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Pearls and pitfalls in DHF management

Dr. Aung Kyi Wynn


Senior consultant pediatrician

DENGUE

Definition
Acute illness caused by four serotypes of

dengue virus and characterized by a


hemorrhagic diathesis and a tendency to
develop a shock syndrome (dengue shock
syndrome DSS) that may be fatal.
Thrombocytopenia with concurrent

haemoconcentration is a constant findings.

Causal Agent

Dengue virus = Serotype 1- 4

Infection with one type gives lifelong


immunity for this type, but partial
immunity for other types

Vector
Transmitted by Aedes aegypti.
Bite during daytime
Grow in clear water

Countries/areas at risk of dengue transmission, 2008

Virus multiplies in midgut, brain,


body fat, salivary glands

Man-Mosquitoe-Man cycle

(3-14days
(8-12days
avr 4-6 days
virus
replicates)
(about 5 days)
(about 5 days)
virus replicates)

Principal
reservoir host

Awareness of DHF
Pearls - Aware and Recognize DHF

Pitfall Failure to get diagnosis of


DHF

CRITERIA FOR DENGUE


Probable dengue
-live in /travel to dengue endemic area.
-Fever and 2 of the following criteria:
Nausea, vomiting
Rash
Aches and pains
Tourniquet test positive
Leukopenia
Any warning sign

Laboratory-confirmed dengue
(important when no sign of plasma leakage)
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Use of NS 1 Antigen

NS 1 rapid tests (eg. SD BIOLINE) had


similar diagnostic sensitivities ( 61.6% )
compared to RT PCR ( 62.4%) in
confirmed cases
Both tests have 100% specific
Sensitivity become significantly
improved (83.7%)when NS 1 and/or Ig
G and/or IgM was positive.

Use of NS 1 Antigen

significantly more sensitive for Primary


than secondary Dengue.
Associated with underlying viraemia

(Vianney Tricou et,al at Oxford University Clinical Research


Unit)

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USG findings

Hepatomegaly
87.5 %
Pericholecystic oedema 83%
Gallbladder wall thickening 80%
Ascites
74%
Pleural effusion (Rt)
44%
Splenomegaly
3.4%
Pleural effusion (Bilateral) 2%
(on third and fourth day of fever)
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CRITERIA FOR SEVERE DENGUE

Severe plasma leakage


leading to:
Shock (DSS)
Fluid accumulation with respiratory distress

Severe bleeding
as evaluated by clinician

Severe organ involvement


Liver: AST or ALT 1000
CNS: Impaired consciousness
Heart and other organs
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Bleeding in
mesentry and
intestinal wall

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Many faces of DHF

DHF with GE
DHF with Asthmatic Bronchitis
DHF with Appendicitis
DHF with extreme drowsiness
DHF with Hepatitis
DHF with acute intravascular hemolysis

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HESS TEST
Pearls Proper doing and interpretation

Pitfall Wrong methods and interpretation

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HESS TEST

Appropriate cuff
Exact 5 minutes
Proper method
Wait till the bluish discoloration gone
1 square inch square at maximum area

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HESS TEST - Interpretation

Not any spot is positive


> 20 positive
10-20 Equivocal
< 10 Negative
Be aware of false (+)

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Positive tourniquet test

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Febrile, critical and recovery phases in dengue

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engue case classification and level of


everity

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A stepwise approach to the management of dengue

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DETECTION OF SHOCK
Pearls Predict or Detect in Time
Pitfall Failure to recognize shock

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DETECTION OF SHOCK

Warn parents that fall in temperature is more


important than fever

Afebrile with improvement or deterioration

Proper written instruction

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DETECTION OF SHOCK
At the time when the temperature drops i.e.,

from day 3 onwards with worsening of


general condition
In other diseases, with the drop in

temperature,
the child feels better, eats better, is alert, up and

go about and can play


wherelse in DSS, it is reversed
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WHY DETECTION OF SHOCK IS IMPORTANT

Stagnant acidemia promote

occurrence and enhanced


severity of DIC

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WHEN TO ADMIT
Pearls Proper admission
Pitfall Too early or late admission

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WHEN TO ADMIT

Dangerous mistake DHF patients


need admission only when develop
shock

Admission Criteria
Patients with warning signs
Those with co-exisitng
conditions that may make
dengue or its management
more complicated
(infancy, obesity, diabetes
mellitus, renal failure,
chronic haemolytic
diseases)

Admission criteria

Signs and symptoms related to hypotension


(possible plasma leakage)
Dehydrated patient, unable to tolerate oral fluids
Giddiness or postural hypotension
Profuse perspiration, fainting, prostration during

defervescence
Hypotension or cold extremities

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Admission criteria

Bleeding
spontaneous bleeding
independent of the platelet count

Organ impairment
Renal, hepatic, neurological or cardiac

enlarged, tender liver, although not yet in


shock
chest pain or respiratory distress, cyanosis

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Admission criteria

Findings through further investigations


Rising haematocrit
Pleural effusion, ascites or asymptomatic

gall-bladder thickening

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Admission criteria

Co-existing conditions
Pregnancy
Co-morbid conditions, such as diabetes

mellitus, hypertension, peptic ulcer,


haemolytic anemias and others
Overweight or obese (rapid venous access
difficult in emergency)
Infancy or old age

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Admission criteria

Social circumstances
Living alone
Living far from health facility
Without reliable means of transport

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WHERE TO ADMIT
Pearls Close monitoring and
Titration
Pitfall Inadequate monitoring
& Inadequate experience

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Management according to groups AC

Group A
patients who may be sent home

Group B
patients who should be referred for in-hospital

management

Group C
patients who require emergency treatment and urgent

referral when they have severe dengue

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Group A
(who may be sent home)

Patients who do not have warning signs


OR

who are able to tolerate adequate volumes of


oral fluids and
pass urine at least once every six hours
do not have any of the warning signs
particularly when fever subsides

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Group B
(Referred for in-hospital care)

Patients with any of the following features:


co-existing conditions
such as pregnancy, infancy, old age, diabetes
mellitus, renal failure
social circumstances
such as living alone, living far from hospital

OR

Existing warning signs

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Group C
(Require emergency treatment)

Patients with any of the following features:


severe plasma leakage with shock and/or fluid

accumulation with respiratory distress


severe bleeding
severe organ impairment

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Group A patient
Treatment

Advice for:
adequate bed rest
adequate fluid intake
Paracetamol, 3gram maximum per day in adults

and accordingly in children.(10mg/dose)

Patients with stable HCT can be sent home

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Group A patient
Monitoring

Daily review for disease progression:


decreasing white blood cell count
defervescence
warning signs (until out of critical period).

Advice for immediate return to hospital if


development of any warning signs, and

written advice for management (e.g. home care card

for dengue)

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Use of Drugs

Pearls Use of appropriate Drugs and


avoidance of unnecessary and
dangerous drugs

Pitfalls Use of unnecessary and


dangerous drugs

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Use of Drugs

Use Paracetamol only as antipyretic

Not need to have food

Avoid all others NSAID No Nimuslide, No


Ibuprofen

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OTHER DRUGS

ORS or Any fluid and Salt

Avoid unusual large amount especially in


older children

? Antacids & Ranitidine

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Group B
(with co-existing conditions or social circumstances)

Treatment
Encouragement for oral fluids
If not tolerated, start intravenous fluid therapy 0.9%

saline or Ringers Lactate at maintenance rate

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Group B
(with co-existing conditions or social circumstances)

Monitor:
temperature pattern
volume of fluid intake and losses
urine output (volume and frequency)
warning signs
HCT, white blood cell and platelet counts

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Group B
(with existing warning signs)

Treatment

Obtain reference HCT before fluid


therapy
Give isotonic solutions
such as 0.9 % saline, Ringers Lactate
Start with 57 ml/kg/hr for 12 hours,
then reduce to 35 ml/kg/hr for 24 hr, and
then reduce to 23 ml/kg/hr or less according

to clinical response

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Group B
(with existing warning signs)

Reassess clinical status and repeat HCT:


if HCT remains the same or rises only minimally ->
continue with 23 ml/kg/ hr for another 24 hours;

if worsening of vital signs and rapidly rising HCT ->


increase rate to 510 ml/kg/hr for 12 hours

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49 & 50

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Group B
(with existing warning signs)

Reassess clinical status, repeat HCT and


review fluid infusion rates accordingly:

reduce intravenous fluids gradually


when the rate of plasma leakage decreases

towards the end of the critical phase

This is indicated by:


adequate urine output and/or fluid intake
HCT decreases below the baseline value in a stable

patient

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Group B
(with existing warning signs)

Monitor

vital signs and peripheral perfusion (14 hourly) until


patient is out of critical phase
urine output (46 hourly)
HCT (before and after fluid replacement, then 612
hourly)
blood glucose
other organ functions (renal profile, liver profile,
coagulation profile, as indicated)
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Pearls and Pitfalls In the


Management of Shock
DSS is hypovolemic shock due to plasma

leakage:
Volume replacement with isotonic salt

solutions, plasma, plasma substitute, for the


period of plasma leakage(24 - 48hrs)is lifesaving

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Pearls and Pitfalls in the


Management of Shock

Volume replacement should be monitored according


to the rate of plasma leakage (PCV, vital signs, urine
output) to avoid fluid over load

The rate of leakage is more rapid in 1 st 6 12 hrs

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Group C
(Require emergency treatment)

Treatment of compensated shock

Start IV fluid resuscitation with isotonic


crystalloid solutions at 510 ml/kg/hr
over 1 hour
Reassess patients condition

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Group C
(Require emergency treatment)

Treatment of compensated shock


If patient improves:
IV fluids should be reduced gradually to 57 ml/kg/hr for

12 hours,
then to 35 ml/kg/hr for 24 hours,
then to 2-3 ml/kg/hr for 24 hours and
then reduced further depending on haemodynamic
status;
IV fluids can be maintained for up to 2448 hours
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Group C
(Require emergency treatment)
Treatment of compensated shock
If patient is still unstable:
check HCT after 1st bolus;
if HCT increases/still high (>50%), repeat a 2nd bolus of
crystalloid solution at 1020 ml/kg/hr for 1hr
if there is improvement after 2nd bolus, reduce rate to 710
ml/kg/hr for 12 hrs and continue to reduce as above
if HCT decreases, this indicates bleeding and need to
cross-match and transfuse blood as soon as possible

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Group C
(Require emergency treatment)
Treatment of hypotensive shock

Initiate IV fluid resuscitation with crystalloid or colloid


solution at 20 ml/kg as a bolus for 15 minutes

-If patient improves:


give a crystalloid/colloid solution of 10 ml/kg/hr for 1 hr, then

reduce gradually as above

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Group C
Treatment of hypotensive shock
-If patient is still unstable:
review the HCT taken before the 1st bolus;
if HCT was low (<40% in children), this indicates
bleeding, the need to cross-match and transfuse
if HCT was high compared to baseline value, change to
IV colloids at 1020 ml/kg as a 2nd bolus over 30 minutes
to 1 hr; reassess after second bolus
If patient is improving reduce the rate to 710ml/kg/hr for
12 hr, then back to IV crystalloids and reduce rates as
above

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Group C
Treatment of hypotensive shock
-If patient is still unstable:
repeat HCT after second bolus.
If HCT decreases, this indicates bleeding
if HCT increases/remains high (>50%), continue colloid
infusion at 1020 ml/kg as a 3rd bolus over 1 hr,
then reduce to 710 ml/kg/h 12 hr, then change back
to crystalloid solution and reduce rate as above
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Group C
(Require emergency treatment)

Treatment of haemorrhagic complications


Give 510 ml/kg of fresh packed red cells or

1020 ml/kg of fresh whole blood

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Pearls and Pitfalls In the


Management of Shock ( contd)
Stagnant acidemia promote occurrence and

enchanced severity of DIC


PRP transfusion as prophylaxis for bleeding in

all shock cases is not recommended

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Pearls and Pitfalls In the


Management of Shock ( contd)
There are abnormal haemostatic changes that

potentiate bleeding in DHF/DSS


Severe bleeding ( may be concealed ) often

occurs in cases with prolonged shock and


further perpetuates shock

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Pearls and Pitfalls In the


Management of Shock ( contd)
Refractory shock despite adequate volume

replacement and a drop in PCV ( at any rate


e.g. from 50 % to 40 % ) indicates significant
bleeding and a need for FWB transfusion
( 10 ml/kg/dose )

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Pearls and Pitfalls In the


Management of Shock ( contd)
Major contributory factor to the high mortality rate
failure to recognize internal bleeding
over transfusion with crystalloid and/or plasma fluid

instead of blood

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Pearls and Pitfalls In the


Management of Shock ( contd)
Pitfall------------ Too much rely on platelet count and
PCV
Pearl------------ In conjunction with hemodynamic
Status

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Key decisions
When
When

to give blood?

to stop IV fluid or
give diuretics?

IV fluid therapy

Narrow therapeutic index


Timely
Appropriate volume
Rate
Appropriate type
Appropriate duration

(Fluid replacement- 40-60ml/kg)

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PREVENTION
Pearls - Correct prioritization

Pitfall Just for show

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PREVENTION

Larva control more important than killing adult mosquitoes

School, Tuition, Nursery, Day care centre

Whole wards or villages

Health more important than Education

DHF more important than lung diseases

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Prevention (contd)
Key Container should not be in the vicinity

where 3 -8 yrs old children are aggregated


e.g. primary school, private tuition, day- care centre

Control measures should be emphasized in

these areas

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CONCLUSIONS

It is a preventable and treatable disease

Awareness of clinical features, early and


effective treatment of shock, appropriate
management with close monitoring can save
the lives of patients

Effective preventative measures will reduce


the burden of DHF
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FAQS

Secondary dengue infection Vs


virulence theory
Role of corticosteroid
Two attacks of dengue in the same
season?
Importance of D/C diagnosis

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FAQS cont.

Role of OPD MO
Role of ward MO
Role of abate
Dengue vaccine

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Thank you

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