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DISEASE MONITORING Dr Mahiran Mustafa Chairman of CPG Development Committee.

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Presentation on theme: "DISEASE MONITORING Dr Mahiran Mustafa Chairman of CPG Development Committee."— Presentation transcript:

1 DISEASE MONITORING Dr Mahiran Mustafa Chairman of CPG Development Committee

2 CONTENTS Brief review on different phases in dengue infection Issues at different phases Clinical monitoring for each phase Laboratory monitoring for each phase

3 INTRODUCTION Monitoring dengue cases require the understanding that dengue infection is a systemic and dynamic disease. Its clinical, haematological and serological profiles changing from day to day and accelerate by the hour during the critical phase, particularly in those with plasma leakage Failure in recognising and interpreting the clinical and laboratory manifestations can lead to delay in appropriate management thus cause intractable shock and death



6 OUTPATIENT MONITORING Symptoms: 1.Warning signals 2.Bleeding manifestations 3.Inability to tolerate oral fluids 4.Reduced urine output 5.Seizure Signs: 1.Dehydration 2.Shock 3.Bleeding 4.Any organ failure Laboratory: 1.HCT 2.Hb 3.Platelet

7 DISEASE MONITORING CARD DENGUE DISEASE PROGRESSION CARD Patient ’ s name: ________________________________ I/C No. : _______________________________ Date of onset of fever : __________________________ DateTemp °CBPPRPCV/ HCT WBCPlatelet Attending Clinic/ phone no. Next Appointment


9 Clinical deterioration often occurs during the critical phase because of marked plasma leakage  Evidence of plasma leakage includes: raised HCT haemodynamic instability fluid accumulation in extravascular space

10 Vascular permeability leads to leakage Haemoconcentration Hypovolaemia leads to reflex tachycardia and vasoconstriction Inadequate perfusion of the tissue leads to increased anaerobic glycolysis and resultant lactic acidosis Shock that leads to DIC and bleeding Pathophysiology

11 WARNING SIGNALS Vomiting Abdominal pain Restlessness or altered mental state Mucosal Bleed Sudden change of temperature to subnormal Raising HCT with rapid drop in platelet



14 SEVERE MANIFESTATIONS Acute abdomen Hepatitis and hepatic failure CNS manifestations Carditis or cardiomyopathy

15 Pathophysiological changes from normal circulation to compensated and decompensated shock Normal CirculationCompensated shockDecompensated / Hypotensive shock Clear consciousness Change of mental state – restless, combative or lethargy Brisk capillary refill time (<2 sec) Prolonged capillary refill time (>2 sec) Mottled skin, very prolonged capillary refill time Warm and pink extremitiesCool extremitiesCold, clammy extremities Good volume peripheral pulses Weak & thready peripheral pulses Feeble or absent peripheral pulses Normal heart rate for ageTachycardiaSevere tachycardia with bradycardia in late shock Normal blood pressure for ageNormal systolic pressure with raised diastolic pressure Postural hypotension Hypotension/ unrecordable BP Normal pulse pressure for age Narrowing pulse pressureNarrowed pulse pressure (<20 mmHg) Normal respiratory rate for age TachypnoeaMetabolic acidosis/ hyperpnoea



18 Fluid Guidelines

19 Fluid Therapy: Non Shock Recommendation Encourage adequate oral fluid intake. (Grade C) IV fluid is indicated in patients who are vomiting or unable to tolerate oral fluids. (Grade C) IV fluid is also indicated in patients with increasing HCT (indicating on-going plasma leakage) despite increased oral intake. (Grade C) Crystalloid is the fluid of choice for non shock patients. (Grade C)

20 Indications for referral to Intensive Recurrent or persistent shock Requirement of respiratory support (non-invasive and invasive ventilation) Significant bleeding Encephalopathy or encephalitis

21 DISCHARGE CRITERIA Afebrile for 48 hours Improved general condition Improved appetite Stable haematocrit Rising platelet count No dyspnoea or respiratory distress from pleural effusion or ascites Resolved bleeding episodes Resolution/recovery of organ dysfunction

22 Summary: Principles of disease monitoring 1.Dengue is a systemic and dynamic disease. Therefore disease monitoring is governed by different phases of the disease. 2. The critical phase (plasma leakage) may last for hours. Monitoring needs to be intensified and frequent adjustments in the fluid regime may be required. 3. Recognition of onset of reabsorption phase is also important because intravenous fluid regime needs to be progressively reduced/ discontinued

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