1Management of Dengue in adults 2012 - …jknperak.moh.gov.my/v4/images/stories/informasi/kesihatan/2012... · Management of Dengue in Adults ... Discharge criteria : ... Dengue Fever

Management of Dengue in Adults

Dr Ker Hong BeeInfectious Disease PhysicianHospital Raja Permaisuri Bainun

Kursus 'Management of dengue Perak 2012'

Manifestations of the dengue syndrome

� Incubation period: 4-7 days (range 3-14)

� Spectrum of illness:

Dengue virusInfection

Asymptomatic

Undifferentiatedfever

No hemorrhage

Unusualhemorrhage

Dengue Fever

DHF 1& 2 DHF 3&4DSS

Dengue Hemorrhagic Fever(plasma leakage)

Symptomatic

Infection


Clinical course of dengue infection -

Overview

Febrile Phase

Critical

Lasts for 2 – 7 daysClinical features are indistinguishable between DF and DHF

Happens often after the 3rd day of feverClinical presentation depends on the presence and degree of plasma

The earliest abnormality in FBC - progressive ↓ TWBC

� late febrile phase (often after 3rd day) or around defervescence (usually 3rd to 5th day but may go up to 7th day)

* Critical Phase

RecoveryPhase

Clinical presentation depends on the presence and degree of plasma leakageLasts for about 24-48 hours

In DHF patients – plasma leakage stops and is followed by reabsorption of extravascular fluid


when a rapid drop in T coincide with ↑ capillary permeability � ↓ WBC with relative lymphocytosis, ↓ platelets, clotting abnormalities, ↑ AST>ALT, ↓ albumin� Look out for Warning signs

Appetite better, GI Sx abate, stable haemodynamic, ↑ TWBC with subseq ↑ platelet

*

#

Differential diagnosis for dengue illness

during critical phase



Critical Phase

During this phase if,

� Minimal or no plasma leakage occurs

� Patient feels better as the

• Critical volume of plasma leakage occurs– Patient develops DHFPatient feels better as the

temperature subsides

� Dengue fever– Varying degrees of

circulatory disturbances occur depending on the degree of plasma leakage


120

110

10090

80

Blood pressure, pulse pressure, heart rate in hypovolemic shock

PULSE

PRESSURE

( SBP-DBP )

RESPIRATORY

RATE80

70

60

Time

LCS Lum

Compensated shock Decompensated shock

RATE



WHO classification - DHF

� Grade 1

In the presence of haemoconcentration, fever and symptoms, a positive TT and/or easy bruising

� Grade 2

spontaneous bleeding in addition to the manifestation from Grade 1Grade 1

� Grade 3*

circulatory failure – rapid, week pulse and narrowing of pulse pressure or hypotension with the presence of cold, clammy skin and restlessness.

� Grade 4*

profound shock – with undetectable blood pressure or pulse.


Other important manifestations

� Severe bleeding or organ impairment might occur without plasma leakage

� Acute abdomen� Acute abdominal pain is a common symptom in dengue infection

� hepatitis, acalculous cholecystitis and shock, and occasionally � hepatitis, acalculous cholecystitis and shock, and occasionally misdiagnosed as acute appendicitis

� Need to differentiate from surgical causes

� Fever before abdominal pain

� Leucopenia, thrombocytopenia, prolonged APTT with normal PT

� Improvement of pain with fluid resuscitation

� Most recover within 48-72 hours with conservative treatment


� Hepatitis and liver failure

� May be mild or severe regardless of the degree of plasma leakage

� Acute liver failure may occur

� Patients with liver failure have a high propensity to bleed esp. GIT bleeding

� Neurologjcal manifestation

� <1% - mainly encephalitis or encephalopathy

Other important manifestations

� <1% - mainly encephalitis or encephalopathy

� Rare – myelitis, GBS

� Haemophagocytic syndrome

� an uncommon syndrome

� Cytokine storm - unusual progressive cytopenia and multiorgan complications

� Serum LDH and serum ferritin markedly elevated



Critical Phase

Clinical warning signs of severe dengue or high possibility of rapid progression to shock


, which is tender

Feel the pulse for rate & volume

Blood Pressure

Strict IO charting

Monitoring vital signs

Monitor Respiratory RateCRT

Strict IO charting

Check on the IVD regime, IV flow , any thrombophlebitis?

Ask patient for WARNING signs, & signs of bleeding

DIAGNOSIS

� Dengue fever / severe dengue

� Day of illness

� With/ without warning signs

� Febrile / Defervesence 12 hours

� Not in shock / in compensated or decompensated shock

Severe dengue ( D4 illness ) with warning signs in defervesence phase 24 hours not in shock.




Laboratory investigations

� In the early febrile phase WCC is usually normal - decrease rapidly as the disease progresses

� A rising HCT is a marker of plasma leakage and differentiate between DF and DHF - can be masked by concurrent significant bleeding and in those who receive early fluid replacement – baseline HCT in early febrile phase importantreplacement – baseline HCT in early febrile phase important

� In early febrile phase, platelet count is usually normal -decrease rapidly during late febrile phase or at defervescence and continue to remain low for the first few days of recovery

� There is a significant negative correlation between disease severity and platelet count but it is not predictive of bleeding.







Fluid management - maintenance


If patient weighs 60kg……..

4 mL/kg/h for first 10kg body weight

+ 2 mL/kg/h for next 10kg body weight

+ 1 mL/kg/h for subsequent kg body weight for 1x maintainance

� 4ml/kg/hr x 10 = 40 ml/hr

� 2ml/kg/hr x 10 = 20 ml/hr� 2ml/kg/hr x 10 = 20 ml/hr

� 1ml/kg/hr x 40 = 40 ml/hr

� total = 100 ml/hr = 1 pint over 5 hrs

� ( 2400 ml/day )

�


Fluid management - general rules

� Frequent adjustment of maintenance fluid regime

� 1.2-1.5 X Maintenance in critical phase,

� If > 1X Maintenance required, regime need to be reviewed 4-6 Hly.

� Rising HCT- increase infusion rate� Rising HCT- increase infusion rate

� DSS – fluid resuscitation algorithm

� Stop fluid therapy once after critical phase and patient is stable (post defevercence).


Non shock patients (DHF grade I & II)


Dengue with warning signs :


Dengue with warning signs :


Dengue Shock Syndrome – DHF Grade 3

and 4 (DSS)

� Medical emergency

� Early and prompt management lead to better outcome

� Should be nursed in High dependency unit or ICU

� Fluid resuscitation should be prompt� Fluid resuscitation should be prompt

� Following initial resuscitation there maybe recurrent episodes of shock because capillary leakage can continue for 24-48 hours


Dengue Shock Syndrome – DHF Grade

3 and 4 (DSS)

� IV fluid therapy is the mainstay of treatment

� No clear advantage of using any of the colloids over crystalloids in terms of the overall outcome� Dung NM, Day NP, Tam DT, et al. Fluid replacement in dengue shock syndrome: a randomized, double-

blind comparison of four intravenous-fluid regimens. Clin Infect Dis. 1999 Oct;29:787-94. blind comparison of four intravenous-fluid regimens. Clin Infect Dis. 1999 Oct;29:787-94.

� Ngo NT, Cao XT ,Kneen R, et al. Acute management of dengue shock syndrome : a randomized double-blind comparison of 4 intravenous fluid regiments in the first hour. Clin Infect Dis. 2001. 32:(2) 204-13.

� Wills BA, Nguyen MD, Ha TL, et al. Comparison of three fluid solutions for resuscitation

� in dengue shock syndrome. N Engl J Med. 2005 Sep 1;353(9):877-89.

ement of dengue Perak 2012'


3 and 4 (DSS)

� Colloids may be preferable as the fluid of choice in patients with intractable shock in the initial resuscitation

� Colloids seem to restore the cardiac index and reduce the level of HCT faster than crystalloids in patients with level of HCT faster than crystalloids in patients with intractable shock

� The choice of colloids includes gelatin solution (e.g. Gelafusine) and starch solution (e.g. Voluven)


DSS – Fluid resuscitation

� 2 IV lines (largest branula possible)

� 1st line: for replacement/bolus

� 2nd line: for blood taking OR blood transfusion


X 2



� If the first two cycles of fluid resuscitation with crystalloids (about 40 ml/kg) fails to establish a stable haemodynamic state and HCT remains high, colloids should be considered for the third cycle

� If the repeat HCT drops after two cycles of fluid resuscitation and the patient remains in shock, one should suspect and the patient remains in shock, one should suspect significant bleed (often occult) and blood transfusion should be instituted as soon as possible





3 and 4 (DSS)

� Fluid therapy has to be judiciously controlled

to avoid fluid overload, result in massive pleural

effusion, pulmonary oedema or ascites


How to Recognise Significant Occult Bleeding?


Management of bleeding in dengue


Any role of prophylactic platelet transfusion ?


Inappropriate transfusion of blood components increases the risk of pulmonary oedema and respiratory embarrassment

Action plan for treatment of fluid

overload


Indications for referral to Intensive Care:

� Recurrent or persistent shock

� Requirement of respiratory support (non-invasive and invasive ventilation)

� Significant bleeding

Encephalopathy or encephalitis � Encephalopathy or encephalitis


Recovery Phase

� Plasma leakage stops after 24-48 hours of defervescence

� This followed by reabsorption of extravascular fluid

� Patients’ general well being improves, appetite returns, gastrointestinal symptoms abate, returns, gastrointestinal symptoms abate, hemodynamic status stabilises and diuresis ensues.

� Recovery of platelet count is typically preceded by the recovery of WBC count


� Stop fluid therapy once after critical phase and patient is stable (post defevercence).


Discharge criteria :

� • Afebrile for 48 hours

� • Improved general condition

� • Improved appetite

� • Stable haematocrit

� • Rising platelet count

� • No dyspnoea or respiratory distress from pleural effusion or ascites

� • Resolved bleeding episodes

� • Resolution/recovery of organ dysfunction


Summary:

Principles of disease monitoring

1.Dengue is a systemic and dynamic disease. Therefore disease monitoring is governed by different phases of the disease.

2. The critical phase (plasma leakage) may last for 24-48 hours. Monitoring needs to be intensified and frequent adjustments in Monitoring needs to be intensified and frequent adjustments in the fluid regime may be required.

3. Recognition of onset of reabsorption phase is also important because intravenous fluid regime needs to be progressively reduced/ discontinued


THANK YOU FOR YOUR ATTENTION

Dengue Fever is a six-member band from Los Angeles who combine Cambodian pop music and lyrics with psychedelic rock.

Documents

1Management of Dengue in adults 2012 - …jknperak.moh.gov.my/v4/images/stories/informasi/kesihatan/2012... · Management of Dengue in Adults ... Discharge criteria : ... Dengue Fever