Capacity building: Dengue fever in 15 minutes

Epidemiological Situation in the World

Last five decades an 300% increase occurred in the disease incidence; Estimates:
50-100 million infections a year; 20.000 deaths a year; Outpatient and hospital costs: 514 1.394 dollars; 264 life years lost per million inhabitants.

Overburden on tropical countries: health system and economy.

Fonte: Global Strategy for dengue prevention and control, 2012-2020 , OMS.

Scenario

The emergence and diffusion of all dengue serotypes from Asia to America, Africa, and Eastern regions of the Mediterranean represent a threat of pandemics.
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Results of the Evaluation of Deaths

Alarm and shock signs of dengue fever are not routinely researched.
Health professionals have not been using the clinical staging prescribed by the Ministry of Health (MoH). Patient hydration levels were lower than those prescribed by the handbook.

Laboratorial tests, such as blood cell count, which are necessary for the proper hydration and platelets dosage, were not solicited in the recommended frequency.
Test results took longer than they should for the appropriate care of patients with dengue fever. The type of assistance (supervised) and the gap between reassessments were lower than the established by the Ministry of Health. Conclusion: the high levels of mortality are correlated with the nonfollowing of technical rules for the diagnosis and treatment of cases of dengue fever, as established by the MoH

Dengue
Dengue fever is a dynamic and systemic disease. The proper care depends on the early recognition of the alarm signs, the continued monitoring, the restaging of cases (dynamic and continued) and the prompt water reposition.
Alarm Signs: intense and continued abdominal pain, persistent vomiting, postural hypotension and/or lipothymy, painful hepatomegaly, mucosal bleeding or important hemorrhages (hematemesis and/or melena), drowsiness and/or irritability, decrease of diuresis, sudden decrease of body temperature or hypothermia, sudden increase of hematocrit, sudden drop of platelet count and breathing discomfort.

The determinant factor of the severe forms of dengue fever are the vascular endothelial alterations, with plasmatic leakage, which leads to shock, expressed by hemoconcentration, hypoalbuminnemy and/or cavity spillage.

Dengue Step by Step.

It is necessary to revise the clinical history of the patient, along with the complete physical exam at each reevaluation with the proper registration in pertinent instruments and consultation of the patients flow chart. General Evaluation: clinical history, physical examination, fever characterization. Search of alarm and/or shock signs. Search of spontaneous or induced skin bleeding (Tourniquet test) Search of comorbidities, special clinical situations and/or social risk ones.

Laboratorial exams (complete blood count) and specific exams for dengue fever.
Treatment Follow-up plan
HIPTESE DIAGNSTICA CASO SUSPEITO

Notification
Histria Clnica

EXAME FSICO

Dengue
Warning: The complete blood count (CBC) is mainly used to assess the hematocrit, to identify hemoconcentration. Hemoconcentration indicates the likely alteration of capillary permeability (plasmatic leakage), associated with severity, as well as defining the need for hydration and response to instituted reposition therapy.

In dengue fever, the leukogram is variable (leucopenia may indicate another viral infection and leukocytosis does not eliminate the disease); Thrombocytopenia does not necessarily constitute a risk factor to bleeding in patients with suspected dengue fever, but the progressive decrease in platelet count indicates the need for closer monitoring, for it indicates the patient may suffer complications, which will be considered an alarm sign.

Dengue - CBC
Hematocrit One hematocrit at the beginning of the feverish phase establishes the personal basal value of the patient; From first through third day - generally normal; Rising hematocrit: establishes the beginning of the Critical Phase; The value is directly proportional to the severity; An increase of the hematocrit, compared to the prior result, is highly suggestive of an evolution to the critical phase of the disease, with plasma leakage.

Hct Children

Increased Hematocrit > 38 %

Women
Men

> 44 %
> 50%

Increase of the usual value above 10% 8

IMMUNOPATHOGENESIS OF DENGUE FEVER

IMMUNE RESOPONSE
MICROENVIRONMENT OF CYTOTOXINS GENETIC FACTORS

Unregulated Response

SEVERE CASES

Immune Response

DEATH 9

HEALING

Dengue Phases of the Disease

Day of the Disease Temperature 1
40

5 6

Reabsorption

Clinical Manifestations Unspecific Laboratorial Exams Secific Laboratorial Exams

Dehydration

Shock Bleeding
Organic Damage

Risk of Liquid Overflow

Platelets Hematocrit Viraemia Ac IgM Plasma Leakage

Phases of the Disease

Feverish

Critical

Recovery

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Clinical Staging of the Disease

Group A
Negative tourniquet test, without spontaneous bleeding, without comorbidity or at risk group or special clinical conditions, lack of alarm signs. Positive tourniquet test or spontaneous skin bleeds (petechiae), or with comorbidities, or at risk groups or special clinical conditions. Lack of alarm signs.

Group B

Group C

Presenceof ofone oneor ormore morealarm alarmsigns signs Bleedingpresent presentor ornot. not. Presence . .Bleeding Nohypotension. hypotension. No

Group D

Hypotension or shock. Bleeding present or not.

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Post Exam

Post-exam 1st question

ABC, male, 28 years old, fever for 5 days, headache, myalgia,
persistent vomiting, continued abdominal pain, absence of spontaneous bleeding. At examination presents regular

general condition, hydrated, normo-chrome. Tourniquet

negative. BP normal. Analyzing the case, which is the clinical staging of the patient? ( ) Group A ( ) Group B ( ) Group C ( ) Group D

Post-exam 1st question

ABC, male, 28 years old, fever for 5 days, headache, myalgia, persistent vomiting, continued abdominal pain, absence of spontaneous bleeding. At examination presents a regular general condition, hydrated, normo-chrome. Tourniquet test negative. BP normal. Analyzing the case, which is the clinical staging of the patient? Group A Group B Group C Group D

Grupo C

Presence of one or more alarm signs. Presence or not of spontaneous bleeding. No hypotension

Post-exam 2nd question

Based on your classification, which is the therapeutic conduct?

a) Antiemetic, paracetamol or dypirone and at home rehydration. b) Supervised oral rehydration of 80ml/Kg/day, of which 1/3 in 4 hours. Keep in observation bed, with clinical and hematocrit reassessment 4 hours after hydration c) Volume replacement: 20ml/Kg/day in 1 hour with saline. Monitoring in hospital bed. Clinical and hematocrit reassessment every 2 hours. Repeat expansion phase up to 03 phases if there is no improvement in hematocrit (hemoconcentration) and clinical parameters. d) IV hydration: 20ml/Kg in 20 minutes. ICU bed. Repeat this phase up to 3 times. Clinical reassessment every 15-30 minutes and hematocrit after 2 hours.

Post-exam 3rd question

The alarm signs must be searched and the Dengue Fever Card handed to patients with suspected dengue fever, who are discharged following the MoH protocol. Which of the following symptoms are considered alarm signs? a) Persistent vomiting, continued abdominal pain, postural hypotension; b) Breathing discomfort, drowsiness and/or irritability, painful hepatomegaly c) Important bleedings d) Sudden increase in hematocrit or sudden drop in platelet count e) All the above

Post-exam