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7/25/2019 Qr Management of Dengue Infection in Adults (2nd Edition)
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MANAGEMENT OF DENGUE INFECTION IN ADULTS (2ndEdition) QUICK REFERENCE FOR HEALTH CARE PROVIDERS
KEY MESSAGES
Dengue is a sstemic and dnamic disease.
There are three phases in dengue infection-febrile phase, critical phase
and recover (reabsorption) phase.
Diagnosis should be clinical with guidance from laborator results.
Clinical deterioration often occurs in the critical phase (often 3rd
da of fever onwards) and is marked b plasma leakage. There isa continuum of circulator disturbances in dengue requiring frequent
monitoring of the dengue patient.
Rising haemotocrit (HCT)/packed cell volume (PCV) is a marker of
plasma leakage.
Look out for warning signs which ma indicate severe dengue or high
possibilit of rapid progression or shock.
Recognition of shock in its earl stage and prompt uid resuscitation
will give a good clinical outcome.
There is no role of prophlactic transfusion with platelets and fresh
frozen plasma in dengue patients.
This Quick Reference provides ke messages and a summar of the
main recommendations in the Clinical Practice Guidelines (CPG)Management of Dengue Infection in Adults (2ndEdition) (2008).
Details of the evidence supporting these recommendations can
be found in the above CPG, available on the following websites:
Ministr of Health Malasia : ht tp://www.moh.gov.m, or
Academ of Medicine Malasia : http://www.acadmed.org.m
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MANAGEMENT OF DENGUE INFECTION IN ADULTS (2ndEdition) QUICK REFERENCE FOR HEALTH CARE PROVIDERS
WARNING S IGNS
Abdominal pain or tenderness
Persistent omiting
Clinical uid accumulation (pleural effusion/ascites)
Mucosal bleed
Restlessness or lethargy
Lier enlargement >2 cm Laboratory : Increase in HCT concurrent with
rapid decrease in platelet
DISEASE NOTIFICATION
All suspected dengue cases* must be notied b telephone to
the nearest health ofce within 24 hours of diagnosis, followed
b written notication within one week using the standard
notication form.
LABORATORY INTERPRETATION
In the absence of baseline HCT, a HCT value of >40% in adultfemale and >46% in adult male should raise the suspicion ofplasma leakage.
DENGUE SEROLOGY TESTS
If the dengue IgM is negative before da 7, a repeat sample must
be taken in the recover phase. Dengue Non-structural protein -1 (NS1 Antigen) can be helpful
in earl phase (< Da 5) of dengue infection.
A patient has an acute febrile illness with two or more features : Rash
Malgia Headache Arthralagia
OR Dengue endemic/hot spot/outbreak area
Leucopenia
Retro-orbital pain Haemorrhagic manifestations
DISEASE NOTIFICATION
All suspected dengue cases* must be notied b telephone to
the nearest health ofce within 24 hours of diagnosis, followed
b written notication within one week using the standard
notication form.
WARNING S IGNS
Abdominal pain or tenderness
Persistent omiting
Clinical uid accumulation (pleural effusion/ascites)
Mucosal bleed
Restlessness or lethargy
Lier enlargement >2 cm Laboratory : Increase in HCT concurrent with rapid
decrease in platelet
SUSPECT A CASE OF DENGUE*
SUSPECT A CASE OF DENGUE
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Step 1: Oerall assessment1. History Date of onset of fever/illness Oral intake Assess for warning signs Diarrhoea Bleeding Change in mental state/seizure/dizziness Urine output (frequenc, volume and time of last voiding) Pregnanc or other comorbidities
2. Physical examinationRefer to clinical parameters for disease monitoring (Table 3)
3. Inestigationsi. FBC and dengue serolog should be taken (as soon as possible)ii. If no facilit for HCT, refer patient to the nearest hospital
Step 2 : Diagnosis, disease staging and seerity assessment
Based on the above the clinician should be able to determine:
1. Dengue diagnosis (provisional)
2. The phase of dengue illness if dengue is suspected (febrile/critical/recover)
3. The hdration and haemodnamic status of patient (in shock or not)
4. Whether the patient requires admission
Step 3 : Plan of management1. Notication is required2. If admission is indicated refer to prerequisites for transfer3. If admission is not indicated:
Dail or more frequent follow up is necessar especiall fromda 3 onwards until the patient becomes afebrile for at least
24-48 hours without antipretics Serial FBC/HCT must be monitored as disease progresses
(Table 3)
Table 1:STEPWISE APPROACH IN OUT PATIENT MANAGEMENT
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1. Symptoms: Warning signs
Bleeding manifestations
Inabilit to tolerate oral uids
Reduced urine output
Seizure
2. Signs: Dehdration
Shock
Bleeding
An organ failure
3. Special Situations: Patients with co-morbidit e.g. diabetes, hpertension,
ischaemic heart disease, morbid obesit, renal failure,chronic liver disease
Elderl (>65 ears old)
Pregnanc
Social factors that limit follow-up e.g. living far from healthfacilit, patient living alone
4. Laboratory Criteria:
Rising HCT accompanied b reducing platelet count
Prerequisites for transfer to hospital1. All efforts must be taken to optimise the patients condition
before and during transfer.
2. The Emergenc & Trauma Department and/or MedicalDepartment of the receiving hospital must be informedprior to transfer.
3. Adequate and essential information must be sent together withthe patient and this includes the uid chart, monitoring chartand investigation results.
Table 2:
WHEN TO REFER FORADMISSION
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MANAGEMENT OF DENGUE INFECTION IN ADULTS (2ndEdition) QUICK REFERENCE FOR HEALTH CARE PROVIDERS
Table 3:DISEASE MONITORING FOR DIFFERENT PHASES OFDENGUE ILLNESS
Parameter for monitoringFrequenc of monitoring
Febrilephase Critical phase
Recoverphase
CLINICAL PARAMETERS
General well beingAppetite/oral intakeWarning signs
Smptoms of bleedingNeurological/mental state
Dail or morefrequentltowards latefebrile phase
At least twice a daand more frequentl
as indicated
Dailor morefrequentlas indicated
Haemodnamic status Pink/canosis Extremities (cold/warm) Capillar rell time Pulse volume Pulse rate
Blood pressure Pulse pressureRespirator status Respirator rate SpO
2
4-6 hourldepending
on clinicalstatus
2-4 hourldepending onclinical status
In shock-Ever 15-30 minutestill stable then 1-2hourl
4-6 hourl
Signs of bleeding,abdominal tenderness,
ascites and pleural effusion
Dail or morefrequentltowards late
febrile phase
At least twice a daand more frequentl
as indicated
Dailor morefrequentl
as indicated
Urine output 4 hourl2-4 hourlIn shock-Hourl
4-6 hourl
LABORATORy PARAMETERS
FBCDail or morefrequentl ifindicated
4-12 hourldepending on
clinical statusIn shock-Repeat before andafter each attemptof uid resuscitationand as indicated
Dail
BUSE/Creatinine
Liver function testRandom blood sugarCoagulation proleHCO
3/TCO
2/Lactate
As indicated
At least dail or morefrequentl as indicated
In shock-Crucial to monitoracid-base balance/ABG closel
Asindicated
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MANAGEMENT OF DENGUE INFECTION IN ADULTS (2ndEdition) QUICK REFERENCE FOR HEALTH CARE PROVIDERS
FLUID MANAGEMENT
Non-shock patient
Encourage adequate oral intake Intravenous uids are indicated in patients who are vomiting, unable to
tolerate oral uids or an increasing HCT despite increasing oral intake.
Crstalloid is the uid of choice.
Normal maintenance uid per hour can be calculated based on the
following formula (Equivalent to Hallida-Segar formula) : 4 ml/kg/h for rst 10kg bod weight
+ 2 ml/kg/h for next 10kg bod weight
+ 1 ml/kg/h for subsequent kg bod weight
-- For overweight/obese patients calculate normal maintenance uid
based on ideal bod weightDengue Shock Syndrome
Refer to algorithm for uid management for DSS (back cover)
WHEN TO SUSPECT SIGNIFICANT OCCULT BLEEDING?
HCT not as high as expected for degree of shock to be explained b
plasma leakage alone. A drop in HCT without clinical improvement despite adequate uid
replacement (40-60 ml/kg).
Severe metabolic acidosis and end organ dsfunction despiteadequate uid replacement.
MANAGEMENT OF BLEEDING
Patients with mild bleeding from the gums, per vagina, epistaxis orpetechiae do not require blood transfusion.
Blood transfusion with whole blood or packed cell (as fresh as isavailable, preferabl less than 1 week old).
If bleeding continues then consider the use of blood components.
INvASIvE PROCEDURES Endoscop in upper GIT haemorrhage should be avoided. Intercostal drainage for pleural effusion is not indicated.
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