Fluid Management in

DHF Patients

Dr Rasnayaka M Mudiyanse
Senior Lecturer in Paediatrics
Faculty of Medicine Peradeniya
 Short Duration Fever - OPD
Treat and Admit Need
send home No resuscitation Resuscitation

1. Treat Fever 1. Immediate 1. Evaluate & ABC care

2. Rest attention 2. Fluid boluses
3. Fluid 2. Fluid 3. Oxygen
4. Specific drugs 3. Oxygen 4. Hand over MO-MO
5. Warning signs 4. Observation
DD
Dengue ( group C)
DD DD
(Sever dengue )
Dengue ( group A) Dengue (group B)
( No warning signs ) ( with warning signs) Septicemia
Viral fevers Other infections Diarrhea
Other D Other D Anaphylaxis
 Classification of Dengue
Old WHO classification
Classical Dengue Fever
Dengue Fever with hemorrhagic
manifestations
DHF grade one
DHF grade two
New WHO classification
Probable dengue ( group A - OPD
management)
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 three Severe Dengue ( Group C -

DHF grade four
DHF with unusual manifestations
resuscitation and management)
1. With compensated shock
2. With hypotensive shock
3. With severe organ impairment
Dengue Hemorrhagic Fever or
Dengue Leaking Fever

Essential Feature In DHF is Leaking

DF 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%
Evidences
of
plasma
leakage
in
DHF (Rt. lateral decubitus position)

A. Rising hematocrit ~ 50% 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)
 Sensitivity of early diagnostic
indicators of Dengue
Flushi Tourqu Leucope Liver enzymes
ng et test nia
1st day 73% 53% 70%
within AST rise 90%
2nd day 90% 90% 24 hrs pt
will enter AST > 60 – PPV 80%
critical
rd phase AST > ALT (2-3
3 day 85% 98%
times)
Dengue is a Dynamic Disease
 Febrile, Critical and Recovery Phase

1 2 53
3
105
51
104
140 49
103
47
102
120 45
101
43
100
100 41
99
39
98
80 37
35
60

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

1 2 3 4 5 6 7 8
2-7 days 1-2 days
 Rate of Fluid Leakage

1 2 53
3
105
51
104
140 49
103

102
M + 5% 47
120 45
101
43
100
100 41
99
39
98
Optimum 80 37
volume of 35
fluid … 60

1 2 3 4 5 6 7 8
 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 Prolong Shock

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
1

• 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)

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
10-20
20-10 ml/kg

1 5-10 ml/kg 2 10-5 ml/kg

3 53
105
51
5-3 ml/kg
104 3-5 ml/kg 140 49
103
47
102 3-1 ml/kg 120 45
101
1-3 ml/kg
43
100
100 41
KVO
99 1.5 ml/kg 39
98
80 37
M + 5% 35
48 hrs 60

1 2 3 4 5 6 7 8
 Fluid Allocation for Non Shock Patient
10-20
20-10 ml/kg

1 5-10 ml/kg 2 10-5 ml/kg

3 53
105
51
5-3 ml/kg
104 3-5 ml/kg 140 49
103
Fluid over load 47
102
1-3 ml/kg
3-1 ml/kg and shock 120 45
101
43
100
100 41
KVO
99 1.5 ml/kg 39
98
80 37
M + 5% 35
48 hrs 60

1 2 3 4 5 6 7 8
 Fluid Allocation for Non Shock Patient
10-20
20-10 ml/kg

10-5 ml/kg
1 5-10 ml/kg 2
3 Shock 53
105
5-3 ml/kg and Fluid Over Load51
104 3-5 ml/kg 140 49
103
47
102 3-1 ml/kg 120 45
101
1-3 ml/kg
43
100
100 41
KVO
99 1.5 ml/kg 39
98
80 37
M + 5% 35
48 hrs 60

1 2 3 4 5 6 7 8
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 supply
40% - compromise renal and brain
 Prevent Shock – Manage PCV
10-20
20-10 ml/kg

1 5-10 ml/kg 2 10-5 ml/kg

3 53
105
51
5-3 ml/kg
104 3-5 ml/kg 140 49
103
47
102 3-1 ml/kg 120 45
101
1-3 ml/kg
43
100
100 41
KVO
99 1.5 ml/kg 39
98
80 37
M + 5% 35
48 hrs 60

1 2 3 4 5 6 7 8
 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

Lack
Failures WHY
WHY
of knowledge ??and training
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.
1-10 yrs - 5th Centile SBP = 70+ (agex2)
Adults
SBP <90 mm Hg or MAP <70 mm Hg or Drop of SBP >40 mm Hg
 Management of DHF Grade 4
Severe 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 4
Severe Dengue with Hypotensive shock
Fluid bolus 10-20 ml/kg Normal Saline / 15 mt
Improving , HCT coming down gradually , good UOP

• 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

No improvement No improvement
HCT dropping – Blood transfusion 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
Check HCT before fluid bolus or after fluid bolus
If HCT is dropping Rising HCT
< 40 for Children and female
< 45 for adult male 2ndBolus - Colloids
1. 10 – 20 ml/kg/ ½-1 hr
Blood transfusion
whole blood 10 -20 ml/kg 3rd bolus - Colloids
Packed RBC 5-10 ml/kg 1. 10 – 20 ml/kg/1 hr
 DHF Grade 3
Dengue 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)
Fluid bolus 5-10 ml/kg Normal Saline / 1hr
Improving , HCT coming down gradually , good UOP
• 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
 Management of DHF grade 3
(Severe Dengue with Compensated Shock)
Fluid bolus 5-10 ml/kg Normal Saline / 1hr
Rpt fuid bolus 5-10 ml/kg Normal Saline / 1hr
NO IMPROVEMENT
HCT rising If HCT is dropping
< 40 for Children and female < 45 for adult male

Fluid bolus saline /colloids Blood transfusion

10 -20 ml/kg for 1hr Packed RBC 5-10 ml/kg
Whole blood 10-20 ml/kg
However, a rising or persistently high HCT together with
stable haemodynamic status and adequate urine output
does not require extra intravenous fluid.
 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
20-10 ml/kg

1 2 10-5 ml/kg
3 53
105
51
104
5-3 ml/kg
140 49
103
47
102 3-1 ml/kg 120 45
101
43
100
100 41
99
KVO
39
98
80 37
M + 5% 35
24 hrs 60

1 2 3 4 5 6 7 8
 Fluid Allocation for Non Shock Patient
10-20
20-10 ml/kg

1 5-10 ml/kg 2 10-5 ml/kg

3 53
105
51
5-3 ml/kg
104 3-5 ml/kg 140 49
103
47
102 3-1 ml/kg 120 45
101
1-3 ml/kg
43
100
100 41
KVO
99 1.5 ml/kg 39
98
80 37
M + 5% 35
48 hrs 60

1 2 3 4 5 6 7 8
 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
fluid
DHF 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
only 10-15% patients need blood

• 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

Circulatory failure with high HCT should be managed with

colloids ( + Lasix if fluid overloaded) before blood
 Why do you do platelet counts ?
(Answer this MCQ)

• To decide on platelet transfusion

• To recognize the beginning of critical
stage -
• As a prognostic indicator-
 Why do you do platelet counts ?

• To decide on platelet transfusion - X

• To recognize the beginning of critical
stage -
• As a prognostic indicator-
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)
 Management of Fluid over load
• 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
 How to prevent fluid over load
Leaking Blood vessels ! – Give only minimal & essential

• 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
 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 dengue
Health Dengue
Ml/kg/hr Ml/kg/hr
Total intake 3 3
UOP 2 1
Insensible loss 1 1
Leaking 0 1
(+ ve balance)

Water for growth was not taken in to consideration

Fluid balance in health and dengue
Health Dengue
Ml/kg/hr Ml/kg/hr
Total intake 3 5
UOP 2 2
Insensible loss 1 1
Leaking 0 2
(+ ve balance)

Water for growth was not taken in to consideration

Fluid balance in health and dengue
Health Dengue
Ml/kg/hr Ml/kg/hr
Total intake 3 1.5
UOP 2 0.5
Insensible loss 1 1
Leaking 0 0.25
(+ ve balance)

Water for growth was not taken in to consideration

Monitoring Charts
 HCT/ HR BP RR UOP CRFT Cold Fluid
22 kg plt ness Ml/kg
11.00 38 146 90/80 47 5 ml 8 Mid 10 ml/kg bld
am calf

12.00 48 100 110/8 49 10 2 ankle 10 ml/kg

noon 0 SOB HS + Laxis 20 mg

1.00 pm 41 100 100/7 40 100 2 - 3 ml/kg

0 Acitis NS
effus
ions
2.00 pm 110 100/7 38 60 2 - 1.5 ml/kg
0 Effus
ions ?
2222/2640 3 ml/kg NS /one hr
1 2 3 4 5 6 7 8 9 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0

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

0
1
2
3
4
5
6
7
8
9
10
BP R

1
90/80 140 52
3R5 00

4
*
90/80 30 140 45
00

6
*
90/80 35 140 20 51

*
95/70 35 110 45 46

*
95/70 35 110 30

*
95/65 30 110 30
80/70 38 160 15 49 *
*

90/80 32 120 65
*

90/80 34 120 65
*

65/50 38 160 10 40
8 10 12 14 16 18 20
*

100/70 45 100 10 48
22
*

95/70 35 110 95
24
*

100/75 35 100 60
26
*

95/70 30 100 60
28

35
*

95/70 25 100 75
30
*

95/70 25 110 60
32
*

95/70 25 100 45
34
*

95/70 20 110 45
36
*

100/70 20 100 60
38
*

100/70 20 100 85
40
*

95/70 20 100 100

42
*

95/70 20 100 100

44
*

95/70 20 100 40
46
*

100/70 20 98 50
48

42
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

 Interpretation of HCT

Condition of
the patient HCT Rising HCT Dropping

Deteriorating
Colloids Blood
transfusion
Observe
Improving Improving !
Increase fluid rate during Encourage
early critical phase 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 Management

after admission to ward • Total fluid during critical period
1850 / 1900
• HCT - Maximu – 52, minimum – 32
• Crystalloid boluses – 3
• Platelets – Max – 120, Mini – 40 • Colloid boluses – 1
• Blood pressure – min – 40/ ? • 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