MODULE 8B: Management of Group B Dengue with Warning Signs or Dengue with Co-existing Conditions

Transcription

1 MODULE 8B: Management of Group B Dengue with Warning Signs or Dengue with Co-existing Conditions Dengue Clinical Management Acknowledgements This curriculum was developed with technical assistance from the University of Malaya Medical Centre. Materials were contributed by the Ministry of Health, Singapore, the United States Centers for Disease Control and Prevention, and the University of Malaya Medical Centre.

2 Summary of management of dengue Group A Sent home (all of following) Getting adequate volume of oral fluids Passing urine at least once every 4 to 6 hours No warning signs Has stable hematocrit and is hemodynamically stable Does not have co-existing conditions Group B (any of following) Has warning signs Has co-existing condition: Diabetes mellitus, renal failure, pregnant, infant or elderly Has social circumstances: Living alone or living far away without a reliable means of transport Group C (any of following) Severe plasma leakage with shock and/or fluid accumulation with respiratory distress Severe bleeding Severe organ impairment: AST or ALT 1000 and/or impaired consciousness 1. Give anticipatory guidance before sending home (see patient handout) 2. Follow up daily 3. Do serial CBCs 4. Identify warning signs early 1. Admit for inpatient care 2. Monitor haemodynamic status frequently 3. Use HCT to guide interventions 4. Use isotonic IV fluids judiciously 5. Correct metabolic acidosis, electrolytes as needed Requires emergency treatment and urgent referral

3 Group B: Dengue with warning signs (not in shock) Inpatient fluid management Obtain reference HCT before starting IVF therapy Improved Start with isotonic crystalloids 5 7 ml/kg/hr for 1 2 hours IV isotonic crystalloids^ 3 5 ml/kg/hr for 2 4 hours *REASSESS * Reassess haemodynamic state 1. Vital signs 2. 5-in-1 magic touch : CCTV-R Colour Capillary refill time Temperature Volume of pulse Rate 3. Urine volume IV isotonic crystalloids^ 2 3 ml/kg/hr for 2 4 hours Clinical improvement or improved oral intake, reduce IVF accordingly If improvement in oral intake, HCT remains same or minimal high: 1. Step-wise reduction in IVF 2. Consider glucose-electrolyte for children Stop IVF therapy within hours Continue to monitor patient until out of critical period Stop IVF within hours

4 Group B: Dengue with warning signs (not in shock) No improvement after first bolus Obtain reference HCT before starting IVF therapy Start IV isotonic crystalloids 5 7 ml/kg/hr for 1 2 hours * Reassess haemodynamic state: Vital signs 5-in-1 magic touch CCTV-R Urine volume *REASSESS Not improved Check haematocrit If there is NO improvement, check HCT If HCT is increasing or high, increase IV crystalloids to 5 10 ml/kg/hr for 1 2 hours Increasing or high HCT Increase IV crystalloids to 5 10 ml/kg/hr for 1 2 hours * Reassess

5 Group B: Dengue with warning signs (not in shock) No improvement after first bolus (cont.) Obtain reference HCT before starting IVF Start IV isotonic crystalloids 5 7 ml/kg/hr for 1 2 hours Improved *REASSESS Not improved IV crystalloids 3 5 ml/kg/hr for 2 4 hours Check haematocrit IV crystalloids 2 3 ml/kg/hr for 2 4 hours Increasing Or high HCT Decreasing HCT Clinical improvement or improved oral intake, reduce IVF accordingly Increase IV crystalloids 5 10 ml/kg/hr for 1 2 hours Bleeding? Consider "Severe Dengue" algorithm Stop IV fluids at 48 hours * Reassess the patient s clinical condition (vital signs, 5-in-1 magic touch CCTV-R and urine output) and decide on the situation.

6 Dengue WITH warning signs What do you monitor? Document disease progression and defervescence Monitor until risk period is over (24 to 48 hrs after defervescence). Watch for signs of plasma leakage, shock and bleeding Maintain detailed fluid balance oral fluids, IV fluids and urine volume Empower patients or parents to document intake and output Monitor parameters including: vital signs and peripheral perfusion (every 1 to 2 hours until out of critical phase) HCT (before and after IVF therapy, then every 6 to 8 hours) blood glucose (every 6 to 12 hours or as indicated, consider glucoseelectrolyte solutions for children) electrolytes and organ functions as indicated by clinical status (LFT, acid base) DENCO Slide

7 Group B: Dengue WITH co-existing conditions but without warning signs If patients are/have: Pregnant Infants Elderly Diabetes mellitus Hypertension Ischaemic heart disease/heart failure Liver cirrhosis Chronic renal failure Chronic lung disease Haemolytic disease G6PD deficiency, thalassaemia Poor social conditions living alone, no transport Admit early (in febrile phase) Monitor baseline HCT Monitor glucose and blood pressure

8 Group B: Dengue WITH co-existing conditions but without warning signs (cont.) Encourage oral fluids If not tolerated, start IV fluids (0.9% saline or Ringer s lactate solution) with or without dextrose at maintenance rate Patients may be able to take oral fluids after a few hours of IV fluid therapy. Reduce IV fluids in a step-wise approach. Avoid fluid overload. Monitor: Temperature pattern, especially defervescence Hydration status: oral intake, IV fluids, losses and urine output Haematocrit, white blood count and platelet count