1. Fluid Management in DHF Patients
Dr Rasnayaka M Mudiyanse
Senior Lecturer in Paediatrics
Faculty of Medicine Peradeniya

2. Short Duration Fever - OPD
Treat and send home
Admit
No resuscitation
Need
Resuscitation
Treat Fever
Rest
Fluid
Specific drugs
Warning signs DD
Dengue ( group A)
( No warning signs )
Viral fevers
Other D
Immediate attention
Fluid
Oxygen
Observation DD
Dengue (group B)
( with warning signs)
Other infections
Other D
1. Evaluate & ABC care
2. Fluid boluses
3. Oxygen
4. Hand over MO-MO DD
Dengue ( group C)
(Sever dengue )
Septicemia
Diarrhea
Anaphylaxis
Ask the question ; “ what are the primary decisions by a first contact doctor. First contact doctors have to decide treat and send home or admit. But the most important category that you have to recognize is those who are critically ill and require resuscitation. Save lives

3. Classification of Dengue
Old WHO classification
New WHO classification
Classical Dengue Fever
Probable dengue ( group A - OPD management)
Dengue Fever with hemorrhagic manifestations
Dengue with warning signs ( Group B - inward observation and management)
( patients are admitted for social reasons and when they are in high risk category)
DHF grade one
DHF grade two
DHF grade three
Severe Dengue ( Group C - resuscitation and management)
With compensated shock
With hypotensive shock
With severe organ impairment
DHF grade four
DHF with unusual manifestations

4. Dengue Hemorrhagic Fever or Dengue Leaking Fever Essential Feature In DHF is Leaking DF may have bleeding but not leaking

5. The Cause of Shock in Dengue
Plasma leakage
Bleeding – external and internal
Hypocalcaemia
Vascular involvement
Inadequate fluid intake
Myocarditis

6. What is the cause of Plasma Leakage
Endothelial cell dysfunction rather than destruction

7. Evidence of Plasma Leakage
Rise in HCT
20% = children 35  42 adults 40  48
Circulatory failure
Fluid accumulation – Ascites, Pleural effusions
Albumin < 3.5 gr/dl
Cholesterol < 100 mg%

8. (Rt. lateral decubitus position)
Evidences of
plasma
leakage in
DHF
(Rt. lateral decubitus position)
A. Rising hematocrit ~ 50%
Rt pleural effusion
Ascites

9. Plasma Leakage  Shock  Prolonged shock
Organ hypo perfusion & Organ impairment
Metabolic acidosis + DIC
Severe Hemorrhage ( Drop HCT & rise of WBC )
All these complications may develop without obvious plasma leakage or shock

10. Rising HCT indicate plasma leakage
20-30% rise  GIT ischemia including liver
30-40 % rise  Renal and brain ischemia

11. Patients at risk of major bleeding
Prolonged/refractory shock;
Hypotensive shock & renal or liver failure
Severe and persistent metabolic acidosis;
Receiving NSAID agents;
Pre-existing peptic ulcer disease;
On anticoagulant therapy;
Any form of trauma( IM injection)

12. Sensitivity of early diagnostic indicators of Dengue
Flushing
Tourquet test
Leucopenia
Liver enzymes
1st day
73%
53%
70%
within 24 hrs pt will enter critical phase
AST rise 90%
AST > 60 – PPV 80%
AST > ALT (2-3 times)
2nd day
90%
3rd day
85%
98%

13. Dengue is a Dynamic Disease

14. Febrile, Critical and Recovery Phase53
105 51
104
140 49
103 47
102
120 45
101 43
100 41 99 39 98 80 37 35 60 1 2 3 4 5 6 7 8 1 2 3
Incubation period 5-8 days ( 3-14 days)
2-7 days
1-2 days

15. Optimum volume of fluid …
Rate of Fluid Leakage 53
105 51
104
140 49
103 47
102
120 45
101 43
100 41 99 39 98 80 37 35 60 1 2 3 4 5 6 7 8 1 2 3
M + 5%
Optimum volume of fluid …

16. Calculation of M +5% Maximum Fluid for adult ( 50kg) = 4600
1st 10 kg – 100 ml/kg/day ( 4 ml/kg/hr)
2nd 10 kg – 50 ml/kg/day ( 2 ml/kg/hr)
Subsequent ..kg – 20 ml/kg/day ( 1ml/kg/hr)
Calculation of 5%
5% = 50ml/kg/day ( 2ml/kg/hr)
Maximum Fluid for adult ( 50kg) = 4600
M+ 5% for boy 60kg (IBW 50kg ) = ?

17. Fluid Management in DHF patients

18. Rational Use of Fluid = Management of Dengue
Avoid Prolong Shock
Avoid Fluid Overload

19. Spectrum of Dengue DHF Grade 4 ( SD with hypotnsive shock )
No pulse – 20ml/kg rapid bolus
Drop SBP (Pulse + ) – 10 ml/kg rapid bolus, Rpt sos
DHF Grade 3 ( SD with compensated shock)
10 ml/kg/hr
No circulatory failure ( D warning signs)
DF +/- Bleeding ( oral fluid ? M+5%)
DHF in Febrile phase (1.5 ml/kg/hr)

20. DF & DHF in Febrile Phase

21. DF & DHF in Febrile Phase1
Parcetamole 15mg/kg 6 hrly
Physical methods of controlling fever
Don’t use Aspirin and NSAID
Fluid to maintain nutrition and hydration
Oral – between M and M+5% ( 5ml/kg/hr)
Too much fluid during febrile phase can contribute to fluid over load

22. Recognize the Time of Entry to the Critical Phase ( when blood vessels become leaky)
Dropping platelet count below /dl
Rising HCT & Evidence of plasma leakage

23. Fluid management during Critical Phase not in shock ( when blood vessels become leaky)
Establish IV line & IV fluid to KVO
Limit total ( IV + Oral) fluid to 1.5 ml/kg/hr
Monitor UOP ( 0.5ml/kg/hr is OK)
Rising HCT - Increase fluid ml/kg/hr
Monitor for circulatory failure – Fluid boluses
HCT monitoring 4-6 hrly initially then hrly

24. Fluid Allocation for Non Shock Patient53
105 51
104
140 49
103 47
102
120 45
101 43
100 41 99 39 98 80 37 35 60 1 2 3 4 5 6 7 8
10-20 ml/kg
20-10 ml/kg 1 2 3
10-5 ml/kg
5-10 ml/kg
5-3 ml/kg
3-5 ml/kg
3-1 ml/kg
1-3 ml/kg
KVO
1.5 ml/kg
M + 5%
48 hrs

25. Fluid Allocation for Non Shock Patient53
105 51
104
140 49
103 47
102
120 45
101 43
100 41 99 39 98 80 37 35 60 1 2 3 4 5 6 7 8
10-20 ml/kg
20-10 ml/kg 1 2 3
10-5 ml/kg
5-10 ml/kg
5-3 ml/kg
3-5 ml/kg
Fluid over load
and shock
3-1 ml/kg
1-3 ml/kg
KVO
1.5 ml/kg
M + 5%
48 hrs

26. Fluid Allocation for Non Shock Patient53
105 51
104
140 49
103 47
102
120 45
101 43
100 41 99 39 98 80 37 35 60 1 2 3 4 5 6 7 8
10-20 ml/kg
20-10 ml/kg 1 2 3
10-5 ml/kg
Shock
and Fluid Over Load
5-10 ml/kg
5-3 ml/kg
3-5 ml/kg
3-1 ml/kg
1-3 ml/kg
KVO
1.5 ml/kg
M + 5%
48 hrs

27. Prolonged shock

28. Prolonged Shock Detecting absent pulse is too late
Drop in SBP is too late
Drop in pulse pressure, CRFT, Cold extremities .. can detect early shock
We can prevent shock !
Rise in HCT = loss of IV compartment
20% - compromise GIT blood supply
40% - compromise renal and brain

29. Prevent Shock – Manage PCV53
105 51
104
140 49
103 47
102
120 45
101 43
100 41 99 39 98 80 37 35 60 1 2 3 4 5 6 7 8
10-20 ml/kg
20-10 ml/kg 1 2 3
10-5 ml/kg
5-10 ml/kg
5-3 ml/kg
3-5 ml/kg
3-1 ml/kg
1-3 ml/kg
KVO
1.5 ml/kg
M + 5%
48 hrs

30. Cause of Prolonged Shock in Dengue
Failure to detect shock is rare in SL
Clinicians thought prolonged shock is due to bleeding as a result of low platelets
Clinicians did not appreciate that shock precipitate bleeding and other organ damage
Clinicians did not monitor/manage PCV ( instead they managed platelet count )
personal opinion
WHY ?
Lack of knowledge and training
Failures in teaching/training programs
WHY ?

31. (DHF grade 4) Severe Dengue with Hypotensive shock
5 year old boy; fever 5 days, cold extremities and prolonged CRFT.
HCT 48, Plt /dl SBP 60/40.
1-10 yrs - 5th Centile SBP = 70+ (agex2)
Adults
SBP <90 mm Hg or MAP <70 mm Hg or Drop of SBP >40 mm Hg

32. Management of DHF Grade 4 Severe Dengue with Hypotensive shock
Oxygen,Keep flat +/- Head low
IV canula – Blood samples
Rapid Fluid bolus + Rpt SOS
Monitoring ABCS
Consider other possibilities
Record keeping & Communication

33. Investigations for DHF patients
FBC
Blood grouping and cross matching
Blood sugar
Blood electrolytes ( Na,Ca,K,HCo2)
Liver Function tests
Renal Function tests
Blood gases
Coagulation profile ( PTT,PT,TT)

34. Management of DHF Grade 4 Severe Dengue with Hypotensive shock
Fluid bolus ml/kg Normal Saline / 15 mt
Improving , HCT coming down gradually , good UOP
Slow bolus – 10 ml/kg Crystalloid/colloids over one hour
Infusion 5- 7 ml/kg/hr for 1-2 hrs ( Hartmann)
Infusion rate 3- 5ml/kg/hr for 2-4 hrs
Infusion rate 3ml/kg/hr for 2-4 hrs
Stop fluid in 48 hrs
No improvement
HCT dropping – Blood transfusion
No improvement
HCT Rising – Colloid transfusion

35. Management of DHF Grade 4 (Severe Dengue with Hypotensive shock )
Fluid bolus ml/kg Normal Saline / 15 mt
Rpt fluid boluses – 2 crystalloids'  colloids
NO IMPROVEMENT
Check HCT before fluid bolus or after fluid bolus
If HCT is dropping
< 40 for Children and female
< 45 for adult male
Rising HCT
2ndBolus - Colloids
10 – 20 ml/kg/ ½-1 hr
Blood transfusion whole blood ml/kg
Packed RBC 5-10 ml/kg
3rd bolus - Colloids
10 – 20 ml/kg/1 hr

36. DHF Grade 3 Dengue with Compensated Shock
10 year old boy; fever 5 days. Cold extremities. Tender Hepatomegaly. PCV 52, Platelets /dl
CRFT 5 sec. SBP 100/85.
5th Centile SBP = 70+ (agex2)

37. Management of DHF grade 3 (Severe Dengue with Compensated shock)
Fluid bolus 5-10 ml/kg Normal Saline / 1hr
Improving , HCT coming down gradually , good UOP
Hartmann ml/kg/hr for 1-2 hrs
Hartmann ml/kg/hr for 2-4 hrs
Hartmann ml/kg/hr for 2-4 hrs
Stop fluid in 48 hrs

38. Management of DHF grade 3 (Severe Dengue with Compensated Shock)
Fluid bolus 5-10 ml/kg Normal Saline / 1hr
Rpt fuid bolus 5-10 ml/kg Normal Saline / 1hr
NO IMPROVEMENT
HCT rising
If HCT is dropping
< 40 for Children and female < 45 for adult male
Blood transfusion
Packed RBC 5-10 ml/kg
Whole blood ml/kg
Fluid bolus saline /colloids
ml/kg for 1hr
However, a rising or persistently high HCT together with stable haemodynamic status and adequate urine output does not require extra intravenous fluid.

39. Patients not responding to usual fluid boluses
Massive plasma leakage – rising PCV
Concealed hemorrhage – Drop of PCV
Hypocalceamia
Hypoglycaemia
Hyponatremia
Acidosis

40. Fluid Management During Critical Phase DON’T OVER LOAD LEAKING VESSELES
Manage PCV and shock; use monitoring chart
Fluid quota for leaking phase is M+5%
Pre shock in 48 hours , Grade 3& 4 in 24 hours
Use colloids to retain longer
UOP – 0.5 ml/kg /hr is OK (Void volume chart)
Cut down fluid at recovery phase
Eg - 10ml/kg/hr  1.5 ml/kg/hr
Give blood when indicated

41. Fluid Allocation for shocked Patient53
105 51
104
140 49
103 47
102
120 45
101 43
100 41 99 39 98 80 37 35 60 1 2 3 4 5 6 7 8
20-10 ml/kg 1 2 3
10-5 ml/kg
5-3 ml/kg
3-1 ml/kg
KVO
M + 5%
24 hrs

42. Fluid Allocation for Non Shock Patient53
105 51
104
140 49
103 47
102
120 45
101 43
100 41 99 39 98 80 37 35 60 1 2 3 4 5 6 7 8
10-20 ml/kg
20-10 ml/kg 1 2 3
10-5 ml/kg
5-10 ml/kg
5-3 ml/kg
3-5 ml/kg
3-1 ml/kg
1-3 ml/kg
KVO
1.5 ml/kg
M + 5%
48 hrs

43. What is M+5% in management of DHF (MCQ)
Fluid volume to be given during critical period after excluding boluses
Fluid volume to be given during critical period after including boluses
Upper limit of fluid volume for critical period
Upper limit that should never be exceeded
M + 5% is only a guide to understand the risk for fluid over load

44. Fluid Management in Recovery Phase

45. Fluid Management in Recovery Phase
Dengue patients have accumulated fluid within his/her body
Cut down fluid
Give oral fluid if tolerating
Dropping HCT is not bleeding
Rising HCT in stable child manage with oral fluid
DHF grade 3 recovery phase; nurse inform that child has massive meleana
HCT dropped to 35 !
Don’t panic if the child is stable, hematocrit 35 is because he is recovering
child is passing what he bled yesterday

46. 6 yr old boy DHF grade 4 recovered after 3 fluid boluses
6 yr old boy DHF grade 4 recovered after 3 fluid boluses. His HCT dropped from 48 to 39. However he again developed circulatory failure with reduced pulse pressure.

47. Management of severe bleeding
Probably he has internal bleeding
Manage with
10 ml/kg whole blood
5 ml/kg Packed RBC

48. Indications for Blood Transfusions
only 10-15% patients need blood
Overt bleeding ( more than 10% or 6-8ml/kg)
Significant drop of HCT < 40 ( < 45 for males) after fluid resuscitation
Hypotensive shock + low/normal HCT
Persistent or worsening metabolic acidosis
Refractory shock after fluid ml/kg
Circulatory failure with high HCT should be managed with colloids ( + Lasix if fluid overloaded) before blood

49. Why do you do platelet counts ? (Answer this MCQ)
To decide on platelet transfusion
To recognize the beginning of critical stage -
As a prognostic indicator-

50. Why do you do platelet counts ?
To decide on platelet transfusion - X
To recognize the beginning of critical stage -
As a prognostic indicator-

51. Fluid Over Load

52. Causes of Fluid Over Load
Too much fluids in febrile phase
Excessive and/or too rapid IV fluids
Use of hypotonic crystalloid solutions
Inappropriate IV fluids for “severe bleeding”
Inappropriate - FFP, platelet & cryo
Continuation of IV fluids after Critical phase
Co-morbid conditions
congenital or ischaemic heart disease
chronic lung and renal diseases
Obesity – Fluid not calculated for IBW

53. Early Clinical Features of Fluid Overload
Respiratory distress
Difficulty in breathing
Rapid breathing
Chest wall in-drawing
Wheezing (rather than crepitations)
Large pleural effusions &/or Tense ascites
Increased jugular venous pressure (JVP)

54. Management of Fluid over load
Minimize fluid
Stop if in recovery phase
Minimize in critical phase
Nurse in the R lateral position
Maintain oxygen saturation above 95%
IV Furosemide +10% Dextran (40) 10 ml/kg ?
Correct hypokalaemia
Assess ABCS

55. How to prevent fluid over load
Leaking Blood vessels ! – Give only minimal & essential
Try to manage within the fluid quota (M+5%)
For 48 hrs for non shock patients
For 24 hrs for shocked patients
Expected Urine out put is only 0.5 ml/kg/hr
Calculate oral fluid also
Monitor fluid intake regularly during critical period – Use a fluid monitor

56. 3 yr old mucus diarrhea mild dehydration had HCT 55%
What to do in practice
3 yr old mucus diarrhea mild dehydration had HCT 55%

57. 8 year old 30 kg girl Fluid for 48 hrs
IBW - 25 kg M
1700
1600
M+5%
3200
2850
5 ml/kg
7200
6000
3 ml/kg
4320
3600
1.5 ml/kg
2160
1800

58. Fluid balance in health and dengue
Ml/kg/hr
Dengue
Total intake 3
UOP 2 1
Insensible loss
Leaking
(+ ve balance)
Water for growth was not taken in to consideration

59. Fluid balance in health and dengue
Ml/kg/hr
Dengue
Total intake 3 5
UOP 2
Insensible loss 1
Leaking
(+ ve balance)
Water for growth was not taken in to consideration

60. Fluid balance in health and dengue
Ml/kg/hr
Dengue
Total intake 3
1.5
UOP 2
0.5
Insensible loss 1
Leaking
(+ ve balance)
0.25
Water for growth was not taken in to consideration

61. Monitoring Charts

62. ? 3 ml/kg NS /one hr 22 kg HCT/plt HR BP RR UOP CRFT Coldness Fluid
11.00 am 38
146
90/80 47
5 ml 8
Mid calf
10 ml/kg bld
12.00 noon 48
100
110/80 49
SOB 10 2
ankle
10 ml/kg
HS + Laxis 20 mg
1.00 pm 41
100/70 40
Acitis
effusions -
3 ml/kg NS
2.00 pm
110
Effusions 60
1.5 ml/kg ?
3 ml/kg NS /one hr
2222/2640 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47

63. * 10 9 8 7 6 5 4 3 2 1 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48
PCV 52 45 51 49 35
UOP 00 15 65 95 60 75 85
100 50 HR
140
110
160
120 98 RR 25 BP
90/80
95/70
95/65
80/70
65/50
100/70
100/75

64. Fluid over load
Why?

65. Causes of fluid over load
Clinicians gave too much fluid - eg 3-5 ml/kg/hr
Clinicians thought that extra fluid in the febrile can prevent shock
Clinicians thought giving blood can be dangerous
Personal opinion with no proof
WHY ?
Lack of knowledge and training

66. Colloids Blood transfusion Observe Condition of the patient HCT Rising
Interpretation of HCT
Condition of the patient
HCT Rising
HCT Dropping
Deteriorating
Colloids
Blood transfusion
Improving
Observe
Increase fluid rate during early critical phase
Improving !
Encourage normal feeding

67. Use Void Volume Chart

68. 7 year old (20 kg ) boy passed 100 ml of urine at 12 MN
7 year old (20 kg ) boy passed 100 ml of urine at 12 MN. He passed urine at 5 pm soon after coming to the ward. Interpret his UOP
UOP is 0.74 ml/kg/hr

69. He was given 100 ml/hr of Hartmann solution from MN up 6 am when he passed 400 ml of urine.
UOP is 3.3 ml/kg/hr ?
His blood counts done on admission
total 5.6 , Platelets /dl, PCV 45

70. Same fluid rate was continued. At 12 noon he passed 40 ml of urine.
UOP is 0.3 ml/kg/hr ?
Blood counts done at 6 am – Platelets 50 , HCT 42
Circulation – HR 120, cold limbs CRFT 5 sec

71. Blood counts done at 6 am – Platelets 60 , HCT 36
Patient develop massive fluid over load. After 30 hours in critical phase, he is on fluid 15 ml/kg/hr. He passed 300 ml of urine in 4 hrs.
UOP is 3.75 ml/kg/hr ?
Blood counts done at 6 am – Platelets 60 , HCT 36
Circulation – HR 98, no cold limbs CRFT 3 sec

72. Use monitoring chart
Chart one – Suspected dengue patient not in critical stage
Chart two – Start once patient enter the critical stage
Knowing the stage of the illness by everybody
in the team is very important
in management of dengue patients

73. Unusual Manifestations of Dengue
Encephalopathy
Hepatic failure
Renal Failure
Dual infections
Underline conditions

74. Ward round presentation by ho/sho
This 7 yr old IBW 20 kg child came to the ward 3 days ago, entered the critical phase yesterday morning. Now 24 hrs in critical phase. On 5 ml/kg/hr of Hartmann.
Stable circulation. Warm limbs, CRFT 2 sec, BP 100/60
UOP for last six hours 0.8 ml/kg/hr
Last HCT 48 ( it has gone up from 42)
So far We have given 1200 ml out of 2500 ml 48 hr fluid quota
We thought of increasing fluid to 7 ml/kg/hr

75. Diagnosis Card of DHF Patient
Dengue Hemorrhagic Fever Grade 4
(Severe Dengue with hypotensive shock)
Patient entered critical phase 24 hrs after admission to ward
HCT - Maximu – 52, minimum – 32
Platelets – Max – 120, Mini – 40
Blood pressure – min – 40/ ?
Management
Total fluid during critical period
1850 / 1900
Crystalloid boluses – 3
Colloid boluses – 1
Blood – 10ml/kg x1
Complications –
Fluid over load – Wheezing, Pleural effusions and ascites. Lasix 20 mg x2
Bleeding ( HCT 32, need blood 10ml/kg)
Hypocalcaemia – Serum Ca – 1.8 ( treated with 10 ml 10% ca Gluconate)

76. Initial fluid for following DHF patients
DHF with no palpable pulse
10-20 ml/kg/15 mt normal saline
DHF palpable pulse but low BP
10ml/kg/15 mt NSS or colloids
DHF normal BP, cold limbs+ CRFT 4 sec
10ml/kg/hr NSS + 10% Dextrose
DHF no shock just entered the critical phase
1.5 ml/kg/hr
DF/DHF in febrile phase – Oral fluid ?5 ml/kg/hr

77. Thank You