Fluid Management in DHF Patients

Dr Rasnayaka M MudiyanseSenior Lecturer in Paediatrics

Faculty of Medicine Peradeniya

Short Duration Fever - OPD

1. Treat Fever 2. Rest3. Fluid4. Specific drugs5. Warning signs

DDDengue ( group A)( No warning signs ) Viral feversOther D

1. Immediate attention

2. Fluid3. Oxygen 4. Observation

DDDengue (group B)( with warning signs)Other infections

Other D

1. Evaluate & ABC care2. Fluid boluses 3. Oxygen4. Hand over MO-MODDDengue ( group C)(Sever dengue ) SepticemiaDiarrhea Anaphylaxis

Treat and send home

AdmitNo resuscitation

NeedResuscitation

Classification of DengueOld WHO classification New WHO classification

Classical Dengue Fever Probable dengue ( group A - OPD management)

Dengue Fever with hemorrhagic manifestations

Dengue with warning signs ( Group B - inward observation and management) ( patients are admitted for social reasons and when they are in high risk category)

DHF grade one

DHF grade two

DHF grade three Severe Dengue ( Group C - resuscitation and management) 1.With compensated shock2.With hypotensive shock3.With severe organ impairment

DHF grade four

DHF with unusual manifestations

Dengue Hemorrhagic Fever or Dengue Leaking Fever

Essential Feature In DHF is LeakingDF may have bleeding but not leaking

The Cause of Shock in Dengue

• Plasma leakage• Bleeding – external and internal • Hypocalcaemia • Vascular involvement • Inadequate fluid intake• Myocarditis

What is the cause of Plasma Leakage

Endothelial cell dysfunction rather than destruction

Evidence of Plasma Leakage

• Rise in HCT – 20% = children 35 42 adults 40 48

• Circulatory failure• Fluid accumulation – Ascites, Pleural

effusions• Albumin < 3.5 gr/dl • Cholesterol < 100 mg%

A. Rising hematocrit ~ 50%

Evidences Evidences of of

plasma plasma leakage leakage

in in DHFDHF (Rt. lateral decubitus position)

Rt pleural effusion Ascites

Plasma Leakage Shock Prolonged shock

• Prolonged shock – Organ hypo perfusion & Organ impairment– Metabolic acidosis + DIC – Severe Hemorrhage ( Drop HCT & rise of

WBC )

All these complications may develop without obvious plasma leakage or shock

Rising HCT indicate plasma leakage

• 20-30% rise GIT ischemia including liver • 30-40 % rise Renal and brain ischemia

Patients at risk of major bleeding

• Prolonged/refractory shock;• Hypotensive shock & renal or liver failure • Severe and persistent metabolic acidosis;• Receiving NSAID agents;• Pre-existing peptic ulcer disease;• On anticoagulant therapy;• Any form of trauma( IM injection)

Flushing

Tourquet test

Leucopenia

Liver enzymes

1st day 73% 53% 70% within 24 hrs pt will enter critical phase

AST rise 90%

AST > 60 – PPV 80%

AST > ALT (2-3 times)

2nd day 90% 90%

3rd day 85% 98%

Dengue is a Dynamic Disease

Febrile, Critical and Recovery Phase

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60

1 2 3 4 5 6 7 8

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Incubation period 5-8 days ( 3-14 days)

2-7 days 1-2 days

Rate of Fluid Leakage

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60

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Optimum volume of

fluid …

M + 5%

Calculation of M +5%

• Calculation of M– 1st 10 kg – 100 ml/kg/day ( 4 ml/kg/hr)– 2nd 10 kg – 50 ml/kg/day ( 2 ml/kg/hr)– Subsequent ..kg – 20 ml/kg/day ( 1ml/kg/hr)

• Calculation of 5%– 5% = 50ml/kg/day ( 2ml/kg/hr)

Maximum Fluid for adult ( 50kg) = 4600

M+ 5% for boy 60kg (IBW 50kg ) = ?

Fluid Management in DHF patients

Rational Use of Fluid = Management of Dengue

Avoid Fluid Overload

Spectrum of Dengue

• DHF Grade 4 ( SD with hypotnsive shock ) – No pulse – 20ml/kg rapid bolus– Drop SBP (Pulse + ) – 10 ml/kg rapid bolus, Rpt sos

• DHF Grade 3 ( SD with compensated shock)– 10 ml/kg/hr

• No circulatory failure ( D warning signs)– DF +/- Bleeding ( oral fluid ? M+5%)– DHF in Febrile phase (1.5 ml/kg/hr)

DF & DHF in Febrile Phase

DF & DHF in Febrile Phase

• Parcetamole 15mg/kg 6 hrly • Physical methods of controlling fever• Don’t use Aspirin and NSAID• Fluid to maintain nutrition and hydration

– Oral – between M and M+5% ( 5ml/kg/hr)

1

Too much fluid during febrile phase can contribute

to fluid over load

Recognize the Time of Entry to the Critical Phase

( when blood vessels become leaky)

• Dropping platelet count below 100 000/dl• Rising HCT & Evidence of plasma leakage

Fluid management during Critical Phase not in shock

( when blood vessels become leaky)

• Establish IV line & IV fluid to KVO • Limit total ( IV + Oral) fluid to 1.5 ml/kg/hr• Monitor UOP ( 0.5ml/kg/hr is OK) • Rising HCT - Increase fluid- 3-5-7-10 ml/kg/hr• Monitor for circulatory failure – Fluid boluses

HCT monitoring 4-6 hrly initially then hrly

Fluid Allocation for Non Shock Patient

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M + 5%48 hrs

20-10 ml/kg

10-5 ml/kg

5-3 ml/kg

3-1 ml/kg

KVO

10-20 ml/kg

5-10 ml/kg

3-5 ml/kg

1-3 ml/kg

1.5 ml/kg

Fluid Allocation for Non Shock Patient

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M + 5%48 hrs

20-10 ml/kg

10-5 ml/kg

5-3 ml/kg

3-1 ml/kg

KVO

10-20 ml/kg

5-10 ml/kg

3-5 ml/kg

1-3 ml/kg

1.5 ml/kg

Fluid over load and shock

Fluid Allocation for Non Shock Patient

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60

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M + 5%48 hrs

20-10 ml/kg

10-5 ml/kg

5-3 ml/kg

3-1 ml/kg

KVO

10-20 ml/kg

5-10 ml/kg

3-5 ml/kg

1-3 ml/kg

1.5 ml/kg

Shock and Fluid Over Load

Prolonged shock

Prolonged Shock

• Detecting absent pulse is too late• Drop in SBP is too late• Drop in pulse pressure, CRFT, Cold

extremities .. can detect early shock• We can prevent shock !

Rise in HCT = loss of IV compartment 20% - compromise GIT blood supply40% - compromise renal and brain

Prevent Shock – Manage PCV

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M + 5%48 hrs

20-10 ml/kg

10-5 ml/kg

5-3 ml/kg

3-1 ml/kg

KVO

10-20 ml/kg

5-10 ml/kg

3-5 ml/kg

1-3 ml/kg

1.5 ml/kg

Cause of Prolonged Shock in Dengue

• Failure to detect shock is rare in SL• Clinicians thought prolonged shock is due to bleeding

as a result of low platelets • Clinicians did not appreciate that shock precipitate

bleeding and other organ damage • Clinicians did not monitor/manage PCV ( instead they

managed platelet count ) personal opinion

WHY ?Lack of knowledge and training WHY ?Failures in teaching/training programs

(DHF grade 4) Severe Dengue with Hypotensive shock

5 year old boy; fever 5 days, cold extremities and prolonged CRFT. HCT 48, Plt 45 000/dl SBP 60/40.

Adults SBP <90 mm Hg or MAP <70 mm Hg or Drop of SBP >40 mm Hg

1-10 yrs - 5th Centile SBP = 70+ (agex2)

Management of DHF Grade 4Severe Dengue with Hypotensive shock

• Oxygen,Keep flat +/- Head low• IV canula – Blood samples • Rapid Fluid bolus + Rpt SOS • Monitoring ABCS• Consider other possibilities • Record keeping & Communication

Investigations for DHF patients

• FBC• Blood grouping and cross matching• Blood sugar• Blood electrolytes ( Na,Ca,K,HCo2)• Liver Function tests• Renal Function tests• Blood gases• Coagulation profile ( PTT,PT,TT)

Management of DHF Grade 4Severe Dengue with Hypotensive shock

• Slow bolus – 10 ml/kg Crystalloid/colloids over one hour• Infusion 5- 7 ml/kg/hr for 1-2 hrs ( Hartmann)• Infusion rate 3- 5ml/kg/hr for 2-4 hrs• Infusion rate 3ml/kg/hr for 2-4 hrs• Stop fluid in 48 hrs

Fluid bolus 10-20 ml/kg Normal Saline / 15 mt

Improving , HCT coming down gradually , good UOP

No improvement HCT dropping – Blood transfusion

No improvement HCT Rising – Colloid transfusion

Management of DHF Grade 4(Severe Dengue with Hypotensive shock )

Fluid bolus 10- 20 ml/kg Normal Saline / 15 mt Rpt fluid boluses – 2 crystalloids' colloids

NO IMPROVEMENT

If HCT is dropping< 40 for Children and female

< 45 for adult male

Blood transfusion whole blood 10 -20 ml/kgPacked RBC 5-10 ml/kg

Rising HCT

2ndBolus - Colloids1.10 – 20 ml/kg/ ½-1 hr

Check HCT before fluid bolus or after fluid bolus

3rd bolus - Colloids 1.10 – 20 ml/kg/1 hr

DHF Grade 3Dengue with Compensated Shock

10 year old boy; fever 5 days. Cold extremities. Tender Hepatomegaly. PCV

52, Platelets 50 000/dl CRFT 5 sec. SBP 100/85.

5th Centile SBP = 70+ (agex2)

Management of DHF grade 3(Severe Dengue with Compensated shock)

• Hartmann - 5- 7 ml/kg/hr for 1-2 hrs• Hartmann - 3- 5ml/kg/hr for 2-4 hrs• Hartmann - 2-3 ml/kg/hr for 2-4 hrs• Stop fluid in 48 hrs

Fluid bolus 5-10 ml/kg Normal Saline / 1hrImproving , HCT coming down gradually , good UOP

Management of DHF grade 3(Severe Dengue with Compensated Shock)

Fluid bolus 5-10 ml/kg Normal Saline / 1hr

HCT rising

Fluid bolus saline /colloids10 -20 ml/kg for 1hr

If HCT is dropping

Blood transfusion Packed RBC 5-10 ml/kg

Whole blood 10-20 ml/kg

NO IMPROVEMENT

However, a rising or persistently high HCT together with stable haemodynamic status and adequate urine output

does not require extra intravenous fluid.

< 40 for Children and female < 45 for adult male

Rpt fuid bolus 5-10 ml/kg Normal Saline / 1hr

Patients not responding to usual fluid boluses

• Massive plasma leakage – rising PCV• Concealed hemorrhage – Drop of PCV• Hypocalceamia • Hypoglycaemia • Hyponatremia• Acidosis

Fluid Management During Critical Phase DON’T OVER LOAD LEAKING VESSELES

• Manage PCV and shock; use monitoring chart• Fluid quota for leaking phase is M+5%

– Pre shock in 48 hours , Grade 3& 4 in 24 hours

• Use colloids to retain longer • UOP – 0.5 ml/kg /hr is OK (Void volume chart)• Cut down fluid at recovery phase

– Eg - 10ml/kg/hr 1.5 ml/kg/hr

• Give blood when indicated

Fluid Allocation for shocked Patient

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1 2 3 4 5 6 7 8

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M + 5%24 hrs

20-10 ml/kg

10-5 ml/kg

5-3 ml/kg

3-1 ml/kg

KVO

Fluid Allocation for Non Shock Patient

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60

1 2 3 4 5 6 7 8

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M + 5%48 hrs

20-10 ml/kg

10-5 ml/kg

5-3 ml/kg

3-1 ml/kg

KVO

10-20 ml/kg

5-10 ml/kg

3-5 ml/kg

1-3 ml/kg

1.5 ml/kg

What is M+5% in management of DHF (MCQ)

• Fluid volume to be given during critical period after excluding boluses

• Fluid volume to be given during critical period after including boluses

• Upper limit of fluid volume for critical period• Upper limit that should never be exceeded

M + 5% is only a guide to understand the risk for fluid over load

Fluid Management in Recovery Phase

Fluid Management in Recovery Phase

Dengue patients have accumulated fluid within his/her body

• Cut down fluid • Give oral fluid if tolerating• Dropping HCT is not bleeding• Rising HCT in stable child manage with oral

fluidDHF grade 3 recovery phase; nurse inform that child has massive

meleana HCT dropped to 35 !Don’t panic if the child is stable, hematocrit 35 is because he is recovering

child is passing what he bled yesterday

6 yr old boy DHF grade 4 recovered after 3 fluid boluses. His HCT dropped from 48 to 39.

However he again developed circulatory failure with reduced pulse pressure.

Management of severe bleeding

• Probably he has internal bleeding• Manage with

–10 ml/kg whole blood–5 ml/kg Packed RBC

Indications for Blood Transfusions

• Overt bleeding ( more than 10% or 6-8ml/kg)• Significant drop of HCT < 40 ( < 45 for males)

after fluid resuscitation • Hypotensive shock + low/normal HCT • Persistent or worsening metabolic acidosis• Refractory shock after fluid 40-60 ml/kg

only 10-15% patients need blood

Circulatory failure with high HCT should be managed with colloids ( + Lasix if fluid overloaded) before blood

• To decide on platelet transfusion • To recognize the beginning of critical

stage -• As a prognostic indicator-

Why do you do platelet counts ? (Answer this MCQ)

• To decide on platelet transfusion - X• To recognize the beginning of critical

stage -• As a prognostic indicator-

Why do you do platelet counts ?

Fluid Over Load

Causes of Fluid Over Load • Too much fluids in febrile phase• Excessive and/or too rapid IV fluids• Use of hypotonic crystalloid solutions• Inappropriate IV fluids for “severe bleeding”• Inappropriate - FFP, platelet & cryo• Continuation of IV fluids after Critical phase • Co-morbid conditions

– congenital or ischaemic heart disease– chronic lung and renal diseases– Obesity – Fluid not calculated for IBW

Early Clinical Features of Fluid Overload

• Respiratory distress– Difficulty in breathing– Rapid breathing– Chest wall in-drawing– Wheezing (rather than crepitations)

• Large pleural effusions &/or Tense ascites• Increased jugular venous pressure (JVP)

• Minimize fluid– Stop if in recovery phase – Minimize in critical phase

• Nurse in the R lateral position• Maintain oxygen saturation above 95%• IV Furosemide +10% Dextran (40) 10 ml/kg ?• Correct hypokalaemia• Assess ABCS

Management of Fluid over load

How to prevent fluid over load

• Try to manage within the fluid quota (M+5%)– For 48 hrs for non shock patients– For 24 hrs for shocked patients

• Expected Urine out put is only 0.5 ml/kg/hr• Calculate oral fluid also• Monitor fluid intake regularly during critical

period – Use a fluid monitor

Leaking Blood vessels ! – Give only minimal & essential

What to do in practice

3 yr old mucus diarrhea mild dehydration had HCT 55%

8 year old 30 kg girl Fluid for 48 hrs

30 kg IBW - 25 kg

M 1700 1600

M+5% 3200 2850

5 ml/kg 7200 6000

3 ml/kg 4320 3600

1.5 ml/kg 2160 1800

Fluid balance in health and dengueHealth

Ml/kg/hrDengue

Ml/kg/hr

Total intake 3 3

UOP 2 1

Insensible loss 1 1

Leaking (+ ve balance)

0 1

Water for growth was not taken in to consideration

Fluid balance in health and dengueHealth

Ml/kg/hrDengue

Ml/kg/hr

Total intake 3 5

UOP 2 2

Insensible loss 1 1

Leaking (+ ve balance)

0 2

Water for growth was not taken in to consideration

Fluid balance in health and dengueHealth

Ml/kg/hrDengue

Ml/kg/hr

Total intake 3 1.5

UOP 2 0.5

Insensible loss 1 1

Leaking(+ ve balance)

0 0.25

Water for growth was not taken in to consideration

Monitoring Charts

22 kg HCT/plt

HR BP RR UOP CRFT Coldness

FluidMl/kg

11.00 am

38 146 90/80 47 5 ml 8 Mid calf

10 ml/kg bld

12.00 noon

48 100 110/80

49SOB

10 2 ankle 10 ml/kgHS + Laxis 20 mg

1.00 pm 41 100 100/70

40Acitiseffusions

100 2 - 3 ml/kgNS

2.00 pm 110 100/70

38Effusions

60 2 - 1.5 ml/kg

2222/26401 2 3 4 5 6 7 8 9 1

011

12

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20

21

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30

31

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39

40

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47

3 ml/kg NS /one hr

?

Fluid over load

Why?

Causes of fluid over load

• Clinicians gave too much fluid - eg 3-5 ml/kg/hr• Clinicians thought that extra fluid in the febrile

can prevent shock• Clinicians thought giving blood can be dangerous

Personal opinion with no proof

WHY ?

Lack of knowledge and training

Condition of the patient HCT Rising HCT Dropping

Deteriorating Colloids Blood transfusion

ImprovingObserve

Increase fluid rate during early critical

phase

Improving !Encourage

normal feeding

Use Void Volume Chart

7 year old (20 kg ) boy passed 100 ml of urine at 12 MN. He passed

urine at 5 pm soon after coming to the ward. Interpret his UOP

• UOP is 0.74 ml/kg/hr

He was given 100 ml/hr of Hartmann solution from MN up 6

am when he passed 400 ml of urine.

• UOP is 3.3 ml/kg/hr• ?

His blood counts done on admission total 5.6 , Platelets 50 000/dl, PCV 45

Same fluid rate was continued. At 12 noon he passed 40 ml of urine.

• UOP is 0.3 ml/kg/hr• ?

Blood counts done at 6 am – Platelets 50 , HCT 42

Circulation – HR 120, cold limbs CRFT 5 sec

Patient develop massive fluid over load. After 30 hours in critical

phase, he is on fluid 15 ml/kg/hr. He passed 300 ml of urine in 4 hrs.

• UOP is 3.75 ml/kg/hr• ?

Blood counts done at 6 am – Platelets 60 , HCT 36

Circulation – HR 98, no cold limbs CRFT 3 sec

Use monitoring chart

• Chart one – Suspected dengue patient not in critical stage

• Chart two – Start once patient enter the critical stage

Knowing the stage of the illness by everybody in the team is very important

in management of dengue patients

Unusual Manifestations of Dengue

• Encephalopathy• Hepatic failure• Renal Failure• Dual infections• Underline conditions

Ward round presentation by ho/sho• This 7 yr old IBW 20 kg child came to the

ward 3 days ago, entered the critical phase yesterday morning. Now 24 hrs in critical phase. On 5 ml/kg/hr of Hartmann.

• Stable circulation. Warm limbs, CRFT 2 sec, BP 100/60

• UOP for last six hours 0.8 ml/kg/hr• Last HCT 48 ( it has gone up from 42)• So far We have given 1200 ml out of 2500

ml 48 hr fluid quota • We thought of increasing fluid to 7

ml/kg/hr

Diagnosis Card of DHF Patient Diagnosis

Dengue Hemorrhagic Fever Grade 4(Severe Dengue with hypotensive shock)

• Patient entered critical phase 24 hrs after admission to ward• HCT - Maximu – 52, minimum – 32• Platelets – Max – 120, Mini – 40• Blood pressure – min – 40/ ?

Management • Total fluid during critical period 1850 / 1900• Crystalloid boluses – 3• Colloid boluses – 1• Blood – 10ml/kg x1

Complications – • Fluid over load – Wheezing, Pleural effusions and ascites. Lasix 20 mg x2 • Bleeding ( HCT 32, need blood 10ml/kg)• Hypocalcaemia – Serum Ca – 1.8 ( treated with 10 ml 10% ca Gluconate)

Initial fluid for following DHF patients

• DHF with no palpable pulse – 10-20 ml/kg/15 mt normal saline

• DHF palpable pulse but low BP– 10ml/kg/15 mt NSS or colloids

• DHF normal BP, cold limbs+ CRFT 4 sec– 10ml/kg/hr NSS + 10% Dextrose

• DHF no shock just entered the critical phase– 1.5 ml/kg/hr

• DF/DHF in febrile phase – Oral fluid ?5 ml/kg/hr

Thank You