1. Dengue fever Febrile phase 2-7 DAYS Convalescent phase 2-5 DAYS Longer in adults 1

2. Dengue haemorrhgic fever Critical phase Leakage Lasts48 hours Febrile phase 2-7 DAYS Convalescent phase 2-5 DAYS Longer in adults 2

3. Plasma leakage is – Selective Pleural and peritoneal cavities – Transient Lasts 24-48 hours – Functional 3

4. Shock Hemodynamic Instability Leakage transient selective 4

5. Detection of DHF(detection of leakage) At three levels At the onset of leakage At hemodynamic instability Shock 5

6. Detect leakage Diagnose DHF Prevent Shock Clinical Hematology Radiology 6

7. Detection: onset of leakage-clinical Potential leaker- Clinical deterioration with defervescence Enlarged tender liver Confirmed leaker- Pleural effusions, free fluid in abdomen 7

8. Detection of leakage-haematology White cell count Platelet count Haematocrit 8

9. Timing the onset of critical period 17 th 8 am 18 th 8 am 18 th 8 pm 19 th 8 am 19 th 8 pm 20 th 8 am 20 th 8 pm 21 st 8 am 21 st 8 pm 7500 7000 6500 6000 5500 5000 4500 4000 3500 3000 2500 2000 1500 260,000 240,000 220,000 200,000 180,000 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 platelets WBC Slide- courtesy of Dr Lakkumar Fernando 9

10. Platelet count Leakage occurs only after platelets drop below 100,000 mark A rapid drop of platelet is correlated with severity of leakage Rise in platelets occur at least `12 hours after the end of leakage phase 10

11. Haematocrit Rise towards 20% above baseline considered significant This may not be seen in patients with – Intravenous fluid replacement – Concomitant bleeding 11

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13. Radiological diagnosis Ultrasound scan- – Oedema of the gall bladder wall (but seen in dengue fever as well) – Fluid in pleural and/or peritoneal cavities CXR- right lateral decubitus (when clinically undetectable) 13

14. Leakage phase-Basic principles of fluid therapy Leakage is time limited- maximum 48 hours Not static but dynamic- – Starting with a trickle – Reaching a peak – Then tapering off Maximum fluid required to counter the resulting hemodynamic instability is M+5% for 48 hours 14

15. Dynamics of Plasma Leakage 15

16. R R 0 Hr 24 Hr 48 Hr F F C C 6 Hr 36 Hr Rapid Slow Moderate 16

17. Basics of fluid therapy Try and match the dynamics of leakage Calculate the maximum fluid required for 48 hours with formula – M+5%= in 50 kg adult 4600ml Use sufficient amounts needed to maintain just adequate intravascular volume and circulation by monitoring the vital signs. It is not necessary to try and finish M+5% 17

18. Try and match the leakage Patients with early leakage – Start with small volumes – Increase the rate gradually to keep hemodynamically stable (pulse pressure >30) with HCT as a guide. Do not try to normalize HCT – Gradually taper off after 24 hours while keeping HCT and vital signs as a guide again 18

19. Try and match leakage In a patient presenting with SHOCK leakage will usually end in 24-36 hrs. Try and reduce fluids or stop altogether after 24-36 hrs. Patients who leak very rapidly with platelet counts dropping sharply usually have relatively shorter period of leaking 19

20. Keep systolic blood pressure above 100 mmHg Keep pulse rate below 100/min Keep pulse pressure above 30 mmHg Keep UOP above and around 25 ml/hour 20

21. Fluids used Crystalloids- normal saline and Hartmann’s solution – Most require only crystalloids – Used in maintenance and as boluses 21

22. Fluids used Hyper-oncotic colloid solutions i.e dextran and 10% starch. Use only as boluses (500ml/hour) Indications – If shock does not respond to crystalloids – When shock detected in a overloaded patient – When heading towards fluid overload with crystalloids only Maximum doses- – Dextran 30ml/kg/dayStarch 50ml/kg/day 22

23. Iso-oncotic colloids i.e plasma, hemaccel – Not recommended 23

24. Fluids during end of leaking phase... – If patient is well with stable pulse and blood pressure, do not try to correct the PCV – Re-absorption will start soon and PCV will come down. Observe vital parameters closely 24

25. Complications of DHF Too little fluid-profound or prolonged shock – Metabolic acidosis – multiorgan failure – DIC Too much fluid-fluid overload – Massive effusions- respiratory compromise – Pulmonary oedema Try to match leak 25

26. End of leakage (Critical Phase) Not always 48 hours from onset Can be earlier Important to detect More fluid given afterwards can lead to fluid overload 26

27. End of leakage (Critical Phase) Clinical improvement Return of Appetite Haemodynamic stability (pulse, BP normal) Diuresis Stabilization of Hct Rise in WBC followed by platelet count Convalescent rash/generalized itching/bradycardia 27

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29. Management of shock Identify shock – Compensated shock-Pulse pressure <20 tachycardia – Decompensated shock-systolic BP<80,MAP<60 – Profound shock- no pulse, BP Cause for shock – Leakage – Haemorrhage – Leakage with haemorrhage 29

30. Leakage causing shock High haematocrit 20% or more Treat with appropriate fluid – Compensated shock – Hypotensive shock 30

31. Haemorrhage causing shock Normal or low haematocrit – Misdiagnosed earlier as “myocarditis” Treat with blood 31

32. Leakage and hemorrhage causing shock Normal or not so high HCT (equivocal) with shock HCT drops more than expected after fluid resuscitation Bring down HCT below 45 with crystalloid then blood 32

33. Shock not responding to fluid- ABCS Acidosis-pH<7.35and HCO 3 < 15 Bleeding Calcium Sugar 33

34. Massive effusions, gross ascites Invariably due to fluid overload Pleural effusions – Respiratory embarrassment – May need to aspirate Gross tense ascites – Poor renal and splanchnic circulation – May need to relieve 34

35. Pitfalls Shock in early leakage – Rapid leaker – Dehydration in febrile phase Shock without leakage – Haemorrhage during febrile phase Leptospirosis 35

36. Management of shock Identify shock – Compensated shock-Pulse pressure <20 tachycardia – Decompensated shock-systolic BP<80,MAP<60 – Profound shock- no pulse, BP Cause for shock – Leakage – Haemorrhage – Leakage with haemorrhage 36

37. Keep systolic blood pressure above 100 mmHg Keep pulse rate below 100/min Keep pulse pressure above 30 mmHg Keep UOP above and around 25 ml/hour 37