Dengue Fever & Dengue Shock Syndrome. 07-May-18 PLES / SLCP 1
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1 Dengue Fever & Dengue Shock Syndrome 07-May-18 PLES / SLCP 1
2 Objectives Early diagnosis Pathophysiology of DHF Proper management How to avoid complications Case 07-May-18 PLES / SLCP 2
3 Febrile Phase High fever 2-7 days Facial flushing +ve TT Haemorrhaegic diathesis Enlarged liver 07-May-18 PLES / SLCP 3
4 Early diagnosis of Dengue High fever, No coryza FBC in day 3 WBC < 5000 Platelet count < Hess s test positive NS1 Ag Day May-18 PLES / SLCP 4
5 DF Vs DHF DF DHF No plasma leakage Evidence of plasma leakage 07-May-18 PLES / SLCP 5
6 Febrile Recovery Febrile Recovery Febrile Febrile CRITICAL Recovery Recovery 07-May-18 PLES / SLCP 6
7 DF Febrile phase Adequate rest at home Adequate amount of oral fluid intake Paracitamol only (Oral or PR) No NSAID drugs Monitor for warning signs Monitor with FBC 07-May-18 PLES / SLCP 7
8 DF Critical Phase 3-5 days Rapid drop of temp Capillary leak (24-48hrs) Pulse pressure narrowing Abdominal pain FBC HCT & Platelets +/- Liver derangements Hypoalbunaemia 07-May-18 PLES / SLCP 8
9 DF Critical Phase Identify the beginning of the capillary leak Platelets < PCV rise towards 10% 20% Pleural effusions (detected by clinically, by USS) Ascites (detected by clinically, by USS) Low albumin / Low cholesterol? 07-May-18 PLES / SLCP 9
10 Critical phase Capillary leak Fluid leak in to 3 rd space (pleural space & ascites) Hypovolaemia Shock MODS (poor organ perfusion) Death 07-May-18 PLES / SLCP 10
11 Fluids How much? ; How long? Identify the beginning of the leak Predict the end Try to give only M+ 5% of fluids / 48hrs Match the leak 07-May-18 PLES / SLCP 11
12 Rate IV Fluid : Compare adult and children 07-May-18 PLES / SLCP 12
13 How to Match the leak UOP 0.5 ml/kg/hr Only objective parameter PCV (every 4 6 hourly) Pulse volume Peripheral coldness CRFT BP 07-May-18 PLES / SLCP 13
14 Management of leaking phase Minimal fluids in febrile phase Sufficient fluids in critical phase Calculate fluid for the ideal body weight in obese children Minimal fluids in recovery phase 07-May-18 PLES / SLCP 14
15 Indications for urinary catheterization All high risk patients during the critical phase Patient with 1 st shock Patient with complications Platelets <50, May-18 PLES / SLCP 15
16 Case History on Admission to 3 days Clinical Scenario 4 years old child, weight-15kg Commence Specific Treatment WBC 3500, N-27%, L-62% Platelets 98,000 PCV 36.3% PCV monitoring Maintenance IV drip 07-May-18 PLES / SLCP 16
17 Child developing leaking while in the hospital 07-May-18 PLES / SLCP 17
18 Case History - 8hrs after admission Clinical Scenario RR-22/min Extremities cold, Pulse thready, CRFT >4 seconds, BP was 80/65 (normal). Liver 4cm. A V P U PCV 45% Commence Specific Treatment & Monitoring 0.9% Saline 10ml/kg bolus over 1 hour Cathereterize Urine output (0.5-1 ml/kg/hr ) 07-May-18 Compensated PLES / SLCP shock 18
19 How do you adjust the drip rate 10ml/kg/hr 7ml/kg/hr 5ml/kg/hr 07-May-18 PLES / SLCP 19
20 When the patient is not improving Acidosis Bleeding Calcium & electrolytes Sugar 07-May-18 PLES / SLCP 20
21 Case History 12 hrs after admission Clinical Scenario RR-22/min pretty cold, pulse very thready, CRFT 5 seconds, BP was 40/00. A V P U Vomiting coffee ground stuff. PCV 50% Repeat SGPT-1273, SGOT-1023 Commence Specific Treatment & Monitoring 40% Dextran bolus 10ml/kg over an hour Followed by 0.9% N.S 10ml/kg over 1 hour fluid to maintain urine output > 0.5ml/kg/hr Only objective parameter) 07-May-18 Uncompensated PLES / SLCP shock 21
22 Simulating natural course Natural course Admitted with shock 07-May-18 PLES / SLCP 22
23 Case History 26 hrs after admission Clinical Scenario Commence Specific Treatment & Monitoring RR-22/min Cold pulse was moderate CRFT 3 seconds, BP 90/65. Pack cell transfusion 5ml/kg fluid to maintain urine output > 0.5ml/kg/hr A V P U PCV 35% (dropped) 07-May-18 Acute Bleed PLES / SLCP 23
24 Case History 35 hours of leak Clinical Scenario Received 120% fluid quota. Responding to questions, RR-40bpm, reduced AE on the both side, SpO2 94% with face mask O2, pulse low volume with cold up to wrist. Abdomen is distended with asicitis. PCV is rising 40% Commence Specific Treatment & Monitoring 40% Dextran bolus 10ml/kg over an hour with frusemide infusion / Bolus Fluid to maintain urine output > 0.5ml/kg/hr & organ perfusion 07-May-18 Fluid Overload PLES / SLCP 24
25 High risk patients Infants Obese patients Prolonged shock Bleeding Encephalopathy Underlying diseases Pregnancy 07-May-18 PLES / SLCP 25
26 07-May-18 PLES / SLCP 26
27 Summary Early diagnosis Pathophysiology of DHF Rational fluid management How to manage complications 07-May-18 PLES / SLCP 27
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