Lessons from Dengue mortality
Dr Suresh Kumar
Hospital Sungai Buloh
Suresh
2
Warning signs
Adult CPG; revised 2nd edition; 2010
Suresh
Look for warning signs
25 year old chinese female
Day 6 fever
Temp 37.8
Started having vomiting since yesterday
24 hours earlier Current
WCC 1,600 1,500
HCT 37 38
PLT 114,000 87,000
WHO proposed new Dengue case classification
Withoutwith
warning signs
1.Severe plasma leakage 2.Severe haemorrhage3.Severe organ impairment
Severe dengueDengue ± warning signs
Probable dengueLive in/travel to dengue endemic area. Fever and 2 of the following criteria:• Nausea, vomiting• Rash• Aches and pains• Tourniquet test positive• Leucopenia• Any warning signLaboratory confirmed dengue(important when no sign of plasma leakage)
Warning signs*• Abdominal pain or tenderness• Persistent vomiting• Clinical fluid accumulation• Mucosal bleed• Lethargy; restlessness• Liver enlargement >2cm• Laboratory: Increase in HCT concurrent with rapid decrease in platelet count
* Requiring strict observation and medical intervention
1. Severe plasma leakageleading to:• Shock (DSS)• Fluid accumulation with respiratory distress
2. Severe bleedingas evaluated by clinician
3. Severe organ involvement• Liver: AST or ALT>=1000 • CNS: Impaired consciousness • Heart and other organs
Criteria for dengue ± warning signs Criteria for severe dengue
WH
O/T
DR
20
09
Suresh
Case study 1
26 yr malePresented with fever for 6 days, high grade fever+headache and dizzienss+nausea+vomiting-after every meal-->food particle, non projectile+no abd pain+had diarrhea since yesterday
currently afebrile for the past 2 days
Suresh
FBC from GPwbc 2.1, plt 37 , pcv 51.5
no bleeding tendenciesno SOBno chest pain
no hx of jungle trekking,swimming in the lake,fishing,camping
stays and works in Saujana Utamaowns a grocery storeno recent fogging historyno recent travelling history
Suresh
Do you agree with the managmentWhat is the complete diagnosis?
BP-130/80
PR70/min
CRT<2 secs
Good volume pulse
FBC in ED pre bolus:wbc: 1.7, Hb: 18.9, HCT: 52.1 plt: 1
given bolus 10 mls/kg normal saline in EDpost bolus fbc:twc: 2.3Hb: 17.1HCTT: 48.1PLT: 1
Suresh
Complete diagnosis
Management of Dengue infection involves
Making a complete diagnosis
Phase of the disease – febrile, defervescence (critical), recovery
Warning signs
Compensated shock / decompensated shock
Evidence for severe dengue
Plasma leakage
Liver impairment
Hemorrhage
Suresh
Case study 1
26 yr malePresented with fever for 6 days, high grade fever+headache and dizzienss+nausea+vomiting-after every meal-->food particle, non projectile+no abd pain+had diarrhea since yesterday
currently afebrile for the past 2 days
Suresh
FBC from GPwbc 2.1, plt 37 , pcv 51.5
no bleeding tendenciesno SOBno chest pain
no hx of jungle trekking,swimming in the lake,fishing,camping
stays and works in Saujana Utamaowns a grocery storeno recent fogging historyno recent travelling history
Suresh
BP-130/80
PR70/min
CRT<2 secs
Good volume pulse
FBC in ED pre bolus:wbc: 1.7, Hb: 18.9, HCT: 52.1 plt: 1
given bolus 10 mls/kg normal saline in EDpost bolus fbc:twc: 2.3Hb: 17.1HCTT: 48.1PLT: 1
Suresh
Complete diagnosis
Management of Dengue infection involves
Making a complete diagnosis
Phase of the disease – febrile, defervescence (critical), recovery
Warning signs
Not in shock / Compensated shock / decompensatedshock
Evidence for severe dengue
Plasma leakage
Liver impairment
Hemorrhage
Suresh
Fluid regime for Dengue with warning signs
Start with 5–7 ml/kg/hour for 1–2 hours,
then reduce to 3–5 ml/kg/hr for 2–4 hours,
then reduce to 2–3 ml/kg/hr or less according to the clinical response
WHO 2009
Suresh
Fluid resuscitation in Dengue
Plasma loss must be immediately replaced
The volume of fluid
Just enough to maintain an effective circulation during the period of leakage
Too rapid intravenous fluids can lead to fluid overload, increased pleural effusion and ascites
Suresh
Fluid regime in compensated shock
5-
10
5 - 7
3 - 5
2 - 3
1.5 – 2
Aim to stop
1 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 24-48
Suresh
Intermittent boluses
5-
10
2-3
2
10
2 - 3
20
2 - 3
1 2 3 4 5 6 7 8 9 10 12 13 14 15 161
718
19
20 21 22 23 24 24-48
Suresh
Causes of fluid overload
excessive and/or too rapid intravenous fluids
incorrect use of hypotonic rather than isotonic crystalloid solutions;
inappropriate use of large volumes of intravenous fluids in patients with unrecognized severe bleeding;
inappropriate transfusion of fresh-frozen plasma, platelet concentrates and cryoprecipitates;
continuation of intravenous fluids after plasma leakage has resolved (24–48 hours from defervescence);
co-morbid conditions such as congenital or ischaemicheart disease, chronic lung and renal diseases.
WHO 2009
Suresh
Fine tuning the fluid regime
• The fluid regime will depend on
• Stage of disease
• Presence or absence of warning signs
• Hemodynamic status
• BP, PR
• Peripheral circulation
• Fluid regime when the blood was taken
Suresh
Fine tuning the fluid regime
• The fluid regime will depend on
• Stage of disease
• Presence or absence of warning signs
• Hemodynamic status
• BP, PR
• Peripheral circulation
• Fluid regime when the blood was taken
Suresh
WHO 2009
“The period of clinically significant plasma leakage usually lasts 24-48 hours”
Suresh
Critical phase
Usually at day 3-7 of illness
Around the time of defervescence
Temperature drops to 37.5 – 380C
Some patients can progress to the critical phase without defervescence
Changes in FBC will help in identifying the onset of critical phase
WHO 2009
Suresh
Evidence of plasma leakage
Haemoconcentration (20% above baseline)
A drop in haematocritfollowing fluid replacement
Adult male
Hct >46%
Adult female
Hct >40%
3rd space fluid accumulation
Pleural effusion, Ascites
Suresh
Picking up plasma leakage
“Progressive leukopenia followed by a rapid decrease in platelet count usually precedes plasma leakage”
“Chest x-ray and ultrasound abdomen can be useful tools for diagnosis”
WHO 2009
Suresh
“The period of clinically significant plasma leakage usually lasts 24-48 hours”
We need to estimate the onset of leakage and start
counting the hours since the onset of leakage
Potential pitfallsClinically significant leakage starts early if we give too much bolus fluids early on.
If we use only changes in HCT as the marker of plasma leakage, correction of dehydration will make us assume that the leakage has started
Suresh
Suresh
Fine tuning the fluid regime
• The fluid regime will depend on
• Stage of disease
• Presence or absence of warning signs
• Hemodynamic status
• BP, PR
• Peripheral circulation
• Fluid regime when the blood was taken
Suresh
Suresh
09/05;03.20AM: WBC 2.10, Hb 15,0 Hct 46.0, Plt 118 (LAB)500CC - NS
09/05; 04.30AM: WBC 1.4, Hb 12.9 Hct 34.8, Plt 6 (ED)1000CC - NS
09/05; 06.00AM: WBC 1.58 Hb 13.5 Hct 39.8 Plt 58 (LAB)500cc gelafundin
09/05; 07.29AM: WBC 1.55 Hb 10.6 Hct 31.1 Plt 62
Suresh
Photo gxm form
Suresh
Role for red cell/whole blood transfusions
WHO 2009
Suresh
Suresh
1qw
Suresh
Decision making in dengue
• Pulse rate
• Peripheries
• Capillary return
• Most useful
• HCT & WBC count
• Warning signs
• Evidence of plasma leakage
• Look for defervescence
• Hours since onset of leakage
Identify phase of
illness
Symptoms & signs
Assess peripheral circulation
Lab parameters
Suresh
A good
Dengue
team
Suresh
Thank you
Hospital Sungai Buloh
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