Pakistan Dengue Management 14.9.11

Overview & Management of Dengue
Kolitha Sellahewa
MBBS.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 Course DHF
Febrile phase
2 7 days 3-7 days Lasts only for 24 48 hours Begins after the critical phase & lasts for 5 - 7 days
Critical phase

Convalescent phase
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
Common
Tender hepatomegaly Leucopaenia < 5000 Thrombocytopaenia Bleeding manifestations

Critical Phase
Plasma 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/dl
Dynamics of Plasma Leakage
Rapid
Moderat e
Slow
0 Hr
6 Hr
24 Hr
36 Hr
48 Hr
Time of Presentation and Management
0 Hr
24 Hr
48 Hr
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 CXR right lateral decubitus US scan

Radiology

Oedematous gall bladder wall

Ascitis Pleural effusions
Confirm Entry into the Critical Phase
Evidence of plasma leakage
Pleural and/or peritoneal cavities CXR right lateral decubitus US scan

Radiology

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!!!
How to time the onset of critical phase?

17th 8 am D3 WBC N% L% 3200 53 44 18th 8 am 18th 8 pm 19th 8 am D5 2900 26 71 42 19th 8 pm D5 3700 25 73 43 20th 8 am D6 4500 31 67 39 20th 21st 8 Pm 8 am D6 6000 33 66 44 D7 7000 43 55 43 21st 8 pm D7 7300 58 41 38 19000
D4
2800 41 56 36
D4
1900 31 68 39
PCV % 39 Plt
25200 12100 11000 61000 22000 18000 12000 8000 0 0 0 Onset End
How to time the onset of critical phase?

18th 8 am 18th 8 pm 19th 8 am 19th 8 pm 20th 8 am 20th 8 pm 21st 8 am 21st 8 pm
17th 8 am
D4
WB C N % 3200 53 2800 41 56
36 96000
1900 31 68
39
2900 26 71
42
3700 25 73
43
4500 31 67
39
6000 33 66
44
7000 43 55
43 8000
7300 58 41
38 19000
L % 44
PCV 39 % Plt 121000
94000 41000 22000 18000 12000
Timing the onset of critical period

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
8 am
17th
8 am
18th
8 pm
18th
8 am
19th
8 pm
19th
8 am
20th
8 pm
20th
8 am
21st
8 pm
21st
Timing the onset of critical period

7500 7000 6500 6000 5500 5000 4500 4000 3500 3000 2500 2000 1500 260,000 240,000
platelets
220,000 200,000 180,000 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000
WBC
8 am
17th
8 am
18th
8 pm
18th
8 am
19th
8 pm
19th
8 am
20th
8 pm
20th
8 am
21st
8 pm
21st
Convalescent Phase
Good appetite Convalescent rash Pruritus
Heamodynamic stability Bradycardia Diuresis Stabilization of HCT Rise in WBC rise in platelet count
Palms & soles
Convalescent Rash
Management Out Patient
Restricted Physical Activity Diet & fluid Antipyretics
Paracetamol
Do NOT give NSAIDs NOT even

suppositories Advice on review & admission
Criteria for Admission Essential
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 Admission Essential
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
Management Inward

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
Clinical Laboratory data not essential Features of a viral infection

Think of dengue all with fever with in 8 days
Acute onset of fever Myalgia Arthralgia Retro-orbital pain
Usually corhyza is abscent
WBC < 5000 cells / c. mm Positive tourniquet test (PPV >85%) Dr. Kolitha Sellahewa
Rash - Diffuse blanching erythema
Differential Diagnosis
Leptospirosis

Occupational history Muscle tenderness - calves Icterus Conjunctival injection Polymorphonuclear leucocytosis Thrombocytopenia Leucopaenia Normal platelet count
Other viral fevers

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
DHF

No plasma leakage
Plasma leakage Platelet count < 100,000

Patient with unusual or uncommon complications Exceedingly rare

With or without shock With or without bleeding
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
HOW
Day of the illness ? Evidence of plasma leakage ? Convalescent rash ?

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 Oral fluids
Type of fluid

Crystalloid
Colloid
Fluid Shifts

N.Saline 1 hour Colloids 4 to 6 hours
Febrile Phase
Oral fluids only
Electrolyte solutions Undue vomiting or diarrhea Oral fluids not tolerated 1500ml 2500ml/24Hrs Both oral & IV N.Saline
IV fluids are not mandatory

Quantity:

Type:
Critical Phase of DHF Without Shock
Objective:
Monitor Prevent progression to shock HR Avoid fluid overloading PP > 20 mm Hg Judicious fluid therapy- Fluid restriction CRFT < 2 secs U.O.P. 0.5-1ml/kg/hr Quantity calculated HCT M+5% = 4600 ml / 48 hrs (50Kg) RR <20/mt Full quota for entire critical phase 48 hrs

Type:
Approximately 90 ml/hr Adjust infusion rate to match the dynamics of plasma leakage N.Saline
Calculation of Total Fluid Quota for the Critical Period
M = 5% M + 5% =
Guide to rate of fluid intake in Critical Phase
Pulse BP Pulse Pressure CRFT Warmth / Coldness UOP ml/kg/hr Evidence of Bleeding
DHF with Shock Aggressive 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
Compensated Shock

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

venous BGA Calcium Sugar Sodium Grouping & DT
HCT before & after fluid bolus
Colloid bolus 10ml/kg IV over 1 hr Colloid boluses

Blood transfusion
Haemodynamically unstable HCT drops
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

Colloid 10 ml/kg IV bolus over 1 hr
Blood gas analysis Calcium Electrolytes Sugar Grouping & cross matching
Choice of Colloid
Boluses NOT infusions

Dextran 40

3 boluses over 24 hours 6 boluses over 48 hours 5 boluses over 24 hours 10 boluses over 48 hours 1 bolus 3 units approximately 450 600 ml
6% starch-Heta starch(Voluven)

Fresh Frozen Plasma

Monitoring & Documentation
Early detection of shock

Judge the efficacy of IV fluid therapy

Pulse pressure < 20 mm Hg CRFT > 2 secs HCT increase of 20% or more from baseline
PP , CRFT, No postural hypotension Hourly UOP 0.5 1.0 ml/kg/hr Respiratory rate > 20/mt Lung bases SaO2 < 92% CXR
Early detection of complications of fluid therapy

Time of Presentation and Management
0 Hr
24 Hr
48 Hr
DHF
Date/Time Febrile
Date/Time Convalescent
Date/Time Critical
Basic Monitoring All Patients
Pulse rate Pulse pressure CRFT Respiratory rate FBC - HCT Intensity of monitoring depends on

Accurate fluid balance charts

Phase of the illness Severity Aggressiveness of fluid therapy
Monitoring Platelet Count Drops Below 100,000

FBC- twice daily Vital parameters- four hourly

Detailed fluid balance chart
Pulse rate Blood pressure (both systolic and diastolic), Respiratory rate, Capillary refill time Type and route of fluid hourly, Urine output four hourly
Monitoring Evidence of Plasma Leakage Escalate Vital signs - hourly HCT - 8 hourly Fluid intake & the balance left from the calculated quota

Detailed fluid balance chart

Temporal relationship Critical phase In hours
Monitoring
IV Fluid Therapy
Phase of the illness be fully aware Adequacy of fluid therapy

Early detection of fluid overloading

Pulse Pressure >20 mmHg CRFT <2 sec Pulse Rate <80/mt UOP > 0.5 ml/Kg/hr HCT Respiratory rate > 20/mt Lung bases SaO2 < 92% CXR
Shift to ICU
Monitoring Chart I - for Management of Dengue Patients Febrile Phase
Monitoring Chart I - for Management of Dengue Patients Febrile Phase
D3 with Fever WBC <5000/mm3 N-40% L58% TT + ve
D4 without Fever
Patients Febrile Phase
D4 with Fever TT + ve, WBC <5000/mm3 N-40% L-58% Tender Liver
Monitoring Chart II for Management of DHF Patients during Critical Phase

Monitoring Chart II for Management of DHF Patients during Critical Phase Patient to be monitored hourly
Annexure II
Name of the patient BHT.Date and time of admission ward - Weight Height
Ideal body weight -
M-
M+ 5% = ml
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
Used Remaining
HR BP Pulse Pressure RR CRFT extremities UOP UOP ml/Kg/hr Platelet count
Date/Time Scale 20 Hrs
Date/Time Scale 36 Hrs
48 Hr 0 Hr Date/Time Scale 2 Hrs 24 Hr

Monitoring Chart III to be used during the Peak of leakage and during the shock Patient to be monitored every 15 minis
(Maximum 3 per 24h / 6 per 48h) : (Maximum 5 per 24h / 10 per 48 h) : PRC/WB . ABW 19 kg; IBW 21 kg Maintenance 1450 ml M + 5% = 2400 ml for 24 hours
Other fluid
Fluid ml/Kg/ hr 20 10 9 8 7 6 5 4 3 2 1 time
90 min. 1h 45min
3 hours
12.30 p.m. 56%
12.45 p.m.
1.30 p.m 51% 570 ml 1830 ml
1.45 p.m.
2.45 p.m. 41% 760 ml 1640 ml
4.15 p.m. 46% 902.5 ml 1497.5 ml Stable
6.00 p.m. 51% 1002.25 ml 1397.75 ml Weak
7.00 p.m.
8.00 p.m.
10.00 p.m.
PCV 49% Fluids

Used Remaining
1195.25 ml 1207.75 ml Good Good
1477.25 ml 922.75 ml
HR BP Pulse Pressure CRFT UOP ml/Kg/hr

Platelet count - 92000 General Condition
NR NR 75/65 92/56
Stable
No
29000
No
No
well
Stable
DENGUE INVESTIGATION SUMMARY

Name: -------------------------BHT: -----------------------------------Date Full Blood Count 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
Age: --------------------------
Hospital: -----------------------
Ward: ---------------
UOP-ml/hour Pulse Blood Pressure Pulse Pressure

CXR R. Decubitus
US Scan Fluid Rate (ml/kg/Hour) Type of Fluid Other Ix
Remarks
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)
COMPLICATIONS Non?
Vigilance detect Alert plasma leakage Active IV fluid Aggressive - manipulate
THANK YOU
Complications and Adjuvant Therapy

Dr. Jayantha Weeraman Consultant 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 of Bleeding
Mild
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
Puffy eyelids Tachypnea Cough
Clinical
Vital Signs
Bounding Pulse Wide pulse pressure
Distended abdomen
Dyspnea and orthopnea Respiratory distress
Hct
UOP
> 1 ml/kg/hour
overload
Critical Phase
Frusemide 1 mg/kg
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
Restless Irritable
Clinical
Vital Signs
Tachycardia Pulse Pressure - < 20 CRFT - > 2 sec Cold Extremities
Behaviour changes e.g. Confusion, speak fowl language
Hct
UOP
< 0.5 ml/kg/hour
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 no When a pt is deteriorating with

response to fluid therapy.
A: B: C: S: Acidosis Bleeding Calcium 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 improvement

Even 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. Dr. Jayantha Weeraman
..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
S : Hypoglycaemia
Treat if blood sugar below 4 mmol/lt Give 10% dextose 3-5ml/kg bolus followed by an infusion
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
Blood & blood component used in DHF/DSS patients

Crystalloid 100%
Platelet 0.4%
Blood 10-15% Colloid 20-25%
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

Fluid overload
Delayed diagnosis/ delayed resuscitation Late presentation Use of hypotonic saline Given excess fluids Given more than time of leakage Not given blood transfusion Delayed blood transfusion Encephalopathy Underlying co-morbidity Dual infection
Massive bleeding

Unusual manifestations

THANK YOU

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Pakistan Dengue Management 14.9.11

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Overview & Management of Dengue

Consultant Physician Epidemiology Unit SRI LANKA

Dengue Viral Infection

Shock Bleeding - DIC

Clinical Course DHF

Febrile Phase DF? Or DHF?

Skin rash Arthralgia Bone pain

Tender hepatomegaly Leucopaenia < 5000 Thrombocytopaenia Bleeding manifestations

Plasma Leakage 24-48Hrs

Dynamics of Plasma Leakage

Dr. Kolitha Sellahewa

Dr. Kolitha Sellahewa

Time of Presentation and Management

Dr. Kolitha Sellahewa

Early Recognition of Entry into Critical Phase

Oedematous gall bladder wall

Confirm Entry into the Critical Phase

Evidence of plasma leakage

Pleural and/or peritoneal cavities CXR right lateral decubitus US scan

Oedematous gall bladder wall

How to time the onset of critical phase?

How to time the onset of critical phase?

94000 41000 22000 18000 12000

Timing the onset of critical period

Timing the onset of critical period

Good appetite Convalescent rash Pruritus

Palms & soles

Management Out Patient

Restricted Physical Activity Diet & fluid Antipyretics

Do NOT give NSAIDs NOT even

Dr. Kolitha Sellahewa

Criteria for Admission Essential

Platelet count < 100,000 cells/c.mm

Criteria for Admission Essential

Pregnancy Elderly patients & infants Obese Co morbidity

Diabetes IHD Chronic renal failure

Dr. Kolitha Sellahewa

Criteria for Admission

Poor home support Poor access to hospital facility Living alone

Dr. Kolitha Sellahewa

Clinical Laboratory data not essential Features of a viral infection

Think of dengue all with fever with in 8 days

Acute onset of fever Myalgia Arthralgia Retro-orbital pain

Usually corhyza is abscent

Rash - Diffuse blanching erythema

Other viral fevers

Diffuse blanching erythema

Dr. Kolitha Sellahewa

Identify the Clinical Type

Plasma leakage Platelet count < 100,000

Patient with unusual or uncommon complications Exceedingly rare

With or without shock With or without bleeding

Patient - stable but has predictors of developing severe disease

Dr. Kolitha Sellahewa

Recognize the Stage of the Disease

Febrile phase Critical phase Convalescent phase

Day of the illness ? Evidence of plasma leakage ? Convalescent rash ?

Phase Clinical type Oral fluids

N.Saline 1 hour Colloids 4 to 6 hours

Dr. Kolitha Sellahewa

Oral fluids only

IV fluids are not mandatory

Dr. Kolitha Sellahewa

Critical Phase of DHF Without Shock