NO

IV crystalloid, reduce gradually

10ml/kg/hr for 1-2hours

7ml/kg/hr for 2hours

5ml/kg/hr for 4 hours

3ml/kg/hr

Check haematocrit

As clinical improv. Is noted,

Reduce fluids accordingly

Crystalloid(2nd bolus)or colloid 10-20ml/kg/hr x1hr

IMPROVEMENT

Reduce IV crystalloids 7-10ml/kg/hr for 1-2 hours

NOYES

Further boluses may be needed for the next 24-48 hrs

Stop IV fluids at 48 hours

HCT

Severe overt bleeding

NOYES

Urgent blood transfusion Colloid 10-20ml/kg/hr

Evaluate to consider blood transfusion if no clinical improvement

Treatment of PROFOuND sHOCk(hypotensive; undetectable pulse & BP)

Should be managed vigorously. For all pts. initiate IVF resuscitation with

crystalloid/ colloid solu. 20ml/kg as a bolus given over 15-30 mins.

If infants and children condition improves: give colloid infusion 10ml/kg/hr for 1hour. Then continue crystalloid 10ml/kg/hr for 1hour 7.5ml/kg/hr for 2hours 5ml/kg/hr for 4hours 3ml/kg/hr for 24-48hours can be maintained.

If vital signs are still unstable; Review haematocrit obtained before the

bolus.If haematocrit was normal or low(

If haematocrit was high compare to baseline value, change IVF to colloid solutions at 10-20ml/kg as a second bolus over -1hr. After 2nd bolus reassess the pt. if condition improves , reduce rate to 7-10ml/kg/hr for 1-2hrs then ,change back to crystalloid solu and reduce rate of infusion.

If previously not detectable pleural effusion and ascites should be detected after fluid boluses. Monitor their effect on breathing.

Urine O/P should be checked regularly.

When to stop intravenous fluid therapy:

Signs of cessation of plasma leakage; Stable BP, pulse and peripheral perfusion; Haemtocrit decreases in the presence of a good

pulse volume; Apyrexia (without use of antipyretics)for >24-48

hours; Resolving bowel/ abdominal symptoms; Improving urine output.Continuing IVF therapy >48 hrs of Critical phase

will put risk of Pulmon. Oedema & thrombo phlebitis.

Treatment of haemorrhagiccomplications, hyponatraemia, and

metabolic acidosis Blood transfusion only indicated in severe

bleeding. Early volume replacement will usually correct

the metabolic acidosis. Sod. Bicarbonate may be considered in severe metab acidosis.

Hyponatraemia : use of isotonic solution will prevent and correct this condition.

Vertical transmission and neonatal dengue

Pregnant women with dengue virus infection can transmit the virus to the foetus and vertical dengue transmission has been described.

In vertical transmission cases, some newborns may be asymptomatic , or vary from mild illness such as fever with petechial rash, thrombo-cytopenia and hepatomegaly to severe illness such as sepsis, pleural effusion, circulatory failure.

Timing of maternal infection may be important; PERIPARTUM maternal infection may increase the likelihood of symptomatic d/s in the newborn.

The time interval between the mothers onset of fever and that of their neonates, were 5-13days; fever in neonates occurred at 1-11 days of life and their duration of fever was 1-5 days.

Antibodies to the dengue virus in the dengue infected mother can cross placenta and cause severe dengue in newborn infants.

DIFFERENTIAL DIAGNOsIs

Febrile phase influenza, measles, chikungunya,IMN.

Fever, arthralgia, rash, malaise,leukopeniacommon in both chikungunya and dengue. Symmetric arthritis is pathognomonic of chikungunya. Bleeding tendency and thrombocytopenia are usually assoc with dengue fever.

Splenomegaly &prolonged feverconsideration of malaria and typhoid are in d/d.

Rash associated with measles & rubellaparticular distribution from head to trunk & extremities. All though both d/s may have common signs & sympt. myalgia ,arthralgia.

Measles ; always have cough, rhinitis, conjuctivitis.

Pts in Shock d/d of sepsis &meningococcal d/s.

Leukopenia & thrombocytopenia with/ without bleeding may be clinical manifestation of:

Infectious d/smalaria, leptospirosis, typhoid, typhus , bacterial sepsis.

Non-infectious d/s systemic lupus & auto- immune d/s.

During critical phase; plasma leakage/ shock with severe abdominal pain when fever subsides, may mimic a/c appendicitis. USG shows fluid accumulation around appendix, disappear after fever subsides, conservative management.

DIsCHARGE CRITERIA All of the following conditions must be

present:CLINICAL

No fever for 48 hours

Improvement in clinical status(general well being, appetite, haemodynamic status, urine output, no respiratory distress)

LABORATORY

Increasing trend of platelet count

Stable haematocrit without intravenous fluids.

THANk YOu

PROTOCOL FOR MANAGEMENTCourse of Dengue IllnessFEBRILE PHASECRITICAL PHASERECOVERY PHASESlide Number 6MEDICAL COMPLICATIONS SEEN IN DIFFERENT PHASES OF DENGUEStepwise approach to the management of dengueSlide Number 9Step 1- Overall assessmentSlide Number 11The Physical examination should include:Slide Number 13The InvestigationStep 2- Diagnosis, assessment of disease phase and severitySlide Number 16TreatmentGroup aGroup bADMISSION CRITERIASlide Number 21Slide Number 22Slide Number 23If the patient has dengue with co- existing conditions but without warning signs; the plan of action should be:Group CSlide Number 26The goal of fluid resuscitation include;Treatment of shockIf the condition of infant / child improves;If vitals are still unstable(i.e. shock persists)Slide Number 31Slide Number 32Slide Number 33Treatment of profound shock(hypotensive; undetectable pulse & BP)If vital signs are still unstable;Slide Number 36When to stop intravenous fluid therapy:Treatment of haemorrhagic complications, hyponatraemia, and metabolic acidosisVertical transmission and neonatal dengueSlide Number 40Differential diagnosisSlide Number 42Slide Number 43Slide Number 44Discharge criteriaSlide Number 46