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2. Fluid Management in Dengue Hemorrhagic Fever Dengue Expert Advisory Group.

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Presentation on theme: "2. Fluid Management in Dengue Hemorrhagic Fever Dengue Expert Advisory Group."— Presentation transcript:

1 2. Fluid Management in Dengue Hemorrhagic Fever Dengue Expert Advisory Group

2 Dengue Virus Infection AsymptomaticAsymptomatic Symptomatic – Undifferentiated Febrile Illness – Dengue Fever – Dengue Hemorrhagic Fever Non Shock ShockSymptomatic – Undifferentiated Febrile Illness – Dengue Fever – Dengue Hemorrhagic Fever Non Shock Shock

3 Dengue Hemorrhagic Fever Febrile PhaseFebrile Phase Critical phase characterized by plasma leakCritical phase characterized by plasma leak Convalescent PhaseConvalescent Phase

4 Dengue Leak Fever Plasma leak during critical phase is the hall markPlasma leak during critical phase is the hall mark Leading to 3 rd space losses – peritoneal cavity – pleural cavityLeading to 3 rd space losses – peritoneal cavity – pleural cavity Variable in magnitude and exact timingVariable in magnitude and exact timing

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6 Pathogenesis of leak Infection with a virulent dengue virusInfection with a virulent dengue virus Presence of antibodies that enhance dengue virus infection (ADE)Presence of antibodies that enhance dengue virus infection (ADE) Intense immune activationIntense immune activation

7 Pathogenesis Rapidly elevated cytokines (TNF-a, IL-2, IL-6, IL-8, IL-10, IL-12, and IFN-g)Rapidly elevated cytokines (TNF-a, IL-2, IL-6, IL-8, IL-10, IL-12, and IFN-g) Malfunction of vascular endothelial cellsMalfunction of vascular endothelial cells Plasma leakage from intra to extravascular spacePlasma leakage from intra to extravascular space

8 Pathogenesis In severe DHF the loss of plasma is criticalIn severe DHF the loss of plasma is critical Patient becomes hypovolaemicPatient becomes hypovolaemic Signs of circulatory compromiseSigns of circulatory compromise Progress to shock, organ failure, deathProgress to shock, organ failure, death

9 Pathogenesis Cytokine StormCytokine Storm Self limitedSelf limited Ends after 48 hoursEnds after 48 hours

10 Clinical Implications Extravascular fluid loss at variable rate that has to be matched ml for mlExtravascular fluid loss at variable rate that has to be matched ml for ml Lasting 48 hoursLasting 48 hours Resorption of fluid during convalescent phaseResorption of fluid during convalescent phase

11 Key Points Manage critical phase with appropriate volume – Dont under transfuse – Dont over transfuseManage critical phase with appropriate volume – Dont under transfuse – Dont over transfuse Meticulous monitoring during critical phase to match rate of fluid infusion with rate of leakMeticulous monitoring during critical phase to match rate of fluid infusion with rate of leak

12 Monitoring Parameters Clinical – Pulse Rate – Blood and Pulse Pressure – Capillary Refill Time – Urinary OutputClinical – Pulse Rate – Blood and Pulse Pressure – Capillary Refill Time – Urinary Output Lab – HematocritLab – Hematocrit

13 Fluid Management Critical Phase

14 Amount of Fluid? Based on weightBased on weight Adults – If less than 50kg use actual weight – If more take weight as 50 kgAdults – If less than 50kg use actual weight – If more take weight as 50 kg Paediatrics – Current OR Ideal body weight whichever is lowerPaediatrics – Current OR Ideal body weight whichever is lower

15 Ideal Body Weight Weight for height using a growth chartWeight for height using a growth chart Weight for ageWeight for age Formulae in emergencyFormulae in emergency

16 Growth Charts

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18 Formulae <1 year : Age (in Months)+ 9/2 1-7 years : (Age x 2)+ 8 >7 years : Age x 3 APLS : (Age in years + 4) x 2

19 Fluid Quota M + 5% = Maintenance + 5% of body weight Over 48 hours if patient presents in the beginning of critical phase (without shock)Over 48 hours if patient presents in the beginning of critical phase (without shock) Over 24 hours for patients coming in shockOver 24 hours for patients coming in shock

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22 M + 5% - Adults Maintenance – 1 st 10 kg – 1000 mls – 2 nd 10 kg – 500 mls – Remaining 30kgs – 600 mls – Sum = 2100 mlsMaintenance – 1 st 10 kg – 1000 mls – 2 nd 10 kg – 500 mls – Remaining 30kgs – 600 mls – Sum = 2100 mls 5% deficit – 50 x 50 = 2500 mls5% deficit – 50 x 50 = 2500 mls Total = 4600 mls Total = 4600 mls

23 Child 22 kg Maintenance – 1000 + 500 + 40 = 1540 mlsMaintenance – 1000 + 500 + 40 = 1540 mls 5% Deficit – 50 x 22 = 1100 mls5% Deficit – 50 x 22 = 1100 mls Total 2640 mlsTotal 2640 mls

24 Types of Fluid Crystalloids – 0.9% Saline – 5%Dextrose 0.9% Saline – 5% Dextrose ½ salineCrystalloids – 0.9% Saline – 5%Dextrose 0.9% Saline – 5% Dextrose ½ saline

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26 Monitoring – Critical Phase Vital parameters - hourlyVital parameters - hourly Fluid balance chart - assess three hourlyFluid balance chart - assess three hourly HCT - six hourlyHCT - six hourly

27 Fluid Management in Dengue Shock Syndrome

28 Compensated Body compensates for fluid lossBody compensates for fluid loss TachycardiaTachycardia Pulse Pressure narrowsPulse Pressure narrows Prolonged CRTProlonged CRT Fall in urine output to 0.5 mls/kg/hrFall in urine output to 0.5 mls/kg/hr

29 Decompensated Pulse pressure narrows further leading to unrecordable pulse and BPPulse pressure narrows further leading to unrecordable pulse and BP Urine output falls less than 0.5 mls/kg/hourUrine output falls less than 0.5 mls/kg/hour

30 Fluid Resuscitation Crystalloids – N SalineCrystalloids – N Saline Colloids – Dextran 40 in N. Saline – 6% StarchColloids – Dextran 40 in N. Saline – 6% Starch All boluses part of fluid quotaAll boluses part of fluid quota

31 Indications for Colloid Failure of crystalloid boluses to normalize pulse /BPFailure of crystalloid boluses to normalize pulse /BP Development of shock – with fluid overload – amount of fluid exceeding M + 5% deficitDevelopment of shock – with fluid overload – amount of fluid exceeding M + 5% deficit 10 ml/kg over 1 hour 10 ml/kg over 1 hour

32 Colloids Dextran may sometimes interfere with grouping and cross matchingDextran may sometimes interfere with grouping and cross matching 3 doses of Dextran 40 during a 24 hour3 doses of Dextran 40 during a 24 hour 5 doses of 6% Starch during 24 hour5 doses of 6% Starch during 24 hour Remain in circulation for much longerRemain in circulation for much longer

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35 Refractory Shock - ABCS Blood – packed cells – whole bloodBlood – packed cells – whole blood BicarbonateBicarbonate GlucoseGlucose CalciumCalcium

36 Monitoring During Shock 15 minute monitoring of vital signs15 minute monitoring of vital signs HCT immediately before and after each fluid bolus and then at least two to four hourlyHCT immediately before and after each fluid bolus and then at least two to four hourly

37 Key Points – Managing DHF Recognizing the start of critical phase of DHFRecognizing the start of critical phase of DHF Predicting the rate of leak which may vary from patient to patient and within the same patientPredicting the rate of leak which may vary from patient to patient and within the same patient Matching the rate of infusion to rate of leakMatching the rate of infusion to rate of leak Being cognizant of the end of critical phase Being cognizant of the end of critical phase

38 Key Points – Managing DSS Meticulous monitoringMeticulous monitoring Switching appropriately from crystalloids to colloidsSwitching appropriately from crystalloids to colloids Recognizing need for blood transfusionRecognizing need for blood transfusion


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