1. Development Committee
DISEASE MONITORING
Dr Mahiran Mustafa
Chairman of CPG
Development Committee

2. CONTENTS Brief review on different phases in dengue infection
Issues at different phases
Clinical monitoring for each phase
Laboratory monitoring for each phase

3. INTRODUCTION
Monitoring dengue cases require the understanding that dengue infection is a systemic and dynamic disease.
Its clinical, haematological and serological profiles changing from day to day and accelerate by the hour during the critical phase, particularly in those with plasma leakage
Failure in recognising and interpreting the clinical and laboratory manifestations can lead to delay in appropriate management thus cause intractable shock and death

4. CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS

6. OUTPATIENT MONITORING
Symptoms:
Warning signals
Bleeding manifestations
Inability to tolerate oral fluids
Reduced urine output
Seizure
Signs:
Dehydration
Shock
Bleeding
Any organ failure
Laboratory:
HCT Hb
Platelet

7. DENGUE DISEASE PROGRESSION CARD
DISEASE MONITORING CARD
DENGUE DISEASE PROGRESSION CARD
Patient’s name: ________________________________
I/C No : _______________________________
Date of onset of fever : __________________________
Date
Temp °C BP PR
PCV/HCT
WBC
Platelet
Attending Clinic/ phone no.
Next Appointment

8. CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS

9. Clinical deterioration often occurs during the critical phase because of marked plasma leakage
Evidence of plasma leakage includes:
raised HCT
haemodynamic instability
fluid accumulation in extravascular space

10. Pathophysiology Vascular permeability leads to leakage
Haemoconcentration
Hypovolaemia leads to reflex tachycardia and vasoconstriction
Inadequate perfusion of the tissue leads to increased anaerobic glycolysis and resultant lactic acidosis
Shock that leads to DIC and bleeding

11. WARNING SIGNALS Vomiting Abdominal pain
Restlessness or altered mental state
Mucosal Bleed
Sudden change of temperature to subnormal
Raising HCT with rapid drop in platelet

13. CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS

14. SEVERE MANIFESTATIONS
Acute abdomen
Hepatitis and hepatic failure
CNS manifestations
Carditis or cardiomyopathy

15. Pathophysiological changes from normal circulation to compensated and decompensated shock
Decompensated / Hypotensive shock
Clear consciousness
Change of mental state – restless, combative
or lethargy
Brisk capillary refill time
(<2 sec)
Prolonged capillary refill
time (>2 sec)
Mottled skin, very prolonged capillary refill time
Warm and pink extremities
Cool extremities
Cold, clammy extremities
Good volume
peripheral pulses
Weak & thready
Feeble or absent peripheral pulses
Normal heart rate for age
Tachycardia
Severe tachycardia with bradycardia in late shock
Normal blood pressure for age
Normal systolic pressure with raised diastolic pressure
Postural hypotension
Hypotension/ unrecordable BP
Normal pulse pressure
for age
Narrowing pulse pressure
Narrowed pulse
pressure (<20 mmHg)
Normal respiratory rate
Tachypnoea
Metabolic acidosis/ hyperpnoea

18. Fluid Guidelines

19. Fluid Therapy: Non Shock
Recommendation
Encourage adequate oral fluid intake. (Grade C)
IV fluid is indicated in patients who are vomiting or unable to tolerate oral fluids. (Grade C)
IV fluid is also indicated in patients with increasing HCT (indicating on-going plasma leakage) despite increased oral intake. (Grade C)
Crystalloid is the fluid of choice for non shock patients. (Grade C)

20. Indications for referral to Intensive
Recurrent or persistent shock
Requirement of respiratory support (non-invasive and invasive ventilation)
Significant bleeding
Encephalopathy or encephalitis

21. DISCHARGE CRITERIA Afebrile for 48 hours Improved general condition
Improved appetite
Stable haematocrit
Rising platelet count
No dyspnoea or respiratory distress from pleural effusion or ascites
Resolved bleeding episodes
Resolution/recovery of organ dysfunction

22. Summary: Principles of disease monitoring
1.Dengue is a systemic and dynamic disease. Therefore disease monitoring is governed by different phases of the disease.
2. The critical phase (plasma leakage) may last for hours. Monitoring needs to be intensified and frequent adjustments in the fluid regime may be required.
3. Recognition of onset of reabsorption phase is also important because intravenous fluid regime needs to be progressively reduced/ discontinued