Facilitators: Dato Dr. Sree Raman Dr. Lim Chew Har Dr. Ho Bee Kiau Case Management 2 Facilitators: Dato Dr. Sree Raman Dr. Lim Chew Har Dr. Ho Bee Kiau

26/6/08 Klinik Kesihatan FEMALE 60 year old C/O: Fever for 3 days Dizzy and lethargy Joint pain and myalgia Nausea but no vomiting PMH: DM and HPT. Not on treatment O/E: T=38 C BP=120/70

Cont.. Fever ? Cause Treatment: Paracetamol Cefaclor 375mg bd Q1: What is your comment on the case management?

Answer Q1: Page 16 A Stepwise approach on outpatient management of dengue infection is important Step 1: Overall assessment 1. History 2. Physical examination 3. Investigations Step 2 : Diagnosis, disease staging and severity assessment Step 3 : Plan of management

27/6/08 (Day 4 of fever) Klinik Kesihatan Patient came back to KK the next day, still c/o fever with diarrhea, vomiting and epigastric pain, feeling lethargy. Seen by MA, O/E T=38.5 C, BP 110/65, PR 100/min, hydration fair, PA: soft, mild epigastric tenderness. Diagnosis: AGE with gastritis TRO DF FBC: Hb 10.3, Platelet count 120 (HCT 41.5%) TCA cm to repeat FBC Q2: a) What are the warning signs? b) Would you have admitted this patient?

Answer Q2(a): WARNING SIGNS Warning signs Abdominal pain or tenderness Page 17 WARNING SIGNS Abdominal pain or tenderness • Persistent vomiting • Clinical fluid accumulation (pleural effusion, ascites) • Mucosal bleed • Restlessness or lethargy • Liver enlargement > 2 cm • Laboratory : Increase in HCT concurrent with rapid decrease in platelet

Answer Q2(b): CRITERIA FOR HOSPITAL REFERRAL / ADMISSION Page 18 The decision for referral and admission should depend on the Total Assessment: 1. Symptoms : • Warning signs • Bleeding manifestations • Inability to tolerate oral fluids • Reduced urine output • Seizure 2. Signs : • Dehydration • Shock • Bleeding • Any organ failure

3. Special Situations : • Patients with co-morbidity e.g. diabetes, hypertension, ischaemic heart disease, coagulopathies, morbid obesity, renal failure, chronic liver disease, COPD, haemoglobinopathy • Elderly (<65 years old) • Pregnancy • Social factors that limit follow-up e.g. living far from health facility, no transport, patient living alone 4. Laboratory Criteria: Rising HCT accompanied by reducing platelet count

28/6/08 (Day 5,10:00 am- Saturday) Ambulance call. Brought to KK at 12:05pm Seen by MA H/o: Fever 5 days, still has diarrhea and vomiting Headache and joint pain Epigastric pain for 2 day Dark sticky stool 2/7 O/E: BP unrecordable. Alert conscious Pulse: fast and small volume

Treatment: IVD- Hartman’s 3pint via 2 IV lines DIAGNOSIS : UPPER GIT BLEED WITH SHOCK SECONDARY TO DHF OR PEPTIC ULCER Ix: RBS=21.4mmol/L Treatment: IVD- Hartman’s 3pint via 2 IV lines Wrote a referral letter Referred to hospital and accompanied by JM Q3. What could have been done by the health provider at KK?

Answer Q3: The BP, Pulse monitoring must be continued while in Page 18 The BP, Pulse monitoring must be continued while in the ambulance and patient must be accompanied by MO/MA

At 12:35pm, the patient was transferred to Hospital A (as requested by the family because one of their family member worked at Hospital A and she was on follow up for DM there) Arrived at Hospital A at 12:55pm JM went to the casualty and showed referral letter to the counter staff at casualty. Case was not accepted because no bed available Case was sent to General Hospital

(Day 5,1.30PM – 2 hours defervescence): A+E General Hospital (Day 5,1.30PM – 2 hours defervescence): C/O: - Fever x 5/7. Settled today - Diarrhoea (5x/day) & black tarry stool for 2 days - Vomiting with epigastric pain - Giddiness, lethargic, myalgia - No hematemesis Neighbour admitted for dengue, still in ward PMH: Diabetes Mellitus and Hypertension DH: Metaprolol 50mg bd and ramipril Glicazide 80mg bd and simvastatin 20mg Took NSAIDS for shoulder pain & myalgia

Q4. What is your diagnosis? Examination: Wt 55kg Pink, alert and conscious BP:90/68mmHg PR:65/min T:37’C SPO2:98-100% Cold peripheries. No rash Capillary refill time > 2sec CVS: S1S2 ESM at left sternal edge Lungs : clear Abdomen: soft, mild epigastric tenderness PR: malena Glucometer :14.9mmol/l Q4. What is your diagnosis?

Answer Q4: Dengue Shock syndrome ( Grade 3) with upper GI bleed. Underlying uncontrolled DM

Q5. Comment on the management Diagnosis : 1) Hypotension secondary to AGE 2) Uncontrolled DM 3) UGIT bleed Management: - Admit general ward - Given 1pint Hartman fast Investigations: FBC, BUSE , RBS, Stool C&S Q5. Comment on the management

Answers Q5 Plan for fluid therapy should be documented This patient should be admitted to HDW or ICU for close monitoring and management

Day 5 (1630) ( 4 hours defervescence ) BP:94/73mmHg PR:101/min T:37’C SPO2 97% G/M:17.9mmol/l CVS: DRNM Lungs :clear Abdomen: soft,non tender PR: yellowish stool, no malena Twbc:4.6 x109 Hb:15.4g/dl HCT:46.5 Plt:4 x109 Urea 13mmol/l Na 125 K 4.1 INR 1.7 APTT 59 ECG: Normal

Diagnosis: 1) Fever with severe thrombocytopenia Dengue haemorrhagic fever Grade III (CriticalPhase) 2) DM uncontrolled Mx: - Start iv dopamine 150mg in 50cc run 5cc/h - SC Actrapid 10 u tds - IV fluid 6 pint N/S over 24 h - to transfuse 4 u platelet - monitor I/O

Q6. Explain why Hb and HCT in this patient was not as low as expected. Comment on the use of dopamine at this stage.

Answers Q6 Hb and HCT were relatively high (inappropriate) considering patient had GIT bleed. Her high HCT was due to hemoconcentration as a result of plasma leakage during this critical phase. It was expected that Hb and HCT would drop once IV fluid therapy being given and hemoconcentration improved. The use of inotropic/vasopressor support at this stage ( when the patient is still hypovolaemic) may further worsen the tissue hypoxia, due to vasoconstriction effect of the dopamine.

Q7: Do you agree with the fluid therapy and platelet transfusion?

Answers Q7 The IV fluid regime was inadequate. IV fluid therapy should be initiated with resuscitation regime as patient was in shock. Resuscitation rate : 10-20ml/kg fast with crystalloid for the first 2 cycles then colloid if hemodynamically not improved. Meanwhile packed cell should be made available as patient was bleeding. Other blood products such as platelet and FFP may be given

Day 5 (2130) ( 9 hours defervescence) BP:102/68mmHg PR:101/min T:37’C RR 24/min SPO2 95% O2 2l/min Lung: crepitation bibasal Abdo: Soft Urine output: 10ml/hr Diagnosis - DSS - Uncontrolled DM - Acute renal failure - Fluid overload - WCC 7 Hb 16.5 Hct 49 Platelet 16,000 -BUSE:13.6/135/6.8/104 16.2/134/7.0/105 -Amylase:69 -ABG: ph:7.3 HCO3:11.7 PCO2:23.7 PO2:99.9 - Chest X ray: pleural effusion on R side

Q8 : What would you do now?

Answers Q8 Fluid resuscitation was inadequate as evidenced by persistently raised HCT and severe metabolic acidosis. The patient had ongoing plasma leakage with pleural effusion and further fluid resuscitation would most likely lead to worsening of respiratory function so intubation was indicated. The patient should have been referred to intensive care unit for consideration of ICU admission.

Early recognition and treatment of shock is essential Management of DSS is a medical emergency and requires prompt and adequate fluid replacement Early and effective replacement of plasma losses results in a favorable outcome, so consider early referral to ICU Severe metabolic acidosis is a sign of prolonged shock and tissue hypoxia In general, respiratory support should be considered early in a patient’s course of illness and should not be delayed until the need arises.

Treatment: IV lasix 40mg stat IV cocktail stat & 50ml NaHCO3 Reduce IV drip to 4pints/24 hours Insulin infusion 3u/hr CVP attempted x 2 but failed

Q9 : Would you have attempted central line insertion ?

Volume resuscitation does not require a central venous Answer Q9 Volume resuscitation does not require a central venous catherisation (CVC) if sufficient peripheral intravenous access can be obtained. When CVC is indicated it should be inserted by a skilled operator, preferably under ultrasound guidance if available. Subclavian vein cannulation should be avoided as far as possible.

Day 6 (0810am) ( 20 hours defervescence) On dopamine 4cc/h. Tailing down dose Examination: Alert GCS 15/15 RR 22/min,pink,no jaundice BP:178/83mmHg PR:110/min T:37’C Lungs: crepitation at the bases Abdomen: tenderness at the epigastrium Bleeding at venepuncture Urine output –anuric since 12 midnight Ix: ABG:PH:7.29 HCO3:9.7 PO2:98 BUSE:17.7/134/.6.9/106

RESULTS: Date/result 28/6 (Day5) 1520 28/6 20.30 29/6 (Day 6) 0400 1000 TWBC 4.6 7.7 13.7 12.7 HB 15.4 16.5 12.3 11.2 HCT 46.5 48.3 37.6 33 PLT 4 16 15 17 BUSE 13.6/135/6.8/104 16.2/134/7.0/105 16.9/136/5.6/104

Diagnosis: 1) Dengue shock syndrome with sepsis 2) Acute renal failure secondary to (1) 3) Persistent hyperkalaemia-cocktail x 2 4) Thrombocytopenia 6) Uncontrolled DM

Mx: - Add Fortum 1g od - Iv Azithromycin 500 mg od - IV fluid 1pint/24 hours - Increase insulin to 4 u /h -1H g/m (aim 6-8mmol/l) - iv sodium bicarbonate 50cc over ½ h - iv cocktail stat kiv hyperkalaemia –for dialysis - iv ranitidine 50mg tds - Put on HFMO2 10L/min

1030am ( 22 hours defervescence) : BP dropping to 98/28mmHg Mx: Started on iv noradrenalin 8 mg in 50cc D5% run at 2cc/h 12 noon ( 24 hours defeversence) Reviewed ABG:PH :7.196 HCO3:7.5 CBD: urine 10cc only Patient :acidotic breathing Case noted to specialist: - to transfused platelet 4 u than proceed with peritoneal dialysis - refer anaest

Patient then desaturated o/e: - Tachypnoeic,gasping - Emergency intubation - BP recordable after started on tripple inotropic agent:81/53mmHg pulse rate:154/min-weak cold peripheries - Pupil dilated and non reactive

Pt asystole then CPR done-3 ampoules of atropine and adrenalin given but not reverted. Confirmed death:2.30pm ( 26 hours defervescence) Cause of death:septicaemic shock

Result / date 28/6 29/6 PT/ APTT INR:2.48 Ratio:3.84 ABG pH:7.31 HCO3:11.7 PO2:99.9 PCO2:23.7 pH:7.29 HCO3:9.7 PO2:48.6 PCO2:20.5 pH:7.196 HCO3:7.5

BFMP:negative Typhoid test :negative Leptospira serology:non reactive Creat:288 Indirect bilirubin:23 Direct:13 ALT:4190 AST:6439 ALP:551 LDH:4464 Plasma lactate:10.4mmol/l Blood C+S:no growth Meiloidosis serology :pending Dengue serology: IgM detected Stool occult blood:negative CK:1143 CXR(discuss with radiologist) right pleural effusion with fluid in the oblique fissure,may represent chest infection