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Dengue Fever & Dengue Shock Syndrome
07-May-18 PLES / SLCP 1
Objectives
Early diagnosis
Pathophysiology of DHF
Proper management
How to avoid complications
Case
07-May-18 PLES / SLCP 2
Febrile Phase
• High fever 2-7 days
• Facial flushing
• +ve TT
• Haemorrhaegic diathesis
• Enlarged liver
07-May-18 PLES / SLCP 3
Early diagnosis of Dengue
• High fever, No coryza
• FBC in day 3• WBC < 5000• Platelet count <150000
• Hess’s test – positive
• NS1 Ag• Day 1-3
07-May-18 PLES / SLCP 4
DF Vs DHF
DF
• No plasma leakage
DHF
• Evidence of plasma leakage
07-May-18 PLES / SLCP 5
Febrile
RecoveryCRITICALFebrile
Recovery
Febrile
Febrile
Recovery
Recovery
07-May-18 PLES / SLCP 6
DF – Febrile phase
• Adequate rest at home
• Adequate amount of oral fluid intake
• Paracitamol only (Oral or PR)
• No NSAID drugs
• Monitor for warning signs
• Monitor with FBC 07-May-18 PLES / SLCP 7
DF – Critical Phase
• 3-5 days
• Rapid drop of temp
• ↑ Capillary leak (24-48hrs) – Pulse pressure narrowing
• Abdominal pain
• FBC – ↑ HCT & ↓Platelets • +/- Liver derangements • Hypoalbunaemia
07-May-18 PLES / SLCP 8
DF – Critical Phase Identify the beginning of the capillary leak
• Platelets <100000
• PCV rise towards 10% 20%
• Pleural effusions (detected by clinically, by USS)
• Ascites (detected by clinically, by USS)
• Low albumin / Low cholesterol?
07-May-18 PLES / SLCP 9
Critical phase – Capillary leak
Fluid leak in to 3rd space (pleural space & ascites)
Hypovolaemia
Shock
MODS (poor organ perfusion)
Death 07-May-18 PLES / SLCP 10
Fluids – How much ? ; How long ?
• Identify the beginning of the leak
• Predict the end
• Try to give only M+ 5% of fluids / 48hrs
• Match the leak
07-May-18 PLES / SLCP 11
Rate IV Fluid : Compare adult and children
07-May-18 PLES / SLCP 12
How to “Match the leak”
UOP 0.5 ml/kg/hr – Only objective parameter
PCV (every 4 – 6 hourly)
Pulse volume
Peripheral coldness
CRFT
BP
07-May-18 PLES / SLCP 13
Management of leaking phase
Minimal fluids in febrile phase
Sufficient fluids in critical phase
Calculate fluid for the ideal body weight in obese children
Minimal fluids in recovery phase
07-May-18 PLES / SLCP 14
Indications for urinary catheterization
•All high risk patients during the critical phase
• Patient with 1st shock
• Patient with complications
• Platelets <50,000
07-May-18 PLES / SLCP 15
Case History – on Admission to Hospital @ 3 days
Clinical Scenario
• 4 years old child, weight-15kg
• WBC –3500, N-27%, L-62%
• Platelets – 98,000
• PCV – 36.3%
Commence Specific Treatment
•PCV monitoring
•Maintenance IV drip
1607-May-18 PLES / SLCP
Child developing leaking while in the hospital
07-May-18 PLES / SLCP 17
Case History - 8hrs after admission
Clinical Scenario
• RR-22/min
• Extremities cold,
• Pulse thready,
• CRFT >4 seconds,
• BP was 80/65 (normal).
• Liver 4cm.
• A V P U
• PCV – 45%
Commence Specific Treatment & Monitoring
• 0.9% Saline 10ml/kg bolus over 1 hour
• Cathereterize
• Urine output (0.5-1 ml/kg/hr )
PLES / SLCP Compensated shock 07-May-18 18
How do you adjust the drip rate
• 10ml/kg/hr
• 7ml/kg/hr
• 5ml/kg/hr
07-May-18 PLES / SLCP 19
When the patient is not improving
Acidosis
Bleeding
Calcium & electrolytes
Sugar
07-May-18 PLES / SLCP 20
Case History – 12 hrs after admission
Clinical Scenario • RR-22/min
• pretty cold,
• pulse – very thready,
• CRFT – 5 seconds,
• BP was 40/00.
• A V P U
• Vomiting coffee ground stuff.
• PCV – 50%
• Repeat SGPT-1273,
• SGOT-1023
Commence Specific Treatment & Monitoring
40% Dextran bolus 10ml/kg over an hour
Followed by 0.9% N.S 10ml/kg over 1 hour
↑ fluid to maintain urine output > 0.5ml/kg/hr – Only objective parameter)
07-May-18 PLES / SLCP 21Uncompensated shock
Simulating natural course
Natural course Admitted with shock
07-May-18 PLES / SLCP 22
Case History – 26 hrs after admission
Clinical Scenario
• RR-22/min
• Cold
• pulse was moderate
• CRFT – 3 seconds,
• BP 90/65.
• A V P U
• PCV – 35% (dropped)
Commence Specific Treatment & Monitoring
Pack cell transfusion 5ml/kg
↑ fluid to maintain urine output > 0.5ml/kg/hr
PLES / SLCP Acute Bleed07-May-18 23
Case History – 35 hours of leak
Clinical Scenario Received 120% fluid quota.
Responding to questions,
RR-40bpm, reduced AE on the both side, SpO2 – 94% with face mask O2,
pulse low volume with cold up to wrist.
Abdomen is distended with asicitis.
PCV is rising 40%
Commence Specific Treatment & Monitoring
40% Dextran bolus 10ml/kg over an hour with frusemide infusion / Bolus
Fluid to maintain urine output > 0.5ml/kg/hr & organ perfusion
PLES / SLCP Fluid Overload 07-May-18 24
07-May-18 PLES / SLCP 25
High risk patients
• Infants
•Obese patients
• Prolonged shock
•Bleeding
• Encephalopathy
•Underlying diseases
• Pregnancy
07-May-18 PLES / SLCP 26
Summary
Early diagnosis
Pathophysiology of DHF
Rational fluid management
How to manage complications
07-May-18 PLES / SLCP 27