1. DENGUE INFECTION 1ST ENCOUNTER CPG Mx of Dengue Infection Revised 2 nd Edition, 2010 Mohd Ghazali AR, 21th November 2012

2. 2010 2014 20042003 2008

3. These are Clinical Practice Guidelines on Management of Dengue Infection in Adults (Revised 2nd Edition) 2010. The CPG supersede the previous CPG on Management of Dengue Infection in Adults (2nd Edition) 2008. Review of the Guidelines These guidelines were issued in 2010 and will be reviewed in 2014 or sooner if new evidence becomes available.

4. Clinical Course 1.Febrile Phase 2.Critical Phase 3.Recovery Phase

5. Febrile Phase Sudden High Grade Fever Skin erythema Generalised body ache – Myalgia, Arthralgia, Headache Sore Throat, Conjunctival injection Anorexia, Nausea, Vomiting *Indistinguishable between DF, DHF, Other viral diseases

6. Febrile Phase (Cont…) Mild Hemorrhagic Manifestations – Petechiae – Epistaxis – Gum bleeding – May be seen in both DF & DHF Mild PV bleeding is common in young adult Females Enlarged tender liver suggestive of DHF

7. Febrile Phase (Cont…) The earliest abnormality of FBC is Progressive decrease total white cell count *Alert & Notify as early as possible to avoid epidemic

8. Differential Diagnoses During Febrile Phase

9. Critical Phase After 3 rd day of fever – Defervescence Period Rapid drop in temperature Patient may become – Better: if no @ minimal plasma leakage – Worse: if critical plasma volume lost Lasted 24-48 hours Between 3 rd -7 th day of illness * Other viral infections: Condition improves as temperature subsides

10. Critical Phase (cont…) Less severe cases – Minimal & Transient – Recover spontaneously @ after short period of fluid therapy Severe form (Sign of Shock) – Restless, Altered conscoius level – Sweating, Cool extermity – Prolong capillary refill time – PR increases, Narrow Pulse pressure (DBP increases) – Clinical fluid accumulation

11. Critical Phase (cont…) Thrombocytopenia & Hemoconcentration – usually detectable before fever subside & onset of shock Hematocrit level correlates with plasma volume loss Hematocrete may be equivocal in – Early fluid therapy – Excessive fluid therapy – Frank HEMORRHAGE

12. Differential Diagnosis During Critical Phase

13. Common Errors at ED & OPD Failure to recognise dengue infection in a febrile patient: No f/up * Always have high index of suspicion in patients with symptoms of viral infection febrile patients coming from dengue areas patients with positive Hess’s test Failure to recognise dengue shock in an afebrile patient: Not Admitted * Always have high index of suspicion for Nausea, vomiting, abdominal pain & WARNING SIGNS Clinical manifestations of Shock Changing HCT (rather than platelet count)

14. WARNING SIGNS Sign of SEVERE DENGUE & high possibility of RAPID PROGRESSION TO SHOCK 1.Persistent vomiting 2.Abdominal pain or tenderness 3.Mucosal bleed 4.Restlessness or lethargy 5.Clinical fluid accumulation (pleural effusion, ascites) 6.Liver enlargement > 2 cm 7.Laboratory : Increase in HCT with rapid decrease in platelet

15. Patients Who Can be Treated at Home Able to tolerate orally well, good urine output and no history of bleeding Haemodynamically stable No tachypnoea or acidotic breathing No bleeding manifestation No alterations in mental state and full GCS score Absence of clinical Warning Signs Stable serial HCT In the absence of a baseline HCT level, a HCT value of >40% in FEMALE adults and >46% in MALE adults should raise the suspicion of plasma leakage.

16. Daily or more frequently towards late febrile phase

17. Home Care ADVICE LEAFLET for Dengue Patient

18. Home Care Advice Leaflet for Dengue Patient

19. Critical Phase Crutial to diagnose – Clinical deterioration Marked by plasma leakage at the onset of defervescence Evidence by – Raised HCT – Hemodynamic instability – Late marker: Fluid in extravascular space Warning sign!!!...

20. The indicator of hemorrhagic tendency Sensitivity varies widely – 0% - 57% – Depends on phase of illness, how often it is repeated 5-21% of dengue like illness have positive torniquet test but negative for dengue serology 95.3% positive preditive value when fever, positive tourniquet, leucopenia / thrombocytopenia / hemoconcentration are present Tourniquet Test

21. How to perform? Inflate the BP cuff on the upper arm to a point midway between the SBP & DBP for 5 minutes A positive test : ≥20 petechiae per 2.5 cm 2 (1 inch 2 ) Helpful in the early febrile phase (< 3 days) esp. -When the platelet count is still normal @ -When diagnosis is in doubt

22. Triaging at ED & OPD To avoid to avoid critically ill patients being missed & managed as outpatient To determine the need of urgent attention/resus  Primary Triage  Sign of Shock (Mental state, Cold or warm peripheries, Palor, Delayed Capillary perfusion)  Vital Parameters (BP, PR, Temperature, RR)  Warning signs!!!

23. Criteria for 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 Lab. criteria Rising HCT with reducing platelet count

24. Consider Early Admission Co-morbidity DM, HPT, IHD, Coagulopathies, Morbid Obesity, Renal failure, Chronic Liver disease, COPD Elderly (> 65 y/o) Pregnancy Social factors: living far, living alone, no transport etc.

25. Prerequisites for transfer All efforts must be taken to optimise the patient’s condition before and during transfer The Medical Department and/or Emergency Department must be informed prior to transfer Adequate and essential information must be sent together with the patients (fluid chart, monitoring chart and investigation results)

26. Initial Fluid Resuscitation Crystalloid – Normal Saline – 10-20 ml/kg ideal body wt – Repeat x2 Consider Colloid 3 rd cycle Other causes of persistent shock – OCCULT BLEEDING – Septic – Cardiogenic IDEAL BODY WEIGHT Male: 50.0kg + 0.91(height-152.4)cm Female: 45.5kg + 0.91(height-152.4)cm

27. Blood Product Suspect occult bleeding if HCT drops and no obvious bleeding – Fresh Packed Cell 5-10 ml/kg – Fresh Whole Blood 10-20 ml/kg Repeat – Further blood loss – No appropriate raise of HCT Prophylactic transfusion? Fresh Blood: < 5 days

28. DSS Compensated shock Decompensated shock

29. CVC line Thrombocytopenia & Bleeding diathesis are relative contraindication – No studies regarding bleeding risk in dengue patient – Incidence of bleeding in coagulopathy patients varies (0-15.5%) Fluid resuscitation does not require CVC if sufficient peripheral access When indicated – Should be inserted by skilled operator preferably under USG guidance – Avoid Subclavian site

30. ICU referral & Respiratory Support Indications for ICU referral Emergency Intubation Elective intubation – Main objectives is to support gas exchange & reduce metabolic cost of breathing

31. Haemodynamic Support FLUID RESUSCITATION IS CRUCIAL !!! Should be initiated first & adequately Vasopressor may be consider if MAP persistently <60mmHg despite adequate resuscitation (dopamine, noradrenaline) * While vasopressor increase BP, tissue hypoxia may be further compromised by vasoconstriction

32. Dengue In Pregnancy All Pregnant women suspected dengue – ADMIT Diagnosis & Assessment Challenges – Baseline HR is higher – Baseline blood pressure is lower (pulse pressure are wider) – HCT elevation may be masked haemodilution in 2 nd & 3 rd trimester – Detection of third space loss is difficult with gravid uterus

33. Dengue In Pregnancy (Cont…) Risk of bleeding is highest during period of plasma leakage – Avoid LSCS @ IOL during critical phase – Avoid procedure @ manoeuvres that may provoke labour during critical phase Differential Diagnosis – Toxemia – HELLP Syndrome

34. Disease Notification All suspected dengue must be notified by telephone to nearest health office within 24 hours of diagnosis Serological confirmation is NOT NECESSARY Notified cases will be followed up by the health authorities for the verification disease and preventive measures Re-notification has to be done if the diagnosis has been changed from DF to DHF or DF to other diagnosis.

35. Failure to notify is liable to be compounded under the Prevention and Control of Infectious Diseases Act, 1988 (Act 342)

36. Summary Stepwise Approach on Outpatient Management of Dengue Infection (Pg-17)

37. Thanks For the attention Question?