Pearls and Pitfalls In the Management of Dengue Hemorrhagic Fever

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Pearls and pitfalls in DHF management

Dr. Aung Kyi WynnSenior consultant pediatrician

DENGUE2DefinitionAcute 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.3Causal Agent Dengue virus = Serotype 1- 4Infection with one type gives lifelong immunity for this type, but partial immunity for other types45

VectorTransmitted by Aedes aegypti.Bite during daytimeGrow in clear water

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Countries/areas at risk of dengue transmission, 2008

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(8-12daysvirus replicates)(3-14days avr 4-6 daysvirus replicates)Principal reservoir hostVirus multiplies in midgut, brain, body fat, salivary glandsMan-Mosquitoe-Man cycle(about 5 days)(about 5 days)9Awareness of DHFPearls - Aware and Recognize DHF

Pitfall Failure to get diagnosis of DHFCRITERIA FOR DENGUEProbable dengue-live in /travel to dengue endemic area.-Fever and 2 of the following criteria:Nausea, vomitingRashAches and painsTourniquet test positiveLeukopeniaAny warning sign

Laboratory-confirmed dengue(important when no sign of plasma leakage)

10Use of NS 1 AntigenNS 1 rapid tests (eg. SD BIOLINE) had similar diagnostic sensitivities ( 61.6% ) compared to RT PCR ( 62.4%) in confirmed casesBoth tests have 100% specificSensitivity become significantly improved (83.7%)when NS 1 and/or Ig G and/or IgM was positive.

Use of NS 1 Antigensignificantly 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 findingsHepatomegaly 87.5 %Pericholecystic oedema83%Gallbladder wall thickening80%Ascites74%Pleural effusion (Rt) 44%Splenomegaly3.4%Pleural effusion (Bilateral)2%(on third and fourth day of fever)

15CRITERIA FOR SEVERE DENGUE

Severe plasma leakageleading to:Shock (DSS)Fluid accumulation with respiratory distress

Severe bleedingas evaluated by clinician

Severe organ involvementLiver: AST or ALT 1000CNS: Impaired consciousnessHeart and other organs

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Bleeding in mesentry and intestinal wall18Many faces of DHFDHF with GEDHF with Asthmatic Bronchitis DHF with Appendicitis DHF with extreme drowsiness DHF with Hepatitis DHF with acute intravascular hemolysis 19&moDwkdif;wGif ? zsm;emvQif aoG;vGefwkyfauG;rSwf/20HESS TEST Pearls Proper doing and interpretation

Pitfall Wrong methods and interpretation21HESS TESTAppropriate cuff Exact 5 minutes Proper method Wait till the bluish discoloration gone 1 square inch square at maximum area

22HESS TEST - InterpretationNot any spot is positive > 20 positive 10-20 Equivocal < 10 Negative Be aware of false (+)

23Positive tourniquet test

Febrile, critical and recovery phases in dengue

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25Dengue case classification and level of severity

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A stepwise approach to the management of dengue

2829DETECTION OF SHOCK Pearls Predict or Detect in Time

Pitfall Failure to recognize shock 30DETECTION OF SHOCKWarn parents that fall in temperature is more important than fever

Afebrile with improvement or deterioration

Proper written instruction 31DETECTION OF SHOCKAt 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 reversed32

WHY DETECTION OF SHOCK IS IMPORTANTStagnant acidemia promote occurrence and enhanced severity of DIC33tzsm;uspOf? rvef;vQif tpOfowdcsyf/34WHEN TO ADMITPearls Proper admission

Pitfall Too early or late admission

WHEN TO ADMITDangerous 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 criteriaSigns and symptoms related to hypotension (possible plasma leakage)

Dehydrated patient, unable to tolerate oral fluidsGiddiness or postural hypotensionProfuse perspiration, fainting, prostration during defervescenceHypotension or cold extremities

37Admission criteriaBleeding 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

38Admission criteriaFindings through further investigations Rising haematocritPleural effusion, ascites or asymptomatic gall-bladder thickening

39Admission criteriaCo-existing conditionsPregnancyCo-morbid conditions, such as diabetes mellitus, hypertension, peptic ulcer, haemolytic anemias and othersOverweight or obese (rapid venous access difficult in emergency)Infancy or old age

40Admission criteriaSocial circumstancesLiving aloneLiving far from health facilityWithout reliable means of transport

4142WHERE TO ADMIT Pearls Close monitoring and Titration

Pitfall Inadequate monitoring & Inadequate experience

Management according to groups AC

Group A patients who may be sent homeGroup B patients who should be referred for in-hospital managementGroup C patients who require emergency treatment and urgent referral when they have severe dengue

43Group A (who may be sent home)Patients who do not have warning signs ORwho 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 failuresocial 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 distresssevere bleedingsevere organ impairment

46Group A patientTreatment

Advice for:adequate bed restadequate fluid intakeParacetamol, 3gram maximum per day in adults and accordingly in children.(10mg/dose)

Patients with stable HCT can be sent home

47Group A patientMonitoring

Daily review for disease progression:decreasing white blood cell countdefervescencewarning signs (until out of critical period).

Advice for immediate return to hospital if development of any warning signs, andwritten advice for management (e.g. home care card for dengue)4849Use of Drugs Pearls Use of appropriate Drugs and avoidance of unnecessary and dangerous drugs

Pitfalls Use of unnecessary and dangerous drugs50Use of DrugsUse Paracetamol only as antipyretic

Not need to have food

Avoid all others NSAID No Nimuslide, No Ibuprofen 51OTHER DRUGS ORS or Any fluid and Salt

Avoid unusual large amount especially in older children

? Antacids & Ranitidine

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

Treatment

Encouragement for oral fluidsIf not tolerated, start intravenous fluid therapy 0.9% saline or Ringers Lactate at maintenance rate

52Group B(with co-existing conditions or social circumstances)Monitor:temperature patternvolume of fluid intake and lossesurine output (volume and frequency)warning signsHCT, white blood cell and platelet counts

53Group B(with existing warning signs)Treatment

Obtain reference HCT before fluid therapyGive isotonic solutions such as 0.9 % saline, Ringers LactateStart 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

54Group 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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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 intakeHCT decreases below the baseline value in a stable patient

57Group B (with existing warning signs)Monitor

vital signs and peripheral perfusion (14 hourly) until patient is out of critical phaseurine output (46 hourly)HCT (before and after fluid replacement, then 612 hourly)blood glucoseother organ functions (renal profile, liver profile, coagulation profile, as indicated)

58Pearls and Pitfalls In the Management of ShockDSS 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 life-saving5960Pearls and Pitfalls in the Management of ShockVolume replacement should be monitored according to the rate of plasma leakage (PCV, vital signs, urine output) to avoid fluid over loadThe rate of leakage is more rapid in 1st 6 12 hrs Group C(Require emergency treatment)

Treatment of compensated shock

Start IV fluid resuscitation with isotonic crystalloid solutions at 510 ml/kg/hr over 1 hourReassess patients condition

61Group 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

62Group 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 aboveif HCT decreases, this indicates bleeding and need to cross-match and transfuse blood as soon as possible

63Group 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

64Group CTreatment of hypotensive shock

-If patient is still unstable:review the HCT taken before the 1st bolus;if HCT was low (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

66Group C(Require emergency treatment)Treatment of haemorrhagic complicationsGive 510 ml/kg of fresh packed red cells or 1020 ml/kg of fresh whole blood

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69Stagnant acidemia promote occurrence and enchanced severity of DIC

PRP transfusion as prophylaxis for bleeding in all shock cases is not recommended

Pearls and Pitfalls In the Management of Shock ( contd)Pearls and Pitfalls In the Management of Shock ( contd)There are abnormal haemostatic changes that potentiate bleeding in DHF/DSSSevere bleeding ( may be concealed ) often occurs in cases with prolonged shock and further perpetuates shock

7071Refractory 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 )Pearls and Pitfalls In the Management of Shock ( contd)72Major contributory factor to the high mortality ratefailure to recognize internal bleedingover transfusion with crystalloid and/or plasma fluid instead of bloodPearls and Pitfalls In the Management of Shock ( contd)73Pitfall------------ Too much rely on platelet count and PCVPearl------------ In conjunction with hemodynamic Status

Pearls and Pitfalls In the Management of Shock ( contd)Key decisionsWhen to give blood?

When to stop IV fluid or give diuretics?IV fluid therapyNarrow therapeutic indexTimelyAppropriate volumeRateAppropriate typeAppropriate duration(Fluid replacement- 40-60ml/kg)7576PREVENTION Pearls - Correct prioritization

Pitfall Just for show 77PREVENTIONLarva 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 78Prevention (contd)Key Container should not be in the vicinity where 3 -8 yrs old children are aggregatede.g. primary school, private tuition, day- care centreControl measures should be emphasized in these areasaoG;vGefwkyfauG;tE&m,fuif;*gxm&moDwkdif;wGif ? zsm;emvQif aoG;vGefwkyfauG;rSwf/tzsm;uspOf? rvef;vQif tpOfowdcsyf/

7980CONCLUSIONSIt 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 FAQSSecondary dengue infection Vs virulence theoryRole of corticosteroidTwo attacks of dengue in the same season?Importance of D/C diagnosis81FAQS cont.Role of OPD MORole of ward MORole of abateDengue vaccine

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83Thank you