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DENGUE FEVER

TO FIGHT THE ENEMY IS


TO UNDERSTAND IT

Dilemma
THINGS ARE
COMPLICATED!
VERY
ATYPICAL
PRESENTATIO
N

RATHER
TO SUMMARISE WHAT YOU AND I
COMPLIC
ALREADY KNOWN
ATION/wa
Histor
y
Takin
g

Physical
Examinati
on

rning
signs?
Lab
Test

Manageme
nt-increase
@reduce
drip?

Febrile Phase

2 7 days
Fever is often accompanied by

Facial flushing, skin erythema, generalised


body ache, myalgia, arthalgia and headache
Anorexia, nausea and vomiting (warning sign
for dengue) are common

Mild hemorrhagic manifestations may be


seen
This may include positive tourniquet test,
petechiae or mucosal bleeding

Earliest abnormality in FBC is a


progressive decrease in total WBC count 5

Unusual presentation
Neurological manifestation
Encephalopathy
Encephalitis
Rarely myelitis, GBS

Acute Abdomen
Acalculous Cholecystitis

(epigastric
pain worries of dengue gastropathy do
ultrasound see gall bladder distended
typical of dengue)

KKM UMMC 2006

Q:WHY IS CRITCAL PHASE


IMPORTANT?

Critical Phase
Unlike other viral infection afebrile means

RECOVERY.

But in dengue it may mean the beginning of

PROBLEMS
Critical phase =leakage.- in certain gp of patients.
Some recover without complication ( no capillary

leakage)

Critical Phase
Occurs either
Towards the late febrile phase
Often after 3rd day of fever

or
Around defervescence
Usually between 3rd day to 5th day of fever; but
may go up to the 7th day of fever.

This phase lasts for 24- 48 hours


9

Understand the
terminologies
LEAKAGE
Marked by the

evidence of warning
signs (vomiting)
Usually accompanied
by rise in HCT,
preceeds the onset of
tachycardia and
hypotension
Lasts 48 hrs (can be
early as 24 hours)

DEFERVERSCENCE
May nor may not leak
Usually when temp <

38

Its a dynamic process


Degree of HCT increase may be diminished by

early fluid therapy


We need frequent hct determination.
Free fluid determined by presence of
Ascites---- by usg
Pleural effusion by usg
Gallbladder edema
Hemorrhagic manifestation

Recovery Phase
Follows the critical phase
Gradual resorption of the extravascular fluid

takes place next 48-72hrs.


Improvement of symptoms
Rash may appear, pruritic/ classical islands of
white in a sea of red.
HCT-back to baseline or may even be lower
( reabs)
BUT MAY BE A NIGHTMARE if overzealous with
fluids

Complications that may


encounter at different phases

Severe dengue
One or more of the following

(i) severe plasma leakage that leads to shock


(dengue shock) and/or fluid accumulation with
respiratory distress;
(ii) severe bleeding;
(iii) severe organ impairment

Clinical examination- recognise


early shock please
Tachycardia in the absence of fever
Quiet tachypnoea without the effort
Compromised CRT (capillary refill time)
Rising diastolic, pulse pressure less than

20mmhg
A low bicarbonate, higher lactate,
compensated metabolic acidosis
A relatively normal or low HCT in the
presence of shock.. Think of dengue shock
with occult bleeding.

History Taking

Physical Examination

Whats the next step


Commit to a diagnosis---Which phase of illness
Leaking or not
Deferversced or not
Get all the information needed and available

and make a decision --- dont jump on one


parameter.

Notify

Whom to admit group


B
Warning signs
Severe comorbidity: elderly, obesity, infancy,

pregnancy, heart failure, renal failure etc


Poor social circumstances
Warning signs (definitely!)
Manage fluids adequately

Group C patients
Severe plasma leakage with shock and?or

fluid accumulation
Severe Bleeding
Severe organ impairment
Management: divided into compensated
shock or decompensated shock

Estimated Ideal Body Weight Based on Height and


Estimated Normal Maintenance Fluid Regime for

Female
Height ( )

Height (cm)

Estimated IBW
(kg)

Normal
Maintenance
Fluid Regime
(ml/hr)

152

45

85

51

155

47

87

53

160

52

92

5 5

165

56

96

57

170

61

101

59

175

66

106

511

180

70

110

61

185

75

115

Estimated Ideal Body Weight Based on Height and


Estimated Normal Maintenance Fluid Regime for
Male
Height ( )

Height (cm)

Estimated IBW
(kg)

Normal
Maintenance
Fluid Regime
(ml/hr)

152

50

90

51

155

52

92

53

160

57

97

5 5

165

62

102

57

170

66

106

59

175

71

111

511

180

75

115

61

185

80

120

63

190

84

124

Pearls of Management
USE IDEAL BODY WEIGHT---- train yourself to do it not when

only asked!!!!!!
Get HELP: Anaes, ID, specialist oncall
Its a judgement call that needs to be made AT THAT TIME
not sometime today/tomorrow
At every review: commit to the following:
peripheral warmth,
CRT,
pulse volume( not just rate) and bp,
lab ix,
presence/reduction/ absence of warning signs,
intake output charting.

---------- MAKE A HOLISTIC DECISION!!!!!!!--------------

Pearls of Management
- conts
Try and use the guidelines as a guide alone

( but its pretty cool and comprehensive)


Obtain referrence hct before and after fluid
resusc
Obtain vbg, rp, lactates regularly, fbc 2 hrly
If HCT improves--- cut down!
If HCT does not improve:
If increased repeat the bolus either 10- 20

mls/hr
If reduced and hemodynamically unstable--occult bleeding

Choice of fluids
No advantage of using colloids or crystalloids
Colloids better at restoring Bp urgently , reducing

HCT faster ( best data with voluven)


Most have their own limitations
Crystalloids
0.9% normal saline
Best for resuscitation intially
Normal anion gap hyperchloraemic acidosis

Ringers lactate
Good alternative if the cl is increasing trend--caution in liver failure and metformin (stop).

Choice of fluids
Colloids
Dextran based, gelafusin
Binds to vonWF as well as factor 8 and impairs
coagulation
Allergic reaction
Gelafusin has the highest allergic reaction but
least impairment in coagulation
Can be used if there is elevation in HCT despite
normal saline boluses( stable or unstable pt)

Sometimes it just does not make


sense..
Pt seems to be improving and there is acidosis.
Could be due to the normal saline infusion given causes
normal anion gap acidosis
Sometimes parameters are improving but Bp is low
is it sepsis wide pulse pressure, bounding pulse

Presented with UGIB coffee ground vomitus, history of

hematemesis, but pt stable now


Reevaluate the case from scratch, does he really need

transfusion! We will lose HCT

Improving but HCT keeps going up


The volume given sometimes becomes malignant
Try colloids.

Interpretation of
blood results

Incubation Period: 4-10

days
viraemia detected from
the time symptoms
occur to absence of
fever
Dengue IgM is detected
usually when no
fever( about 6-10 days.
Dengue IgG usually by
day 9
Ns1 detected from day 2
to day 9
But in secondary
infection: dengue IgG
rapidly high( 30-40 days)
and detectable for
decades.

Unrecognised
disease (not
anymore)
Unrecognised

shock
Unrecognised
occult
haemorrhage
Overzealous fluid

KKM UMMC 2006

SUMMARY
All aspect-clinical phase, warning signs,lab ix

(HCT) and haemodynamic status.

Not one of this aspect can stand on its own!


Careful observation and monitoring after each

correction must be done and further plan


based on this.

THUS
MANAGE DENGUE COMPREHENSIVELY

AND PREVENT COMPLICATION AND


MORTALITY

Case Presentation