E D NGUE WORKSHOP 2015 CHALLENGES IN THE MANAGEMENT OF DENGUE DR LOW LEE LEE ID PHYSICIAN ID HSB 2015
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What are the warning signs? ID HSB 2015
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Fluid resuscitation is needed to sustain the intravascular pressure : Compensated or decompensated shock
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Severe Dengue : Dengue with target organ involvement Dengue with hepatitis Vomiting Right hypochrondriac pain Baseline LFT ( if admitted) Dengue with encephalitis Headache, vomiting, altered sensorium, seizure Comatose ( late stage) Dengue with perimyocarditis Chest pain, dypsnoea, palpitation, Cardiogenic shock ( late stage) ID HSB 2015
Atypical presentations Diarrhoea Myocarditis Encephalitis Myositis Hepatitis Acute abdomen Severe bleeding without plasma leakage Plasma leakage in febrile phase
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Dengue Clerking Sheet ID HSB 2015
Pearls of management Fever + 2 other features . Advise patient to return to clinic/ seek medical attention If fever does not settle after 3days Presence of warning signs Do FBC ± Dengue rapid test (combo) Home advice leaflet Early notification ID HSB 2015
HOME CARE ADVICE LEAFLET FOR DENGUE PATIENTS ID HSB 2015
First step All fever must be considered probable dengue Fever plus 2 symptoms: myalgia/arthralgia, nausea vomiting, rash, bleeding tendency, leucopenia and thrombocytopenia, any warning signs Notify once diagnose clinically ID HSB 2015
Ask yourself are Dengue Warning Signs present? • 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 ID HSB 2015
Second step Disease staging and severity assessment 1. Dengue diagnosis (provisional) 2. Phase of dengue illness if dengue is suspected (febrile/critical/recovery) 3. With or without warning signs 4. Hydration and haemodynamic status of patient (in shock or not) 5. Whether the patient requires admission ID HSB 2015
CRITERIA FOR HOSPITAL REFERRAL / ADMISSION Symptoms: 1. Warning signs 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 ID HSB 2015
CONSIDER EARLY ADMISSION Co-morbidity e.g. DM, HPT, IHD, Coagulopathies, Morbid Obesity, Renal failure, Chronic Liver disease, COPD Elderly > 65 Pregnancy Social factors: living far, living alone etc Lab. criteria Rising HCT with reducing platelet count ID HSB 2015
If you are in KK/district hospital ID HSB 2015
Continue resuscitation and monitoring during transportation Stabilise patient Continue resuscitation and monitoring during transportation Patient should be accompanied by a medical officer ID HSB 2015
How much fluid to give Fluid regime Dengue with no warning signs Dengue with warning signs Decompensated shock Compensated shock Fluid Resuscitation
Dengue without warning signs : but with poor oral intake or mild dehydration Non-shock patient/no warning signs Encourage adequate oral intake Intravenous fluids are indicated in patients who are vomiting, diarrhoea and mild dehydrated. 4/2/1 ( 4ml/kg for first 10 Kg + 2 mls/kg for subsequent 10 kg + 1ml/Kg for every Kg ) ID HSB 2015
Estimated ideal body weight or IBW (kg) Normal maintenance fluid (ml/hour) based on Holiday Segar formula 5 10 20 15 30 60 25 65 70 35 75 40 80 50 90 100 110 120 ID HSB 2015
Dengue with warning signs : 5/3/2 All patients with warning signs should be considered for monitoring in hospitals. Obtain a baseline HCT before fluid therapy. Give crystalloids solution (such as 0.9% saline). Start with 5–7 ml/kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response. If the clinical parameters are worsening and HCT is rising, increase the rate of infusion.(7 mls/5/3/2) Reassess the clinical status, repeat the HCT and review fluid infusion rates accordingly.(during critical phase, review every 4 Hly, monitoring VS 2 Hly) ID HSB 2015
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Pearls of management Dengue patient may bleed during febrile phase. For instance : UGIB In particularly in patient who has pre-existing PUD, is taking anti-platelet / NSAID ID HSB 2015
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Pearls of management Good triaging system ED & OPD To determine whether urgent attention is required Triage Checklist (TO BE SEEN STAT) Warning signs Vital parameters not stable VS to be taken: Mental state, BP, pulse, temp., cold or warm peripheries ID HSB 2015
Pearls in management Take good history on medical illness : eg: DM / CCF / HPT Take BP/PR / Pulse volume / RR Good documentation ID HSB 2015
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How to prevent death Early recognition of dengue Identification of clinical problems in different phases of dengue Early recognition of dengue warning signs Early recognition of shock Early recognition of occult bleeding Recognition of comorbidities and its complications Look out for atypical presentations of dengue Early notification ID HSB 2015
THANK YOU ND ID HSB 2015