Dengue management in icu dwayne

Denguemanagement in

ICU- Dr. Dwayne M

2WHO Handbook for clinical management of Dengue, 2012

Warning signs

Clinical-• Abdominal pain or tenderness• Persistent vomiting• Clinical fluid accumulation• Mucosal bleed• Lethargy, restlessness• Liver enlargment >2 cm, tender hepatomegalyLaboratory:-• Increase in HCT concurrent with rapid decrease in platelet count

3

Clinical fluid accumulation

LAbdominal tendernessMucosal bleedsPersistant Vomiting

ethargyiver enlargement >2cmsabs (increase Hct/ decrease Platelets)

CLAMP down on Dengue

Group C: Require emergency treatment

• Severe plasma leakage leading todengue shock

• Severe haemorrhage

• Severe organ impairment

• Loss of plasma

• Loss of blood

• Loss of organ function


Predictors of Severe Dengue• Young age (esp infants)• Caucasian race• AB blood group• Warning Signs• Abdominal Tenderness• Hepatomegaly• Lethargy• Cold extremities• Bleeding• PC <75000/cu mm• Hct value >50 or rise >22% from

baseline

• Viral load assessment• Viral serotype testing• NS1 level semi-quantitive

measurement• Measurement of plasma/serum

cytokine, elastase, hyaluronan,soluble thrombomodulin, NO level• Detection of circulating endothelial

cells

Jeanne A. Pawitan; Dengue Virus Infection: Predictors for Severe Dengue; Acta Med Indones-Indones J Intern Med

DIAGNOSIS

1. Is it dengue?

2. Which phase?

3. Warning signs?

4. Hydration/ Hemodynamic status?

5. Admission?

Airway

• Usually clear

• No further intervention needed

Breathing

• Respiratory rate• Respiratory effort

• B/L Air entry• B/L Chest movements

• Noisy breathing• Noisy Machines

• Cyanosis

• Mental status

Circulation – Assessment of shock• Heart rate• Peripheral pulses• Central pulses• Colour• Temperature• CFT• BP• Mental Status• Urine Output

PALS Guidelines – American Heart association

COLD SHOCK WARM SHOCKHeart rate ↑ ↑

Peripheral pulses Feeble Bounding

Central pulses Well felt/↓ Well felt

Colour Pale, mottled Pink

Temperature Cold Warm

CFT >3 seconds Flash

PP Narrow Wide

Mental Status Normal altered Toxic sick child

Urine Output ↓ ↓

Dengue Shock (VS Septic shock)

• Less likely to have SIRS• Less likely to have tachycardia• Narrow pulse pressure• Mental status better• Higher Hct• Thrombocytopenia more common• Spontaneous clinical bleeding more common• Required less fluid bolus

S. Ranjit et al; Early differentiation between Dengue and Septic Shock; Pediatric Emergency Care, Vol 23, Number 6, June 2007

AsymptommaticCapillary leak

Cardiac Arrest HypotensiveShock

CompensatedShock

Severe dengue

Goals of fluid resuscitation

Improving central and peripheral perfusion• Decreasing tachycardia• Improving BP and pulse volume• Warm and pink extremities• CFT<2 sec.

Improving end organ perfusion• Stable conscious level• Urine output more than 0.5 ml /kg /hr• Decreasing metabolic acidosis


REASSESS

Examn

UO PCV

17

WHO Handbook forclinical management ofDengue, 2012

Bolus – Slow and steady!!

Compensated shock• 1st: over 1hr• 2nd: over 1hr• 3rd: over 1hr

Hypotensive shock• 1st: over 15mins• 2nd: over 30-60mins• 3rd: over 30-60mins

WHO Handbook for clinical management of Dengue, 2012

Aggressive fluid resuscitation??

• Patients in the W group received less fluids in the 1st hour comparedwith the P group (median 20ml/kg vs 30ml/kg)

• Incidence of acute respiratory distress syndrome significantly greaterin the W group• Duration of ventilation and length of ICU stay longer in P group• Mortality higher in W group

S. Ranjit et al; Aggressive management of dengue shock syndrome may decrease mortality rate. Pediatr Crit Care Med2005; 6: 412-419

Monitoring

• Mental status• Vital signs every 15-30mins till pt is out of shock• Peripheral perfusion then 1-2 hourly

• BP monitoring – Arterial line• Urine output - hourly till patient is out of shock, then 1-2 hourly


Role of early colloids• Colloids may be the preferred choice if the BP has to be restored

urgently. Colloids have been shown to restore the cardiac index andreduce the level of haematocrit faster than crystalloids in patientswith intractable shock• After two to three boluses of crystalloid without haemodynamic

stability and particularly if the haematocrit is still elevated, it isessential to consider the switch to colloid resuscitation which is moreeffective in lowering the haematocrit

• Dung NM, Day NP, Tam DT. Fluid replacement in dengue shock syndrome: a randomized, double-blindcomparison of four intravenous fluid regimens. Clinical Infectious Diseases, 1999, 29:787-794.

• Ngo NT, Cao XT, Kneen R. Acute management of dengue shock syndrome: a randomized double-blind comparisonof 4 intravenous fluid regimens in the first hour. Clinical Infectious Diseases, 2001, 32:204-213.

• Wills BA et al., Comparison of three fluid solutions for resuscitation in dengue shock syndrome. New EnglandJournal of Medicine, 2005, 353:877-889.

No advantage of colloids over crystalloids

• No difference in mortality between groups who received crystalloidsand colloids” - Colloids versus crystalloids for fluid resuscitation in Dengue fever patients – a reviewby Dr Pablo Perel

• “Resuscitation of patients with DSS who already have third space fluidaccumulation with crystalloid boluses on priority basis may contributeto recovery phase pulmonary oedema” - Premaratna et al.: Should colloid boluses beprioritized over crystalloid boluses for the management of dengue shock syndrome in the presence ofascites and pleural effusions? BMC Infectious Diseases 2011 11:52

Ionotropes

• As a temporary measure to prevent life-threatening hypotension indengue shock and during induction for intubation, while correction ofintravascular volume is being vigorously carried out DOPAMINE

(Vasopressors – maintain the central BP but without improving endorgan perfusion. May exacerbate tissue hypoxia and lactic acidosis)

• For myocarditis or ischemic heart disease DOBUTAMINE

• In concomitant septic shock DOPAMINE / NORADRENALINE


Role of steroids

• Dengue shock is a hypovolemic state due to plasma leakage (unlikeSeptic shock which is a catecholamine depleted state )• Serum cortisol levels are high in children with dengue shock.

• “There is no good-quality evidence that corticosteroids are helpful forDSS”

Panpanich R, Sornchai P, Kanjanaratanakorn K: Corticosteroids for treating dengue shock syndrome. CochraneDatabase Syst Rev. 2006; 3:CD00348

Role of IVIg

• The immunological basis of the life-threatening manifestations ofsevere dengue together with the potentially beneficialimmunomodulatory effects of intravenous immunoglobulins (IVIG)suggest a possible place for treatment with this expensive therapy.

• Trials so far have not shown significant benefit in terms of survival orimprovement in clinical parameters with IVIG

Senaka Rajapakse; Intravenous immunoglobulins in the treatment of dengue illness. Transactions of the Royal Society ofTropical Medicine and Hygiene (2009) 103, 867—870

• Child day 4 of fever• on IVF 7ml/kg/hr• PCV 39% 32%• What will you do?

Hemorrhagic manifestations• Persistent acidosis Coagulopathy DIC• Thrombocytopenia

• Only minor prolongations in PT, APTT but moderate to severe depression ofplasma fibrinogen concentrations• Levels of the anticoagulant proteins were normal or depleted at the time of

admission to the hospital and decreased significantly during the subsequent24 h. Levels of all of the remaining proteins, except TFPI, were elevatedsignificantly at admission and also decreased during the next 24 h

Briget A Wills et al; Coagulation Abnormalities in Dengue Hemorrhagic Fever in 167 Vietnamese children with dengue shock

Patients at risk of severe bleeding

• Prolonged/refractory shock• Persistent metabolic acidosis• Renal or liver failure• Non-steroidal anti-inflammatory agents• Any form of trauma, including intramuscular injection.• Haemolytic conditions are at risk of acute haemolysis with

haemoglobinuria


Treatment of hemorrhagic complications

• Epistaxis – pressure, nasal adrenaline packing• NO role of platelet/FFP transfusion – “transfusion of platelet

concentrates and fresh frozen plasma in dengue were not able to sustainthe platelet counts and coagulation profile”• GI bleed – H2 blockers and PPI used, but efficacy not been studied• Care when inserting NG tube or bladder catheters• Central venous line – under USG guidance

• 5–10ml/kg of fresh-packed red cells or 10–20 ml/kg of fresh whole blood30WHO Handbook for clinical management of Dengue, 2012

• Blood transfusions only when PCV has fallen to low levels• Do not wait!! PCV will drop to low levels after several boluses of fluid

resuscitation, or if the bleeding is very severe• Change from crystalloid/colloid infusion to blood transfusion

• DIC regime for severe bleeding• Target for multiple transfusions of FFP, Platelets and Cryo• Plasma leakage and bleeding go on unabated!!• “unless transfusion with fresh whole blood is given urgently, the patient will

succumb to H’agic shock with massive third space fluid accumulation”

• Blood transfusion in a shocked patient with ↑PCV• Give colloid bolus 10-20ml/kg – over 1hr if compensated, over 15mins if not

• Blood transfusion in a stable patient with ↓PCV• Not needed – possibly due to hemodilution


REASSESS

Examn

UO PCV

SHOCK FLUIDOVERLOAD

DENGUE

•Fluids have to be given at justthe right time, in the just theright volume, of just the righttype and for just the rightduration

Fluid Overload

• Child with dengue develops fast breathing on day 4 of illness….? Fluid overload? Pleural effusion? pneumonia

• Shortness of breath misinterpreted as fluid overload or due to pleuraleffusion or pneumonia

• Metab acidosis – quiet tachypnea

• Look for shock

• PCV• ABG ± Lactate


• Prophylactic IVF in febrile phase because NS1 Ag Positive• No role – leads to fluid overload• Maintain on oral fluids• If unable to take, IVF for least possible time, switch to oral

• Step up fluid therapy in a well perfused patient with persistently highPCV• Continue same fluids; Step up monitoring

• IVF in recovery phase because patient is not drinking• Huge positive balance• Lets patient’s thirst mechanism kick in after the diuresis


Management of fluid overload

• Furosemide bolus 0.5-1mg/kg two to three times daily

• Furosemide Infusion 0.05-0.4mg/kg/hr

• Peritoneal dialysis, CVVH

Acute respiratory distress and failure

• Severe metabolic acidosis from severe shock

• Fluid overload – large pleural effusions and acites

• Acute pulmonary oedema

• Acute respiratory Distress Syndrome

Role of Non invasive ventilation

Premaratna et al.: Should colloid boluses be prioritized over crystalloid boluses for the management of dengue shocksyndrome in the presence of ascites and pleural effusions? BMC Infectious Diseases 2011 11:52

Role of diuretics in ARDS

• The efficacy of furosemide infusion with respect to changes in thearterial blood gas demonstrates its role in respiratory function.

• In patients with ARDS, diuretics should be tried, which could improveoxygenation and avoid the need for mechanical ventilation.

KR Bharath Kumar Reddy et al; Furosemide Infusion in Children with Dengue Fever and Hypoxemia. Indian pediatrics Vol 51APRIL 15, 2014

Glucose control

Hyperglycemia• Neuroendocrine stress response• Osmotic diuresis• Increased morbidity and

mortality• IV insulin (not s/c)

Hypoglycemia• Starvation, severe liver

involvement• Seizures, mental confusion,

unexplained tachycardia• Treat as emergency with 0.1-

0.5g/kg• Maintain with fixed rate of

glucose-isotonic solution


Electrolyte imbalance• Hyponatremia – GI losses, hypotonic solution

• Hyperkalemia – severe acidosis, AKI

• Hypokalemia – GI losses, Stress induced hypercortisol state

• Calcium – repeated blood transfusions, bicarbonate infusions

• Hyperchloremia – large volume of 0.9% NaCl


Metabolic acidosis

• Compensated MA – early sign of hypovolemia and shock

• Lactic acidosis

• Sodium bicarbonate – ph<7.1(W/F sodium and fluid overload, increase lactate, decreased Ca)


Abdominal compartment syndrome

• Worsening of ventilator parameters• Oliguria• Unexplained metabolic acidosis• Tense ascites• Reduced cardiac output

• Sedatives, head end elevation, Neuromuscular blockade• NG Decompression, enema• Lasix• Paracentesis• Decompressive Laparotomy

Myocarditis

• Optimize Hb• Optimize preload with fluids if indicated (slow bolus – 10ml/kg)• Decrease WOB by supplemental O2• Consider early intubation• Consider early ionotropes Dobutamine

• Role for ECHO – for EF, Contractility and IVC status• Lesser role for CVP now-a-days

Myocarditis

• EF <50% was found in 6.7%, 13.8%, and 36% of patients with DF, DHF,and DSS during the toxic stage, respectively (p <.01)• DSS patients with poor ventricular function had significantly more

tachycardia and hepatomegaly.• While end-diastolic volumes were similarly reduced, patients with

lower EF tended to have lower cardiac output, developed largerpleural effusion, and had higher incidence of respiratoryembarrassment

Apichai Khongphatthanayothin et alk; Myocardial depression in dengue hemorrhagic fever: Prevalence and clinicaldescription. Pediatr Crit Care Med 2007; 8:524 –529

CNS Involvement

Rajesh Verma et al; Neurological complications of dengue fever: Experience from a tertiary center of north India.Ann Indian Acad Neurol. 2011 Oct-Dec; 14(4): 272-278

• Seizures and altered sensorium – diagnosed as neuroinfection

Febrile phase – febrile seizureTreat as febrile seizure, WATCH FOR WARNING SIGNS

Critical phase – Acute cerebral ischemiaFLUID FLUID FLUID FLUID FLUID FLUIDAny delay (CT scan) Cardiorespiratory collapse and irreversible shock


Acute Kidney injury

• Renal hypoperfusion

• RRT of choice – Continuous veno-venous hemodialysis• Alternatives- peritoneal dialysis

• During critical phase, target UO of 1ml/kg/hr as criterion of adequacyof IVF• Expectation should be scaled down to 0.5ml/kg/hr to avoid fluid overload

• Use of Furosemide for oliguria in critical phase• May worsen hypovolemia while keeping you happy with UO

• “Fluid bolus challenge furosemide” for reduced urine output• Averted oliguric renal failure?!?!• NO!!!! Fluid gone into extravascular space, fluid removed from intravascular

space worsening of hypovolemia

• RRT in critical phase for severe metabolic acidosis and oliguria• RRT only reserved for recovery phase – Haemodynamically stable child• Fluid in critical phase will take care of acidosis and oliguria


When to stop IV fluids

• signs of cessation of plasma leakage• stable BP, pulse and peripheral perfusion• haematocrit decreases in the presence of a good pulse volume• apyrexia (without the use of antipyretics) for more than 24–48 hours• resolving bowel/abdominal symptoms• improving urine output.


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Dengue management in icu dwayne

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