Dengue Case Discussion. When things can go wrong!

Transcription

1 Dengue Case Discussion When things can go wrong!

2 What the local experts say! 99.99% of walked in patients who come to hospital with dengue should walk out from hospital! Even those who come in Shock but without Prolonged Shock should have >99% survival Except very RARELY a walked in dengue patient should not need an ICU bed or ventilator support Is it a dream!!

3 Case Scenario 1 27 year Undergraduate from Colombo presented with fever, headache, severe bodyaches for 3 days He was asked to get admitted by his GP with a blood report of WBC 2300,PCV 38,Plat 118,000 Weight 68kg He was pyrexial 102⁰F,pulse 100,BP- 120/75 CRFT < 2sec, had good urine output at home

4 Case Scenario 1 What phase of illness Febrile Critical Recovery What is your management pyrexial 102⁰F pulse 100 BP- 120/75 CRFT < 2sec WBC 2300 PCV 38 Plat 118,000

5 Case Scenario 1 What phase of illness Febrile Critical Recovery What is your management

6 Case Scenario 1 Management Temp Chart 3 hourly observation chart Symptomatic management PCM/ No NSAIDs Maintenance fluids? Oral or IV FBC twice daily PCV 6hourly?

7 12/4/15 Epidemiology Unit, Ministry of Health

8 12/4/15 Epidemiology Unit, Ministry of Health UOP ml/hr

9 Case Scenario 1 Family is keen for laboratory confirmation? Dengue NS1 Ag?Dengue Ab IgM/IgG Day 3 pyrexial 102⁰F pulse 100 BP- 120/75 CRFT < 2sec WBC 2300 PCV 38 Plat 118,000

10 Laboratory diagnosis NS1 detection Fever IgM Viraemia IgG- 2ry IgG- 1ry /52 Days

11 Diagnostic options and sensitivity of NS1Ag % sensitivity Day of illness PCR IgM NS1 NS1- detection at admission 1. Sensitivity=67% 2. Specificity=100% 3. Positive predictive value=67% 4. Negative predictive value=75%

12 Immune Response to Dengue Infection Antibody Level Onset of Symptoms Onset of Symptoms IgG IgG Cutoff HAI 1:2560 Virus IgM Virus IgM IgM Cutoff Primary Infection Secondary Infection

13 Case Scenario 1 DAY 2 (Fever Day 4) Dengue NS1 Ag+ Fever continues Bodyaches,anorexia Stable 3 hourly observation FBC WBC ,PCV - 40 Plat- 84,000 On oral/iv maintenance Paracetamol SOS Day 1 pyrexial 102⁰F pulse 96 BP- 120/75 CRFT < 2sec WBC 2300 PCV 38 Plat 118,000

14 Case Scenario 1 Day 3 (Day 5 from onset) Apyrexial since previous evening Feeling faintish, abdominal pain, vomiting Pulse - 90,BP- 100/75,CRFT <2 UOP - 30ml/hr,PCV- 44 What phase of illness? Critical Recovery Day 2 pyrexial pulse 96 BP- 110/75 CRFT < 2sec WBC 3400 PCV 40 Plat 84,000

15 How do you detect onset of critical phase Clinical Hematology Radiology Biochemistry

16 Detection: onset of leakage 1.Clinical Potential leaker- Clinical deterioration when fever is settling Abdominal pain, vomitting Faintish on standing Enlarged tender liver Reduced UOP Confirmed leaker (late sign) Pleural effusions, free fluid in abdomen

17 Timing the onset of critical period- Haematology WBC platelets 260, , , , , , , , ,000 80,000 60,000 40,000 20, th 8 am 18 th 8 am 18 th 8 pm 19 th 8 am 19 th 8 pm 20 th 8 am 20 th 8 pm 21 st 8 am 21 st 8 pm 0

18 Haematocrit/PCV Base line haematocrit is important (if not known- adult male female 35-38) Rise towards 20% above baseline considered significant May be less than 20% - fluids taken in excess or overt bleeding (menstrual bleeding) Suspect when PCV rises > 10% If in shock due to leakage usually 30% rise is expected

19 Platelets- Importance to clinicians When count reaches close to during a febrile illness suspect Dengue When count drops to < start 3 hourly observation chart When count drops to < consider admission Patient usually never leaks > so look for evidence of leakage when it drops Expect leakage if there is a rapid drop of platelets The start of rise in platelets marks the end of peak of leakage

20 Radiological diagnosis Point of care Ultrasound scan Progressive accumulation of fluid in pleural or peritoneal cavities CXR- right lateral decubitus (rarely performed now)

21 R /Lateral decubitus film

22 Point of care sonography Galle bladder wall oedema Pericholycystic fluid Fluid in the pelvis Fluid in hepato renal pouch R /Pleural effusion

23 Point of care sonography Galle bladder wall oedema Pericholycystic fluid Fluid in the pelvis Fluid in hepato renal pouch R /Pleural effusion

24 Interpretation of USS DF D H F GB wall Oedema Pericholecystic fluid Plueral effusion usually unilateral Peritoneal cavity Significant (progressive) effusion Plueral cavity No fluid Peritoneal cavity Little/ no fluid in deep pelvis

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28 What strategy to adopt to diagnose the onset of leakage Ward setting Clinical/Haematology/Radiology Emergency Unit Clinical/Radiology/Haematology

29 Case Scenario 1 Blood sent at 8am PCV - 44,Platelets 54,000 US done at 10am Fluid in the Hepato renal pouch What phase of illness? Critical Recovery How do you calculate the onset of leakage

30 How do you define the onset of critical phase Difficult at times! Time from the last fever spike Time when platelets dropped to <100,00 Time from the WBC started to rise Time from you first detected leakage on scan Do not wait for clinical detection of effusion/ascites You may change the onset time later considering the clinical response

31 Management of Critical Phase Where? What monitoring charts needed? What equipment needed?

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34 How good is a multi para monitor Manual BP checks may be subjective Critical phase should be managed relying on a multi para monitor Saves time on the hourly chart Can we provide that facility to all leakers?

35 How often do we need to do PCV? Micro haematocrit centrifuge 3 hourly or more frequently if clinical condition changes

36 Management of Critical Phase Monitoring of hourly urine output needed Do we need an indwelling urinary catheter?

37 Critical Phase Monitoring In Summary Move the patient close to doctors/nurses bay Start Hourly Observation Chart Connect to Multi para monitor Easy access to Micro haematocrit centrifuge Indwelling urinary catheter Above all close vigilance!!

38 LEAKAGE OF PLASMA in DHF 60% UOP

39 Rapid Moderate Slow F 0 Hr 24 Hr 48 Hr 6 Hr 36 Hr C R

40 When plasma leaks Intravascular volume drops Compensatory mechanisms start operating Peripheral vasoconstriction- > diastolic blood pressure goes up- > reduced pulse pressure Sinus tachycardia Urine out put drops (Compensated Shock) Compensation fails Systolic blood pressure drops (Decompensated/Refractory shock)

41 How do you decide the dynamics of leakage Time since onset of critical phase Pulse rate Pulse Pressure PCV CRFT UOP

42 Fluid Management Critical Phase Total fluid (48hrs) 1 st 10 kg 100ml/kg 2 nd 10kg 50ml/kg From 20-50kg 20ml/kg PLUS 5% deficit 50ml/kg max 50kg 65kg adult 4600ml/48hrs Fluids Oral +IV

43 Fluid Management Critical Phase How should we give this volume of fluid? 4600/48 95ml/hr Not at a uniform rate Start with 1.5-3/ml/kg/hr depending on patients clinical status Rate should match the dynamics of leakage

44 Your Treatment Goals Keep systolic blood pressure above 90mmHg Keep pulse rate below 100/min Keep pulse pressure above 30 mmhg Keep UOP above and around 25 ml/hour CRFT<2sec Maintain stable PCV 44

45 Monitoring parameters during Rx 1-24 hours after leakage hours after leakage SBP >90, Pulse <100,UOP >25ml/hr,PP >30,CRFT <2sec,stable PCV Hct bring down if high Narrow Pulse pressure or high PCV may be ignored

46 Case Scenario 1 Critical phase was managed according to National Guidelines Fluid intake was restricted to calculated quota Patient had uneventful critical phase Recovery was heralded by improvement of well being vitals and polyuria Patient was discharged on D6

47 LEARNING POINTS Monitoring during febrile phase Early detection of onset of critical phase Recommended monitoring during critical phase Treatment goals during critical phase

48 Case Scenario 2 34 year male, fever and body aches for 5 days Apyrexial since yesterday feeling faintish vomiting and reduced urine output Examination apyrexial pulse 106,BP- 90/70 CRFT 3,RHC tenderness,?r /Pleural effusion Body weight 65 kg What phase of illness

49 Febrile Phase Critical Phase DHF - I,II,III,IV Fluid Leakage Ascending limb Descending limb Peak (Equilibrium Phase) Recovery Phase Stage of illness

50 Case Scenario 2 Is he in shock Yes compensated shock What is the first bedside test you do/why PCV to define the cause of shock Apyrexial pulse 106 BP- 90/70 CRFT 3 sec What is the next important investigation Point of care Ultrasound

51 Management of Dengue shock Identify shock Look for the cause of shock Leakage - commonest Haemorrhage Leakage with haemorrhage SHOCK is NOT due to MYOCARDITIS!

52 Diagnosis of Dengue Shock Tachycardia >110 Pulse pressure <20 CRFT >2sec ± UOP <25ml/hr Cold peripheries with SBP<90

53 Look for the cause of shock 1. Leakage - commonest 2. Haemorrhage 3. Leakage with haemorrhage

54 LEAKING CAUSING SHOCK 60% UOP

55 BLEEDING CAUSING SHOCK 30% UOP

56 Leaking and Bleeding 40% UOP

57 How do you diagnose the cause of Shock Do bedside PCV Leaking Bleeding Leaking + Bleeding /

58 PCV - 50 Case Scenario 2 Catheterized - only 50cc of residual for last 3 hours Connected to multipara monitor What is your fluid management

59 Rate of IV Fluid in Dengue Shock Syndrome 10 Rate of IV ml/kg/hr ( ml/hr) 5 ml/kg/hr ( ml/hr) 3 ml/kg/hr ( ml/hr) 3-1 ml/kg/hr (40-80 ml/hr) 2 Rate Hours after shock Shock (Rate in adult)

60 Case Scenario 2 500cc of N Saline infused over 1 hour Patients vitals still remain unstable after 1 hr UOP 10ml previous hour What is your next step Repeat PCV 15min after the bolus Apyrexial pulse 106 BP- 90/70 CRFT 3 sec PCV - 50 What is the expected PCV change

61 Expected PCV changes after bolus infusion Crystalloid 10ml/kg drop of 5 Dextran 10ml/kg- drop of 10 Dextran 5ml/kg - drop of 5 Blood 5ml/kg - rise of 5

62 Repeat PCV 52 Case Scenario 2 Patients vitals still unstable What is your next step? Repeat 500ml N saline bolus over 60min Apyrexial pulse 106 BP- 90/70 CRFT 3 sec PCV - 50

63 Case Scenario 2 Pulse 110,BP- 90/70 CRFT 3,UOP- 15ml Repeat PCV 51 What to do next? Apyrexial pulse 106 BP- 90/70 CRFT 3 sec PCV - 52 UOP- 10ml/hr Dextran 500ml bolus

64 COLLOIDS? WHAT & WHEN Dextran 40 is the best Given mainly as 10ml/kg/hr bolus Patients who are in shock and not responding to two boluses of crystalloid Maximum amount is 3 boluses in 24hrs

65 Case Scenario 2 After the dextran patient stabilised pulse - 78,CRFT<2 sec,bp- 105/70,UOP- 50ml Repeat PCV after 15min - 42,Platelets 18,000 What is your next step in fluid management Start crystalloid Apyrexial pulse 106 BP- 90/70 CRFT 3 sec PCV - 51 UOP- 10ml/hr What is the rate of fluid administration Started with 1.5ml/hr

66 Rate of IV Fluid in Dengue Shock Syndrome 10 Rate of IV ml/kg/hr ( ml/hr) 5 ml/kg/hr ( ml/hr) 3 ml/kg/hr ( ml/hr) 3-1 ml/kg/hr (40-80 ml/hr) 2 Rate Hours after shock Shock (Rate in adult)

67 Case scenario 2 Patients vitals after 3 hours pulse - 96, BP 95/70 UOP- 20ml/hr,PCV 46 When a patient is not responding to boluses what else do you need to consider? pulse - 78, CRFT<2 sec, BP- 105/70 UOP- 50ml PCV- 42 ABCS in Dengue

68 Acidosis NOT RESPONDING TO BOLUSES HAEMODYNAMIC INSTABILITY - ABCS Bleeding Calcium Sugar

69 Acidosis Venous gas is recommended Due to profound shock and contributes to DIC Needs early correction When ph <7.35/ HCO3 <15mmol/L NaHCO3 1ml/kg, slow bolus diluted in equal volume of N. saline Refractory acidosis is an indication for blood transfusion

70 Calcium Calcium leaks out with proteins Hypocalcaemia needs be corrected. 10% calcium gluconate 10ml over 10min Given empirically in profound leakers since Calcium levels are not freely available.

71 Case scenario 2 Patients vitals after 3 hours pulse - 96, BP 95/70 UOP- 20ml/hr,PCV 46 No acidosis on VBG Calcium gluconate was given as a slow bolus pulse - 78, CRFT<2 sec, BP- 105/70 UOP- 50ml PCV- 42 What is your fluid management? Fluids stepped up to 5ml/kg/hr for 2 hours and later gradually tailed off from 3ml to 1.5ml/kg/hr

72 Rate of IV Fluid in Dengue Shock Syndrome 10 Rate of IV ml/kg/hr ( ml/hr) 5 ml/kg/hr ( ml/hr) 3 ml/kg/hr ( ml/hr) 3-1 ml/kg/hr (40-80 ml/hr) 2 Rate Hours after shock Shock (Rate in adult)

73 Monitoring parameters during Rx 1-12 hours after shock hours after shock * Hct bring down if high Narrow Pulse pressure or high PCV may be ignored

74 Case Scenario 2 24 hrs after admission Pulse 60,BP - 110/70,PCV - 48,UOP - 30ml/hr Oral maintenance continued Platelets are picking up slowly 6 hrs later vitals remain the same PCV still 48 What phase of illness? What is your management?

75 Plasma leakage : Natural course in severe cases Shock Start Stop Equilibrium Reabsorption hours Plt < 100,000 cells/cumm Hct

76 Management of Equilibrium Phase Latter part or after end of leakage Do not try to correct PCV if the vitals are stable Close monitoring till the patient enters polyuric phase

77 Case Scenario 2 Patients vitals remained stable Patient became polyuric PCV gradually returned to baseline Discharged home 2 days later

78 Learning Points Diagnosis of Dengue shock Defining the cause of shock Management of Dengue shock due to leakage Use of colloids in Dengue ABCS in unstable dengue patients Stepping down the fluid regimen in critical phase Identification of Equilibrium phase in severe disease

79 Case Scenario 3 33 year old mother of 2 presented with a history of fever for 5 days,apyrexial since morning.she complaints of vomiting faintishness and reduced urine output. On examination she is apyrexial pulse BP- 98/70,CRFT 2sec Capillary PCV - 38, POC Ultrasound thin rim of fluid in Morrisons pouch with small R/Pleural effusion,little volume of residual urine in bladder.

80 What phase of illness Case Scenario 3 Critical phase What is the probable onset time of critical phase What is your fluid management Apyrexial 12hr Pulse BP- 98/70 CRFT 2sec PCV - 38 Leakage + 3ml/kg given for 2 hours

81 Case Scenario 3 after 2hrs What complication has occured Dengue shock What is the cause of shock Leakage/Bleeding Leakage + Bleeding Pulse 110 PCV 38 BP - 90/70 UOP- 10ml/hr What is your management Blood 5ml/kg

82 Leakage and bleeding 40% UOP

83 Case Scenario 3 Patients vitals improved marginally but a repeat 5ml/kg transfusion was given since the PCV didn t rise as expected With that the patient stabilised and the PCV and vitals remained stable Patient had uneventful recovery phase with adequate diuresis

84 Learning Points When to suspect concealed bleeding in dengue Leaking and bleeding can coexist in latter half of leakage If a patient is in shock PCV will help to define the aetiology

85 Case Scenario 4 18 year old schoolboy was transferred from a regional base hospital with worsening shortness of breath during management of the critical phase of dengue His weight is 56kg and has had 4800 ml of fluid into 40hrs of critical phase

86 Case Scenario 4 On arrival he has puffy eye lids RR - 36,Sat - 88% on room air pulse 112,CRFT >2 sec,bp- 90/70 clinical evidence of moderate R/ Pleural effusion UOP - 40ml for last 2 hours Inward PCV - 48 POC ultrasound confirms moderate pleural effusion and ascites

87 Case Scenario 4 What stage of illness Critical phase What complication/s has occurred Shock due to leakage Fluid Overload RR - 36, Sat - 88% Pulse 112 CRFT >2 sec BP- 90/70 UOP Mod effusion PCV- 48

88 Case Scenario 4 What is your fluid management Crystalloid/Colloid Colloid alone/colloid with frusemide Problems Fluid overload Fluid quota already finished Shock due to leakage

89 Fluid Overload in Dengue Usually second half/latter phase of leakage Only in profound leakers Excessive fluids during leakage Can be seen even with excessive oral intake Puffy eye lids, tacypnoea, tachycardia,low UOP Important to diagnose correctly

90 Case Scenario 4 Patient was given 250 ml Dextran within 30 minutes and Frusemide 10mg given midway Patient had a diuresis of 600 ml which relieved the respiratory distress PCV dropped to 44 from 48 Pulse - 96,BP - 100/70,RR- 26,Sat - 94%

91 Case Scenario 4 Patient had clinical evidence of pulmonary oedema PCV remained stable around 36 Patient was given 2 further doses of Frusemide 10mg 6 hrs apart Patient had good diuretic response and uncomplicated recovery phase

92 HALF BOLUS OF DEXTRAN 40 5ml/kg DEXTRAN 40 given over 30 minutes In practice the most useful and the commonest way of using Dextran Rising PCV where fluid quota is nearing completion In the descending limb of leakage/evidence of overloading given with Frusemide

93 Fluid over loaded patients UNSTABLE If in shock with High PCV 10ml/kg Dextran bolus over 1 hr with Frusemide 0.5mg/kg midway If in shock with Low PCV Blood transfusion with Frusemide midway STABLE If stable with High PCV Restrict fluids and observe If stable with Low PCV Restrict fluids & IV Frusemide 0.5mg/kg bolus check PCV after 1 hr

94 Learning Points Diagnosis of fluid overload in dengue Management of unstable fluid overload Management of stable fluid overload Clincal use of half Dextran with or without frusemide

95 What the local experts say! 99.99% of walked in patients who come to hospital with dengue should walk out from hospital! Even those who come in Shock but without Prolonged Shock should have >99% survival Except very RARELY a walked in dengue patient should not need an ICU bed or ventilator support It is achievable!!