Presentation on theme: "4. Case Histories Dengue Expert Advisory Group. 24 yr old male came to the OPD with H/O fever for 1 day. Had myalgia, and severe headache. No vomiting."— Presentation transcript:
4. Case Histories Dengue Expert Advisory Group
24 yr old male came to the OPD with H/O fever for 1 day. Had myalgia, and severe headache. No vomiting. O/E Flushed skin, good hydration, pulse 80/min, BP 110/80. No abnormality was detected on examination. He was sent home by the OPD doctor advising him to drink - the amount, type of fluid to take paracetamol in correct dose to have rest.
He was also advised to come back on the 4 th day of the illness with CBC. He came back on 4 th day, still febrile, had nausea. Pulse 80/min, BP 110/80. CBC on D-3 WBC – 3800 Hct – 38.8 Plt – 120,000
FBC and Haematocrit monitored Fluid intake and output monitored IV fluids – 1500 ml with 1000 ml orally per day given. Total – 2500 ml/d Domperidone and PCM sos Vital signs monitored
WBC HCT PLT
Symptomatic management continued Monitoring continued. Fluid increased with rise of PCV No clinical deterioration. Had small right sided pleural effusion. No specific management done. Patient improved i.e.. General condition, appetite. Fever settled. Patient was discharged home once the plt count was >50,000 & Afebrile for 48 hrs
Doing a CBC from 3 rd day is better. Often only symptomatic management is adequate. If there is no active bleeding, there is no place for platelet transfusion even if the platelet count is low. No place for steroids or FFP.
A 33 yr old lady, a mother of a 5 month old baby, was admitted with a H/O fever for 5 days. On admission – pulse 100/min, BP 100/90, CRFT- 3 secs, R/pleural effusion Platelets 181,000 52,000 HCT
IV calcium gluconate given 6 hrly. Amount of fluid reduced to 75ml/hr and then 50ml/hr and then stopped. PCV remained stable Blood pressure, pulse, CRFT and UOP maintained. No further interventions were necessary.
Treat both impending shock (prolonged CRFT, narrow pulse pressure, severe postural drop of BP, hypotension) Full blown shock (BP un-recordable) AGRESSIVELY and PPOMPTLY. With crystalloid bolus and gradual reduction of fluid. If PCV is low, give blood. May need dextran later.
A 30 yr old male with DHF was referred (at a private hospital) on 14 th Sep. Admitted on 12 th at 5 pm & transferred to ICU on 13 th at 6 pm HCT PLATELET 112,000 58,000 12,000
Fluid given for 24 hrs = 4150 ml. Now the patient has got B/L pleural effusions and ascites.
PCV increased to 52 Pulse pressure narrowed to 20 with a postural drop of 30 in SBP. Dextran 500 ml given over one hour with 10 mg of frusemide Pulse pressure improved. Good UOP. Patient recovered without any further intervention
Fluid overload can occur un-intentionally. Patients should be told how much and what to drink Dextran is useful in fluid overloaded patients Frusemide in small doses is very effective
Preferred colloid in DHF Mechanism of Action - Produces plasma volume expansion by virtue of its highly colloidal starch structure, similar to albumin Given as a bolus in DHF– 250 ml over 30 mins or 500 ml over 1 hr. Not as a slow infusion. Recommended maximum – 1500 ml for 24 hrs. Should not be used in a dehydrated patients who present with shock and high HCT until the hydration is corrected with crystalloids.
Mrs. R 53 year old female Diabetic and hypertensive Admitted on 08/06/ pm D3 of fever On admission Pulse 88/min, BP 120/80,(110/80) CRFT < 2 sec, Liver 2 cm, tender. WBC – 1600 N – 43% Hb – 13.7 PCV – 42 platelet – 40,000
SHO seen 09/06/2011 at 4 am. Patient C/O dizziness No bleeding manifestations CVS - PR – 104 BP – 130/90 supine 100/80 sitting CRFT - < 2sec Tender hepatomegaly R/S pleural effusion PCV - 46
Critical period 4.00am 09/06/2011 to 4.00 am 11/09/2011 From 4.00 am to 9.00 am 100ml/hr Bolus of N. saline 500ml at9.00am After that 150ml/hr x 3hrs 100ml/hr x 39 hrs
PCV ? Pul p CRFT 2
Critical period over at 4 am on By end of critical period 5350ml fluid given Blood ordered at 6.30 am Admitted to ICU 9.25 am On admission to ICU PR- 120/min BP 110/90 mmhg Pt dyspnoec, with oxygen SPO2- 96% RR - 38 Blood 2 pints received at 10.40am!! After 4 hrs 10 pm am am PCV
1 st 24 hours after critical period PCV
Patient developed shock on 11/06/2011 evening with impalpable peripheral pulses and cold extremities Femoral CVP catheter inserted. Patient developed respiratory distress and was intubated on 12/06/2011 at 6.30am WBC PLATELET , ,000
2 nd 24 hours after critical period 12/06/11 PCV
Inspite of blood and fluid boluses, patient was going into shock repeatedly. Decided to aspirate the R pleural effusion Activated factor VII two vials given Pleural effusion aspirated.
R/S pleural aspiration repeated 14/06/ ml blood aspirated Patient extubated on 16/06/2011 R/S Intercostal tube inserted due to persistant haemothorax on 17/06/ ml drained.
Throughout clotting profile – normal Slight elevation of liver enzymes Renal functions – low K+ Low Serum calcium – i.v calcium gluconate given Good glycaemic control on insulin CRP – – Patient respiratory secretions culture - MRSA Pleural fluid culture and blood cultures – sterile Treated with antibiotics + chest physiotherapy
A 10 year old boy presented at E/S C/O Fever days high grade, continuous with body aches Melina day two episodes and one episode of hematochezia Altered conscious level --1 hour
Unwell looking GCS 12/15 A febrile Pulse Feeble BP un recordable Cold clammy skin CRT>2sec Abdomen tender, Liver 3cm blcm and tender TT + ve USG abdomen pericholic fluid Pelvic ascites O/E
Managemen t Fluid resuscitation with crystalloid Push with N/saline 20ml /kg Repeat with 10 ml/kg Dextran 40 10ml/kg over 1 hour Pulses palpable but tachycardia Crystalloids continued
Day 5 TLC 8,0007,600 Platelets 10,0009,000 Hct 2835 Crystalloids 18 hours later developed tachycardia Narrowed pulse pressure Amount of fluids increased
A six year old girl presented in emergency with C/O: Fever days high grade continuous with body aches Epistaxis day 3 episodes Vomiting day 2-3 episodes Fit-----half hour 1 episode, Generalized tonic / colonic
ON EXAMIANTION Lethargic, but arouse able child SOMI -Ve PR- 80/min, BP- 100/80mmHg, Temp- 100F, Abdomen mildly tender Liver palpable 2 cm below costal margin TT +VE No clinical and radiological evidence of pleural effusion Ultrasound abdomen showed no free fluid TLC 3,500 Plts 80,000 Hct 36% BSR 20mg/dl