Download - D NGUE WORKSHOP 2015 ID HSB 2015 CHALLENGES IN THE MANAGEMENT OF DENGUE DR LOW LEE LEE ID PHYSICIAN
D NGUE WORKSHOP 2015
ID HSB 2015
E
CHALLENGES IN THE MANAGEMENT OF DENGUE
DR LOW LEE LEEID PHYSICIAN
Fluid resuscitation is needed to sustain the intravascular pressure : Compensated or decompensated shock
Severe Dengue :Dengue with target organ involvement
ID HSB 2015
Dengue with hepatitis
VomitingRight hypochrondriac painBaseline 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)
Atypical presentations
• Diarrhoea• Myocarditis• Encephalitis• Myositis• Hepatitis• Acute abdomen • Severe bleeding without plasma leakage• Plasma leakage in febrile phase
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 signsDo FBC ± Dengue rapid test (combo)Home advice leafletEarly notification
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 signs4. 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 manifestations3. Inability to tolerate oral fluids4. Reduced urine output5. Seizure
Signs:1. Dehydration2. Shock 3. Bleeding4. Any organ
failure
ID HSB 2015
CONSIDER EARLY ADMISSION
ID HSB 2015
• 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
• 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
dehydrationNon-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 1010 2015 3020 60
25 6530 7035 7540 8050 9060 10070 11080 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
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
Pearls of management
• Good triaging system ED & OPD • To determine whether urgent attention is required
• Triage Checklist (TO BE SEEN STAT)1. Warning signs2. 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
How to prevent deathEarly recognition of dengueIdentification of clinical problems in different phases of dengueEarly recognition of dengue warning signsEarly recognition of shockEarly recognition of occult bleedingRecognition of comorbidities and its complicationsLook out for atypical presentations of dengue Early notification
ID HSB 2015