D NGUE WORKSHOP 2015 E ID HSB 2015

OPD – CASE 2 ID HSB 2015

History 33/ Indian /man Presented with fever Myalgia and arthralgia Went to KK on Day 2 of fever FBC : Wbc 9.4 Hb 13.3 Hct 39 Plat 241 ID HSB 2015

FEVER CLERKING SHEET ID HSB 2015

When to suspect dengue Fever with two or more of the following manifestations: - headache - retro-orbital pain - myalgia - arthralgia - rash - haemorrhagic manifestations - leukopenia/ Thrombocytopenia ID HSB 2015

You are the doctor in charge What would you do? Dengue combo rapid test : NS1: Positive , Dengue Ig M : negative Look for warning signs ID HSB 2015

Dengue NS1 The NS1 gene product is a glycoprotein produced by all flaviviruses NS1 antigen appears as early as day 1 after the onset of fever and declines to undetectable levels after day 5–6. It is a tool to facilitate early detection of dengue ID HSB 2015

Dengue Ig M Negative in early febrile phase, a positive result indicates a recent infection, not the acute infection Becomes positive towards defervescence and increasingly more positive; Day 7 of illness almost 80% positive; remains detectable for another 2-3 month ID HSB 2015

Warning signs Listen : Mucosal bleed ( 4 symptoms) Abd pain Persistent vomiting Restless/lethargy Examine : Tender enlarged liver ( 2 signs) Third space loss Lab : ( 1 lab) increase in HCT accompanied by rapid decrease in Platelet count ID HSB 2015

What would you do next ? Assess for hydration status/ BP/PR/ Pulse volume/ CRT/ RR/ Physical Exam Do not for get to : Notify Dengue ID HSB 2015

Dengue Clerking Sheet ID HSB 2015

No warning signs, Vital signs are stable No vomiting, no abdominal pain BP 120/80mmHg, PR 90 /min RR 16/min No rashes , no petechiae Lung : clear PA : soft , no ascites, no tenderness No warning signs, Vital signs are stable ID HSB 2015

Desided to send patient home Prescribe symptomatic therapy Advise patient to return to clinic if : fever persists more ≥ 3days or develops warning signs or unable to take orally What is your advice to patient ? ID HSB 2015

PNEUMONIC : DENGUE D- daily monitoring of patient's status E- encouraging intake of oral fluids N- note for any warnings or signals (persistent vomiting, severe abdominal pain, restlessness, irritability, platelet count, bloated abdomen) G- give symptomatic treatment (avoid aspirin/NSAID) U- use mosquitoe screens, insect sprays, repellant E- early consultation is advised if you have doubts ID HSB 2015

Plan of management If admission is not indicated Daily or more frequent follow up is necessary especially from day 3 of illness onwards until the patient becomes afebrile for at least 24 - 48 hours without antipyretics Refer to Home Care Advice Leaflet for Dengue Patients. ID HSB 2015

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HOME CARE ADVICE LEAFLET FOR DENGUE PATIENTS ID HSB 2015

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Day 5 : still febrile Still poor appetite but able to drink No vomiting , no abdominal pain No other complaints T 38 C,BP 108/80mmHg, PR 90/min Lung : Clear, PA :no tenderness Day 5: Hb 15.8 Hct 45.9 Platelet 102 Wbc 4.07 Day 2: Hb 13.3 Hct 39 Platelet 241 Wbc 9.4 ID HSB 2015

What would you do ? Day 5 illness , still in febrile phase No warning signs VS stable HCT : increasing, Platelet : dropping But entering defervescent phase soon! ID HSB 2015

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Plan of management If admission is indicated Stabilise the patient at primary care before transfer (refer to intravenous fluid regime) Communicate with the receiving hospital: Emergency & Trauma Department AND/Or Medical Department before transfer ID HSB 2015

What is your diagnosis T 38 C,BP 108/80mmHg, PR 90/min Lung : Clear, PA :no tenderness Day 5: Hb 15.8 Hct 45.9 Platelet 102 Wbc 4.07 Day 2: Hb 13.3 Hct 39 platelet 241 Wbc 9.4 Day 5 : Alb 32 ALT 79 AST 167 ID HSB 2015

What is your diagnosis? Day 5 illness, febrile phase with warning signs, vital signs are stable, mild transaminitis ID HSB 2015

What are the warning signs? ID HSB 2015

How much fluid to give? Fluid management in dengue with warning signs Obtain baseline HCt IVD 5-7mls/kg/hr for 1 to 2 hours, then Reduce to 3-5mls/kg/hr for 2 to 4 hours, and then Reduce to 2-3mls/kg/hr or less according to clinical response and HCT If clinical parameters worsening and Hct is rising, increase the rate of infusion 5,3,2 ID HSB 2015

Dengue with alarm signs + but haemodynamically stable : 5/3/2 regime OR 7/5/3 regime 5mg/kg/H : 1-2hrs 7ml/kg/H 3ml/kg/H: 2-4 hrs 5ml/kg/H 2ml/kg/H : till review ( 2-4H) 3ml/kg/H ID HSB 2015

IVD 5ml/kg : 300ml/Hour for 1 hour  review Weight 60kg IVD 5ml/kg : 300ml/Hour for 1 hour  review IVD 3ml/kg : 180ml/Hour for 2hours review IVD 2ml/kg : 120ml/Hour for 2-4hoursreview ID HSB 2015

3 hours later , at completion of 5/3 regime…. BP 110/80mmHg, PR 110/min ( weak ) T 37 C Lung :clear Dengue Fever , day 5 illness, in critical phase In compensated shock ID HSB 2015

What would you do ? Refer to ED and medical team on call 2. Run fluid 10ml/kg over 1 hour, and assess again ID HSB 2015

Dengue CPG : ID HSB 2015

This is to facilitate rapid response to critically ill patient. However, if patient is ill, (i.e : in compensated or decompensated), pre-empting a deterioration that may require resuscitation, you should inform BOTH Emergency Department and Medical Department Physician prior to transfer. This is to facilitate rapid response to critically ill patient. ID HSB 2015

THANK YOU ND ID HSB 2015