Mortality and

Morbidity Conference
September 24, 2009
General Data

 IDJ
 34 years old, Female
 Dulonan, Arevalo, Iloilo City
 August 3, 2009
 2:30 PM
Chief Complaint

 Fever
History of Present Illness

 2 days PTA
◦ Low grade, intermittent fever
◦ CBC requested



CBC
 Hemoglobin= 132
 Hematocrit= 0.41
 RBC= 4.59
 WBC=3.6
 Segmenters= 0.80
 Lymphocytes= 0.18
 Eosinophils= 0
 Monocytes= 0
 Basophils= 0.02
 Platelet count= 216
 4 hours PTA
◦ Persistence of low grade, intermittent
fever
◦ Repeat CBC – leukopenia and
thrombocytopenia
◦ No bleeding problems

CBC
 Hemoglobin= 146
 Hematocrit= 0.45 ↑
Previous:
Hem oglobin= 132  RBC= 5.15
Hem at ocrit = 0.41
 WBC=2.3
RBC= 4.59
WBC= 3.6  Segmenters= 0.54
Segm ent ers= 0.80
 Lymphocytes= 0.45
Lym phocyt es= 0.18
Eosinophils= 0  Eosinophils= 0.01
Monocyt es= 0
Basophils= 0.02
 Monocytes= 0
Plat elet count = 216  Basophils= 0
 Platelet count= 78
Past Medical History
 Non hypertensive
 Non diabetic
 Non Asthmatic
 No history of bleeding dyscrasias
 No history of PTB
 No trauma/ surgical procedures
 Allergy to crustaceans
Personal History
 Works as a school employee
 Non smoker, non alcoholic beverage
drinker

Fa m ily H ist or y
Unrem arkable
Physical Examination
 Ambulatory, conscious, coherent, oriented,
not in cardiopulmonary distress
 BP=90/70 mm Hg CR=75 RR=23 Temp=36 C
 Weight= 71 kg Height= 5’2
 Anicteric sclerae, pink palpebral
conjunctivae
 Good skin turgor, moist lips and buccal
mucosa
 No neck vein engorgement, no cervical
lymphadenopathy, no tonsillopharyngeal
congestion

 Adynamic precordium, PMI at 5th ICS left
midclavicular line, S1 and S2 normal,
regular cardiac rate and rhythm, no
murmurs
 Symmetrical chest expansion,
bronchovesicular breath sounds, no rales,
no wheezes
 Flat abdomen, normoactive bowel sounds,
soft, non-tender, no palpable mass, non-
palpable liver edge and spleen, Liver
span= 10cm MSL, 6cm MCL
 Grossly normal extremities, full peripheral
pulses, no edema
 Negative tourniquet test
Admitting Impression
 Dengue Fever
Dengue Clinical Syndromes
 Undifferentiated fever
 Classic dengue fever
 Dengue hemorrhagic fever
 Dengue shock syndrome


Cent er for Disease Cont rol. Dengue: Clinical and Public Healt h
Aspect s, 2008
Undifferentiated Fever
 May be the most common manifestation of
dengue
 Prospective study found that 87% of
students infected were either
asymptomatic or only mildly symptomatic
 Other prospective studies including all age-
groups also demonstrate silent
transmission


 Source : DS Burke, et al. A prospective study of dengue

infections in Bangkok. Am J Trop Med Hyg 1988; 38:172-80.

Clinical Characteristics of
Dengue Fever
 Fever
 Headache
 Muscle and joint pain
 Nausea/vomiting
 Rash
 Hemorrhagic manifestations


Center for Disease Control. Dengue: Clinical and Public

Health Aspects, 2008
Differential Diagnosis of
Dengue
 Influenza
 Measles
 Rubella
 Malaria
 Typhoid fever
 Leptospirosis
 Meningococcemia
 Rickettsial infections
 Bacterial sepsis
 Other viral hemorrhagic fevers

Center for Disease Control. Dengue: Clinical and Public

Health Aspects, 2008
Laboratory Tests in Dengue
Fever
 Clinical laboratory tests
◦ CBC—WBC, platelets, hematocrit
◦ Albumin
◦ Liver function tests
◦ Urine—check for microscopic hematuria
 Dengue-specific tests
◦ Virus isolation
◦ Serology

Center for Disease Control. Dengue: Clinical and Public Health
Aspects, 2008
On Admission
 IVF= D5LR 1L x 125 cc/hour
 D5NSS 1L x 125 cc/hour
Diet: Full, no dark colored foods

 Laboratories:
◦ CBC
◦ Serial platelet count Q4H
◦ Dengue Rapid test
◦ Typhidot
◦ APTT, Protime
◦ Chest X-ray PA view
◦ ECG
◦ Urinalysis
CBC
 Hemoglobin= 146
 Hematocrit= 0.45
 RBC= 5.15
 WBC=2.3
 Segmenters= 0.54
 Lymphocytes= 0.45
 Eosinophils= 0.01
 Monocytes= 0
 Basophils= 0
 Platelet count= 78
  Dengue Rapid Test: IgM positive
 IgG positive


 Typhidot Test: IgM negative

 IgG negative
Temperature, Virus Positivity,
and Anti-Dengue IgM, by Fever
Day
 APTT
◦ 40.2
 (Normal value: 26.1-36.3 s)
 Protime
◦ Control= 14.3
◦ Patient= 14.6
◦ PTA= 84.6
◦ PTR= 1.24
◦ ISI= 1.22
◦ INR= 1.3
◦

◦
Why is APTT prolonged and
Protime Normal in Dengue?
 Intrinsic pathway of
coagulation cascade is
triggered by thrombin
activating coagulation factor
XI via positive feedback.
 Factor XI generates additional
thrombin by activation of
factors IX and X.
 Patients with DHF have a
comparatively low level of
thrombin-activatable
fibrinolysis inhibitor (TAFI).
 The function of TAFI is to down-
regulate fibrinolysis by
removing C-terminal lysine
residues that are essential
for binding and activation of
plasminogen.
 Thus, hemorrhagia in DHF
results mainly from an
inadequate factor
XI/thrombin/TAFI feedback
loop, which leads to an
imbalance between
coagulation and fibrinolysis.
Chest X-ray PA view
ECG
Urinalysis
 Color= straw
 Transparency= hazy
 Reaction= 6.5 acidic
 Specific Gravity= 1.020
 Albumin= trace
 Sugar= negative
 WBC= 25-40 / hpf (2+)
 RBC= 8-12/ hpf (2+)
Plans
 Paracetamol 500 mg/tablet, 1 tablet Q4H
PRN for temp >37.5 C
 Ranitidine 50 mg IV Q8H
 Transfusion with 2 units platelet
concentrate
 Referred to Infectious disease and
Hematology sections

First Hospital day (10 hours after)
 S:
◦ Epigastric pain
 O:
◦ Awake, concious, not in cardiopulmonary distress
◦ BP= 80/60- 90/70, CR: 80, RR: 20, T: 36.2 C
◦ Anicteric sclerae, pinkish conjunctivae
◦ (-) neck vein engorgement
◦ Adynamic precordium, regular cardiac rate and
rhythm, no murmurs
◦ Symmetrical chest expansion, bronchovesicular breath
sounds, (+) bibasal fine rales
◦ Flat abdomen, normoactive bowel sounds, soft, (+)
direct tenderness epigastric area
◦ Grossly normal extremities
◦ (+) tourniquet test
 Etiology of Abdominal Pain in Dengue Fever
S. Khanna!, J.C. Vij, A. Kumar, D. Singal and R. Tandon
Pushpawati Singhania Research Institute for Liver, Renal and Digestive Diseases, Press
Enclave Marg,
Sheikh Sarai, Phase-II, New Delhi-110017, India

Abdominal pain is a commonly reported symptom in DF. The

reported causes of abdominal pain in DFinclude hepatitis,
pancreatitis, acaculous cholecystitis and peptic ulcer
disease. Till to date, there has been no planned study to
evaluate the cause of pain abdomen in DF. This study was
planned to evaluate the etiology of abdominal pain in DF.
The various causes of pain abdomen diagnosed in patients

with DF were: acute hepatitis, acalculus cholecystitis, acute

pancreatitis, appendicitis, spontaneous bacterial peritonitis,

enteritis, peptic ulcer disease and gastric erosions in 20

(36.4%), 9 (16.4%), 8 (14.5%), 3 (5.45%), 2 (3.63%), 8
(14.54%), 2 (3.63%) and 3 (5.45%) of the patients
respectively.
In patients with dengue fever, the etiology of abdominal pain

should be aggressively looked into for proper management.



CBC
1 day PTA: On Adm ission:  10 hours after
Hem oglobin= 132 Hem oglobin= 146 admission:
Hem at ocrit = 0.45  Hemoglobin= 178
Hem at ocrit = 0.41
RBC= 5.15  Hematocrit= 0.55
RBC= 4.59
WBC= 2.3  RBC= 6.23
WBC= 3.6
Segm ent ers= 0.54  WBC= 3.0
Segm ent ers= 0.80
Lym phocyt es= 0.45  Segmentors=
Lym phocyt es= 0.18
Eosinophils= 0.01 0.63
Eosinophils= 0
 Lymphocytes=
Monocyt es= 0 Monocyt es= 0
0.37
Basophils= 0.02 Basophils= 0
 Eosinophils= 0
Plat elet count = 216 Plat elet count = 78
 Basophils= 0
 Platelet Count=
66
Protime

 On admission: 10 hours after:



 Control= 14.3 ◦ Control= 14.5

 Patient= 14.6 ◦ Patient= 15.7
 PTA= 84.6
 PTR= 1.24 ◦ PTA= 75.7
 ISI= 1.22 ◦ PTR= 1.33
 INR= 1.3 ◦ ISI= 1.22
◦ INR= 1.42


◦
Chest X-ray
ABG
 FIO2= 52%
 pH= 7.35
 pCO2= 28
 pO2= 138
 HCO3= 18
 sO2= 99%
 pAO2/FI02 ratio=265.38 mm Hg
 Required FIO2= 22%
 HCO3 deficit= 56.8 meqs in 24 hours

Definition Criteria for ALI and ARDS
 Criteria for ALI
◦ Acute in onset
◦ Oxygenation: A partial pressure of arterial oxygen to
fractional inspired oxygen concentration ratio < 300 mm
per Hg (regardless of PEEP)
◦ Bilateral pulmonary infiltrates on chest radiograph
◦ Pulmonary artery wedge pressure < 18 mm per Hg or no
clinical evidence of left atrial hypertension
 Criteria for ARDS
◦ Acute in onset
◦ Oxygenation: A partial pressure of arterial oxygen to
fractional inspired oxygen concentration ratio < 200 mm
per Hg (regardless of PEEP)
◦ Bilateral pulmonary infiltrates on chest radiograph
◦ Pulmonary artery wedge pressure < 18 mm per Hg or no
clinical evidence of left atrial hypertension

Pathogenesis of ALI

Welbourn CR and Young Y. Endotoxin,

septic shock and acute lung injury:
neutrophils, macrophages and inflam-
matory mediators. Brit J Surg 1992; 79 (10):
998-1003.
  SGPT= 298
 SGOT= 253
 Serum sodium= 136
 Serum potassium= 3.31
 Serum Calcium= 0.9

Hepatic changes in Dengue
 Alterations of hepatic functions and acute hepatitis
in some patients
 Aminotransferases peak on 9th day after
appearance of symptoms and go back to normal
in 3 weeks.
 Histopathological findings:
◦ Centrotubular necrosis
◦ Fatty alterations
◦ Kupffer cells hyperplasia
◦ Acidophilic bodies
◦ Monocytic infiltrates of the portal tract,

Brazilian Journal of Infectious Diseases

Braz J Infect
Dis vol.6 no.6 Salvador Dec. 2002
 First Day of Admission (10
hours PTA)
 Assessment:
◦ Dengue Hemorrhagic Fever Grade 3
◦ Acute lung injury, secondary
◦ Acute hepatitis secondary
◦ Hypokalemia
◦ T/C Peptic Ulcer disease
◦
◦
Clinical Case Definition for
Dengue Hemorrhagic Fever
 4 Necessary Criteria:
 Fever, or recent history of acute fever
 Hemorrhagic manifestations
 Low platelet count (100,000/mm3 or less)
 Objective evidence of “leaky capillaries:”
◦ elevated hematocrit (20% or more over
baseline)
◦ low albumin
◦ pleural or other effusions

Center for Disease Control. Dengue: Clinical and Public

Health Aspects, 2008
Dengue Hemorrhagic fever
 Increase in vascular
permeability

Leakage of plasm a from int ravascular t o ext ravascular

space

Hypovolem i
a

Signs of circulat ory

com prom ise

Profound shock

Gubler DJ. Dengue and Dengue Haemorrhagic

Fever. Clinical Microbiology Reviews, 1998, 11:
480-496.
Four Grades of DHF
 Grade 1
◦ Fever and nonspecific constitutional symptoms
◦ Positive tourniquet test is only hemorrhagic
manifestation
 Grade 2
◦ Grade 1 manifestations + spontaneous bleeding
 Grade 3
◦ Signs of circulatory failure (rapid/weak pulse, narrow
pulse pressure, hypotension, cold/clammy skin)
 Grade 4
◦ Profound shock (undetectable pulse and BP)


Center for Disease Control. Dengue: Clinical and Public Health

Aspects, 2008
Risk Factors Reported for
DHF
 Virus strain
 Pre-existing anti-dengue antibody
◦ previous infection
◦ maternal antibodies in infants
 Host genetics
 Age
 Higher risk in secondary infections
 Higher risk in locations with two or more serotypes
circulating simultaneously at high levels (hyperendemic
transmission)

Center for Disease Control. Dengue: Clinical and Public Health

Aspects, 2008
Hypothesis on Pathogenesis of
DHF
 Antibody-dependent enhancement is the
process in which certain strains of dengue
virus, complexed with non-neutralizing
antibodies, can enter a greater proportion
of cells of the mononuclear lineage, thus
increasing virus production

Center for Disease Control. Dengue: Clinical and Public Health

Aspects, 2008
Hypothesis on Pathogenesis of
DHF
 Persons who have experienced a dengue
infection develop serum antibodies that
can neutralize the dengue virus of that
same (homologous) serotype
 In a subsequent infection, the pre-existing
heterologous antibodies form complexes
with the new infecting virus serotype, but
do not neutralize the new virus


Center for Disease Control. Dengue: Clinical and Public Health

Aspects, 2008
Hypothesis on Pathogenesis of
DHF
 Infected monocytes release vasoactive
mediators, resulting in increased vascular
permeability and hemorrhagic
manifestations that characterize DHF and
DSS

Center for Disease Control. Dengue: Clinical and Public Health

Aspects, 2008
Homologous Antibodies Form
Non-Infectious Complexes

Center for Disease Control. Dengue: Clinical and Public Health

Aspects, 2008
Heterologous Antibodies Form
Infectious Complexes

Center for Disease Control. Dengue: Clinical and Public Health

Aspects, 2008
Heterologous Complexes Enter
More Monocytes, Where Virus
Replicates

Center for Disease Control. Dengue: Clinical and Public

Health Aspects, 2008
Viral Risk Factors for DHF
Pathogenesis
 Virus strain (genotype)
◦ Epidemic potential: viremia level, infectivity
 Virus serotype
◦ DHF risk is greatest for DEN-2, followed by
DEN-3, DEN-4 and DEN-1


Center for Disease Control. Dengue: Clinical and Public Health

Aspects, 2008
Plans
 Referred for CVP insertion
◦ Initial CVP= 3-4 cm
◦ IVF: D5LR 1 L x 150 cc/hr
 Transfusion with 4 units platelet
concentrate and 4 units FFP
 Hydrocortisone 200 mg IV given as
loading dose then 100 mg IV Q6H
 Furosemide 20 mg IV every 12 hours for 4
doses
Treatment of ALI

MacNaughton PD, and Ewans, TW. Adult respiratory

Distress Syndrome. Recent advances in respiratory
medi cine Edinburgh. Churchill Livingstone. First
edition. 1991. P. 1-22.
 The use of corticosteroids in severe sepsis and acute
respiratory distress syndrome.
Chadda K, Annane D.,Medical Intensive Care Unit, Raymond Poincaré University
Hospital, School of MedicineGarches, France

 In practice, a high dose of corticosteroids (i.e. one to

four boluses of 30 mg/kg of methylprednisolone, or
equivalent) had no effects on survival in severe sepsis or
acute respiratory distress syndrome. There are at least
seven randomised controlled trials reporting the benefits
and risks of low dose corticosteroids (i.e. 200 to 300 mg
daily of hydrocortisone or equivalent) given for a prolonged
period in severe sepsis or in the late phase of acute
respiratory distress syndrome. These trials showed
consistently that, in these patients, the use of low dose of
corticosteroids alleviated inflammation, restored
cardiovascular homeostasis, reduced organ dysfunction,
improved survival and was safe. Further studies are
ongoing to better identify the target population. In the
meantime, cortisol replacement (i.e. 200 to 300 mg daily of
hydrocortisone or equivalent) should be considered as
standard care for these patients.
Corticosteroids for treating dengue shock
syndrome
Panpanich R, Sornchai P, Kanjanaratanakorn K
Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003488. DOI:
10.1002/14651858.CD003488.pub2

 No good evidence that corticosteroids are

helpful in dengue shock syndrome
 The current treatment for dengue shock syndrome
is to give fluids directly into the bloodstream, but
corticosteroids have been suggested as drugs
that may help due to their anti-inflammatory
properties. This review of trials found only
four small trials (with 284 participants) that
were not of good quality and which showed
no benefit overall. Further trials would be
needed before this drug were used in these
patients, as there is the potential for adverse
effects due to the drugs' properties of
suppressing the immune system and potentially
leaving people open to other infections.

  Rapid potassium replacement done
 Ranitidine IV discontinued
 Omeprazole 40 mg IV OD started
 Ciprofloxacin 200mg IV Q12H
 Blood culture and TPAG requested



 Acute Lung Injury and Bacterial
Infection
Didier Dreyfuss,Service de Réanimation Médicale, Hôpital Louis Mourier, Assistance
Publique—Hôpitaux de Paris, Colombes 92700, France

28 March 2005.


 The relationships between acute lung injury and

bacterial infection are complex. Indeed, sepsis
and in particular pneumonia are leading causes
of acute lung injury. Bacterial superinfection of
the lung is a frequent complication of acute lung
injury. Because of impaired host defenses and
prolonged mechanical ventilation, more than one
third of patients with the acute respiratory
distress syndrome acquire ventilator-associated
pneumonia, with resistant pathogens in most
instances. This complication is responsible for
more than a doubling of the time on mechanical
ventilation but does not seem to increase
mortality.
Second Hospital Day (25
hours after admission)
 S/O:
◦ Drowsy
◦ BP: 0-50 palpatory CR= 120s RR= 25 Temp= 36.6 C
◦ Anicteric sclerae, pinkish conjunctivae
◦ (+) Neck vein engorgement
◦ Symmetrical chest expansion, harsh breath
sounds(+) fine rales, mid to base lung fields
◦ Adynamic precordium, regular cardiac rate and
rhythm, tachycardic, no murmurs
◦ Flat abdomen, normoactive bowel sounds, soft, (+)
direct tenderness epigastric area
◦ CVP= 9cm
◦ Platelet count= 36
Chest X-ray
ABG
 FIO2=52%
 pH= 7.33
 pCO2= 24
 PO2= 119
 HCO3= 16
 SO2= 98%
 HCO3 deficit=60 meqs in 24 hours
 Required FIO2=36.35
 PaO2/FIO2= 228.84

 Serum Creatinine= 78. 10
 BUN= 3.43
 Troponin I: 0.53 ug/ L
(borderline)

Assessment
◦ Dengue Hemorrhagic Fever Grade 4
◦ Acute lung injury, secondary
◦ Acute hepatitis secondary
◦ Hypokalemia
◦ T/C Peptic Ulcer disease

Plans
 Summary of Fluids
◦ CVP line= PNSS 1 L x 10 cc/hr
◦ Mainline=D5NSS 1L x 60 cc / hr
◦ Dopamine 400 mg/250 cc at 10 ugtts/min
◦ Dobutamine 500mg/250 cc at 10 ugtts/min
◦ Levophed 8mg/250 cc at 100 ugtts/min
 TOTAL= 190 cc/hr or 4560 cc/ 24 hours
 Dextran 250 cc to run for 2 hours
 Transfusion with FFP
 Hydrocortisone shifted to
Methylprednisolone 500 mg IV q8H
 Comanagement with Nephrology Section
and Cardiology Section


 Second Hospital Day (28 hours after
admission)
 S/O:
◦ Drowsy, no urine output
◦ BP= 80 palpatory CR=150s-170s RR=25
Temp=36.5 C
◦ Anicetric sclerae, pinkish conjunctivae
◦ (+) Neck vein engorgement
◦ Symmetrical chest expansion, harsh breah
sounds, (+) rales, mid to base lung fields
◦ Adynamic precordium, tachycardic, no
murmurs
◦ CVP= 9 cm
◦ ECG at cardiac monitor= non-sustained
ventricular tachycardia

Assessment
◦ Dengue Hemorrhagic Fever Grade 4
◦ Acute lung injury, secondary
◦ Cardiac Arrhythmia– ventricular tachycardia
◦ T/C Viral encephalopathy
◦ Acute kidney injury secondary to dengue shock
syndrome

 Myocardial depression in dengue hemorrhagic fever:
prevalence and clinical description.
Khongphatthanayothin A, Lertsapcharoen P, Supachokchaiwattana P, La-Orkhun V,
Khumtonvong A, Boonlarptaveechoke C, Pancharoen C.
King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

 OBJECTIVES: To determine the prevalence of myocardial

depression and its effect on the clinical severity in patients
with dengue hemorrhagic fever.
 MEASUREMENTS AND MAIN RESULTS: EF during toxic stage was
significantly lower in patients with DSS than DHF, and lower in
DHF than DF (p = .05) with rapid recovery within 24-48 hrs. EF
<50% was found in 6.7%, 13.8%, and 36% of patients with DF,
DHF, and DSS during the toxic stage, respectively (p = .01).
DSS patients with poor ventricular function had significantly
more tachycardia and hepatomegaly. While end-diastolic
volumes were similarly reduced, patients with lower EF tended
to have lower cardiac output, required more aggressive
intravenous fluid resuscitation, developed larger pleural
effusion, and had higher incidence of respiratory
embarrassment. No patient had elevated troponin T level.
CONCLUSIONS: Transient myocardial depression is not
uncommon in patients with DSS. Cardiac dysfunction in
children with DSS may contribute to the clinical severity and
the degree of fluid overload in these patients.
Plans
 Cordarone 150 mg IV given
 Cordarone drip started
 Furosemide 40 mg IV given
 Request for 5 units FFP
 Joint Service with Department of Neurology

 Furosemide drip started
 Repeat platelet count= 34
 Request 6 units platelet concentrate
 Nephrosteril drip 500 cc to run for 24 hours
 Nebulization with Salbutamol 1 neb Q 4H

Second hospital day (31 hours
after)
 S/O:
◦ Drowsy , in cardiorespiratory distress
◦ GCS 10 (E= to pain, V=confused, M=localizing)
◦ BP= 80 palpatory CR=120s RR=36 Temp= 36.5 C
◦ On and off desaturation at 10 lpm
◦ (+) Neck vein engorgement (+) supraclavicular
retractions
◦ Harsh breath sounds(+) rales, mid to base lung
fields, (+) diffuse wheezing
◦ Adynamic precordium, regular cardiac rate and
rhythm, tachycardic, no murmurs
◦ (+) Flat abdomen, (+) abdominal retractions,
normoactive bowel sounds, soft
◦ Grossly normal extremities
◦

ABG
 pH= 7.22
 PCO2= 29
 PO2= 127
 HCO3= 14
 SO2= 98%
 FIO2= 68%
 Required FIO2=45. 15%
 PAO2/FIO2=186.76

Assessment
◦ Dengue Hemorrhagic Fever Grade 4
◦ Acute respiratory distress syndrome,
secondary
◦ Encephalopathy, secondary
◦ Acute kidney injury secondary to dengue shock
syndrome


Unusual Presentations of
Severe Dengue Fever
 Encephalopathy
 Hepatic damage
 Cardiomyopathy
 Severe gastrointestinal hemorrhage

ARDS
 Presence of bilateral pulmonary infiltrates
on chest radiograph
 Impaired oxygenation resulting in a PaO2 to
fraction of inspired oxygen (FIO2) ratio of
less than 200
 The presence of pulmonary edema in the
absence of volume overload or depressed
left ventricular function.

Evangelos Briasoulis, Nicholas Pavlidis, Noncardiogenic

Pulmonary Edema: An Unusual and Serious Complication of
Anticancer Therapy. Department of Medical Oncology, University
of Ioannina, Ioannina, Greece
 Hormones in Sepsis and
ARDS
Activation of hypothalamic pituitary Adrenal glands release cortisol
adrenal axis through a systemic which counteracts inflammatory
pathway, i.e. by circulating pro- process and restores
inflammatory cytokines and through cardiovascular homeostasis.
the vagus nerve

BLOCKED BY SEPSIS

Inadequate hypothalamic pituitary

adrenal axis response to stress

Shock and organ

dysfunction in sepsis
and acute respiratory
distress syndrome.
Warning Signs for Dengue
Shock
Plans
 Intubation done
 VR set-up:
◦ FIO2= 100%
◦ TV= 500
◦ PFR= 50
◦ BUR= 18
◦ Mode=A/C
◦ PEEP= 3 cm
 Fentanyl 0.5 cc Q6H
 In-line nebulization with Salbutamol, 1 neb
Q 4H
 Nebulization with Budesonide respule, 1
respule Q8H


Second hospital day (31 hours
after
 S/O: No urine output
◦ Drowsy, bloody ET aspirate
◦ BP= 30 palpatory CR=120-130 Temp=36 C O2
sat=94
◦ (+) Neck vein engorgement (+) supraclavicular
retractions
◦ Harsh breath sounds, (+) coarse rales, mid to base
lung fields, (+) diffuse wheezing
◦ Adynamic precordium, regular cardiac rate and
rhythm, tachycardic, no murmurs
◦ (+) Flat abdomen, (+) abdominal retractions,
normoactive bowel sounds, soft
◦ Grossly normal extremities
◦ CVP= 8 cm

Chest X-ray
ABG
FIO2= 100%
PH= 7.21

PCO2= 32

PO2= 59

HCO3= 14

So2= 83%

Required FIO2= 133%

HCO3 deficit= 90 meqs in 24 hours

Assessment
 T/C Pulmonary hemorrhage
 Dengue Hemorrhagic Fever Stage 4
 Multiorgan failure secondary to viral sepsis
 Acute Respiratory Distress Syndrome

 Repeat CBC requested STAT
 1 unit Fresh whole blood requested
2 hours later
 S/O:
◦ Unresponsive
◦ BP= 0 CR=0 O2 sat= not appreciated
◦ Pupils fixed dilated
 A:
◦ Cardiopulmonary arrest secondary to
pulmonary hemorrhage
◦ Dengue Hemorrhagic fever Stage IV
◦ Multiorgan failure secondary to viral
sepsis
 P:
◦ CPR done
◦ Patient expired 4:42 AM August 5, 2009
Final Diagnosis
 Cardiopulmonary arrest secondary to
pulmonary hemorrhage
 Dengue Hemorrhagic Fever Stage IV
 Multiorgan failure secondary to viral sepsis
 Acute Respiratory Distress Syndrome (Non
Cardiogenic Pulmonary edema Stage IV)
 Septic shock
Treatment of Dengue Fever
 Fluids
 Rest
 Antipyretics (avoid aspirin and non-
steroidal anti-inflammatory drugs)
 Monitor blood pressure, hematocrit,
platelet count, level of consciousness

Treatment of Dengue Fever
 Continue monitoring after defervescence
 If any doubt, provide intravenous fluids,
guided by serial hematocrits, blood
pressure, and urine output
 The volume of fluid needed is similar to the
treatment of diarrhea with mild to
moderate isotonic dehydration (5%-8%
deficit)

Treatment of Dengue Fever
 Avoid invasive procedures when possible
 Unknown if the use of steroids, intravenous
immune globulin, or platelet transfusions
to shorten the duration or decrease the
severity of thrombocytopenia is effective
 Patients in shock may require treatment in
an intensive care unit

Fluid for Moderate
Dehydration (Intravenous)
weight in lb ml/lb/day weight in kg ml/kg/day

<15 100 <7 220

16-25 75 7-11 165
26-40 60 12-18 132
41-88 40 19-40 88

 Source: Adapted from Guidelines for

Treatment of Dengue Fever/Dengue
Haemorrhagic Fever in Small Hospitals, WHO,
1999.

Rehydrating Patients Over 40
kg
 Volume required for rehydration is twice
the recommended maintenance
requirement
 Formula for calculating maintenance
volume: 1500 + 20 x (weight in kg - 20)
 For example, maintenance volume for 55
kg patient is: 1500 + 20 x (55-20) = 2200
ml
 For this patient, the rehydration volume
would be 2 x 2200, or 4400 ml
 Source: Pan American Health Organization: Dengue and Dengue
Hemorrhagic Fever: Guidelines for Prevention and Control. PAHO:
Washington, D.C., 1994: 67.

Actual Fluid maintenance
requirement of our patient
1500 + 20 x (weight in kg – 20)

Weight= 71 kg

 1500 + 20 x (71 – 20) = 2520

 x 2
 --------
 5040 ml/ 24 hours
 OR 210 cc/ hour
Common Misconceptions
about Dengue Hemorrhagic
Fever
 Dengue + bleeding = DHF
◦ Need 4 WHO criteria, capillary permeability
 DHF kills only by hemorrhage
◦ Patient dies as a result of shock
 Poor management turns dengue into DHF
◦ Poorly managed dengue can be more severe,
but DHF is a distinct condition, which even
well-treated patients may develop
 Positive tourniquet test = DHF
◦ Tourniquet test is a nonspecific indicator of
capillary fragility

Dengue Vaccine?
 No licensed vaccine at present
 Effective vaccine must be tetravalent
 Field testing of an attenuated tetravalent
vaccine currently underway
 Effective, safe and affordable vaccine will
not be available in the immediate future

Comparison of three fluid solutions for resuscitation in
dengue shock syndrome.
Wills BA, Nguyen MD, Ha TL, Dong TH, Tran TN, Le TT, Tran VD, Nguyen TH, Nguyen VC,
Stepniewska K, White NJ, Farrar JJ.Oxford University Clinical Research Unit, Hospital for
Tropical Diseases, Ho Chi Minh City, Vietnam.
 A double-blind, randomized comparison of three fluids for
initial resuscitation of Vietnamese children with dengue
shock syndrome.
 The primary outcome measure--requirement for rescue
colloid--was similar for the different fluids in the two
severity groups. Although treatment with Ringer's
lactate resulted in less rapid improvement in the
hematocrit and a marginally longer time to initial
recovery than did treatment with either of the colloid
solutions, there were no differences in all other
measures of treatment response.
 Initial resuscitation with Ringer's lactate is indicated for
children with moderately severe dengue shock
syndrome. Dextran 70 and 6 percent hydroxyethyl
starch perform similarly in children with severe shock,
but given the adverse reactions associated with the use
of dextran, starch may be preferable for this group.
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