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8/9/2019 WHO_dengue_classification_and_case_management-flyer copy.pdf
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Group AMay be sent home Group BReferred for in-hospital care Group CRequire emergency treatmentGroup criteria
Patients who do not have warningsigns
ANDwho are able:
o To tolerate adequate volumes
of oral fluids
o To pass urine 3-4 times per day
Group criteria
Patients with any of t he following features:
o Existing warning signs OR o Co-existing conditions such aspregnancy, infancy, o ld age, diabetes
mellitus, renal failureo Social circumstances such as l iving
alone, living far from hospital
Group criteria
Patients with any of the following features.o Severe plasma leakage with shock and/or fluid
accumulation with respiratory distress
o Severe bleeding
o Severe organ impairment
Laboratory tests
o Full blood Count (FBC)o Haematocrit (Hct)
Laboratory tests
o Full blood Count (FBC)o Haematocrit (Hct)
Laboratory tests
o Full blood Count (FBC)o Haematocrit (Hct)
Treatment
Advice for:o Adequate bed rest
o Adequate fluid intake
o Paracetamol, 4 gram max. per
day
Patients with stable Hct can be sent
home
Treatment
o Obtain reference Hct before fluid therapyo Give isotonic solutions such as 0,95 saline, Ringer
lactate, start with 5-7 ml/kg/hr for 1-2 hours, then
reduce to 2-3 ml/kg/hr or less according to clinical
response
Reassess clinical status and repeat Hcto
If Hct remains the same or rises only minimally ->
continue with 2-3 ml/kg/hr for another 2 -4 hours
o If worsening of vital signs and rapidly rising Hct - >
increase rate to 5-10 ml/kg/hr for 1-2 hoursReassess clinical status, repeat Hct and review fluid
infusion rates accordingly
o Reduce i ntravenous fluids gradually when the rate
of plasma leakage decreases towards the end of thecritical phase.
This is indicated by:
o Adequate urine output and/or fluid intake
o Hct deceases below the baseline value in a stablepatient
Treatment
o Encouragement for oral fluidso If not tolerated, start intravenous
fluid therapy 0,9% saline or
Ringer Lactate at maintenance rate
Treatment of shock:
o Start intravenous fluid resuscitation with isotoniccrystalloid solutions at 5-10 ml/kg/hr
o Reassess patients s condition,
If patient improves:
o Intravenous fluids should be reduced gradually to 3-
5 ml/kg/hr, then to 2 -3 ml/kg/hr and then dependingon haemodynamic status
o Can be maintained for up to 24 - 48 hours
If patient still unstable:
o Check Hct after first boluso If Hct increases/ still high (>50%), repeat a second
bolus of crystalloid solution at 10-20 ml/kg/hr.
o If improvement after second bolus, reduce rate to 7-
10 ml/kg/hr, continue to reduce as aboveo If Hct decreases, this indicates bleeding and n eed to
cross-match and transfuse blood as soon as possible
Treatment of hypotensive shock
Monitoring
o Daily review for warning signs
(until out of critical period)
o Advice for immediate return tohospital if development of any
warning signs
o Written advice of management
(e.g. home card for dengue)
Monitoring
o Vital signs and peripheral perfusion (1-4 hourly
until patient is out of critical phase
o Urine output (4-6 hourly)o Hct (before and after fluid replacement, then 6-12
hourly)
o Blood glucose ( before f luid replacement and repeat
as indicatedo Other organ functions (renale profile, liver profile,
coagulation profile, before fluid replacement and as
indicated)
Monitoring
o Temperature pattern
o Volume of fluid intake and losses
o Urine output volume andfrequency
o Warning signs
o Hct, white blood cell and platelet
counts
o Initiate IV fluid resuscitation with crystalloid or
colloid solution at 20 ml/kg as a bolus for 15 min
If patient improves
o Give a crystalloid / c olloid solution of 10 ml/kg/hr,them reduce gradually
If patient still unstable
o Check Hct after the first bolus
o
If Hct increases/ still h igh (>50%), change IV fluidsto colloid solutions at 10 ml/kg/hr, then reduce to 7-
10 ml/kg/h, then change back to crystalloid solution
and reduce rate as above
o If HCT decreases, this indicates bleeding, see a bove
Treatment of haemorrhagic complications:
o Give 5-10 ml/kg of fresh packed red cells or 10-20
ml/kg of fresh whole blood
Dengue Case Management
Classification
Assessment
Presumptive Diagnosis:
Neighbourhood dengue/travel to endemic area plus
Fever and two of the following: Anorexia and nausea Rash Aches and pains +/- warning signs Leucopenia
Tourniquet test +/-
Warning signs: Abdominal pain or tenderness
Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy; restlessness Liver enlargement >2cm Laboratory: Increase in HCT concurrent with rapiddecrease of platelet count
negative positive
Co-existing conditionsSocial circumstances
negative
positive
Dengue withoutwarning signs
Dengue withwarning signs
Severe Dengue
Management
Lab.confirmed dengue(important when no signof plasma leakage)
8/9/2019 WHO_dengue_classification_and_case_management-flyer copy.pdf
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Dengue case classification by severity
Without
with
warningsigns
1.Severe plasma
leakage
2.Severehaemorrhage
3.Severe organimpairment
Severe dengueDengue warningsigns
Probable dengue
Live in/travel todengue endemicarea. Fever and 2 ofthe following criteria:
Nausea, vomiting Rash
Aches and pains Tourniquet testpositive Leucopenia
Any warning signLaboratoryconfirmed dengue(important when no sign of
plasma leakage)
Warning signs*
Abdominal pain ortenderness Persistent vomiting Clinical fluid
accumulation Mucosal bleed
Lethargy;restlessness Liver enlargement>2cm
Laboratory:
Increase in HCTconcurrent with rapiddecrease in plateletcount
* Requiring strict observationand medical intervention
1. Severe plasma
leakage leading to: Shock (DSS) Fluid accumulationwith
respiratory distress
2. Severe bleedingas evaluated by
clinician
3. Severe organinvolvement
Liver: AST orALT>=1000 CNS: Impaired
consciousness Heart and other
organs
Criteria for dengue warning signs Criteria for severe dengue
WHO/TDR200
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