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Dengue hemorrhagic fever and Dengue shock syndrome- Severe Dengue Fever
Outlines
Clinical presentationsLaboratory examinationsDiagnosisManagement
Clinical Presentations
Before admissionFever Vomiting, watery diarrhea with blood in stool Periumbillical abdominal pain for 1 dayAfter admissionCold peripheral perfusion, mottled skin, shortness of breathFresh blood from NG tube, mouth, endotracheal tube, anal tube Diffuse petechiae over trunk
Laboratory Examinations (1)
WBC (/uL)5800 D127700 D25band (%)15 D1Platelet (/uL)14000 D1CRP (mg/ml) 88.8 D1 146.9 D8PCT (ng/ml)2.73 D1 23.15 D12Dengue NS1 Ag rapid test (+) D1
Laboratory Examinations (2)
Hb (g/dL)18.9 D1 7.9 D4Hct (%)51.6 D127.9 D5PT/APTT (Sec)14.4 /48.0 D115.1 /59.6 D3D-Dimer (ng/ml)7463.4 D1FDP (ug/ml)27.6 D1Fibrinogen (mg/dL)231 D1
Laboratory Examinations (3)
Lactate (mmol/L)4.1 /7.9 D1/D3PO2/FiO2 (mmHg)76.6 /66.3 D2/D4(Day 4) CPPV mode, Vt: 360 ml, PEEP: 18 cmH2O, FiO2: 100%, PIP: 42 cmH2O, Pplateau: 40 cmH2O, Fetanyl + Ativan + NimbexGOT/GPT (U/L)4319 /1366 D17718 /1257 D2Bil-T/D (mg/dL)4.45 /3.17 D118.54 /13.78 D19Ammonia (umol/L)135 D2
Laboratory Examinations (4)
BUN/Cr. (mg/dL)50 /4.14 D1194 /12.46 D21Amylase (IU/L)225 D2931 D7Lipase (IU/L)594 D21359 D7Abdominal CT: diffuse mild swelling of pancreas D11Albumin (g/dL)3.7 D11.8 D3
Diagnosis
Severe Dengue fever (Dengue hemorrhagic fever and Dengue shock syndrome) withacute hepatitis, acute kidney injury, disseminated intravascular coagulation, gastrointestinal bleeding, acute pancreatitis,probable coexisting bacterial infection and severe sepsisacute respiratory failure s/p mechanical ventilation
Management
Treat underlying diseasesDengue & coexisting bacterial infection: inflammation, bleedingHospital acquired infection: VAP, catheter related sepsisHemodynamic support and Fluid status managementPerfusion pressure, perfusion, O2 delivery, intravascular volumeInternal and external fluid statusMechanical ventilationLung protective ventilatory strategy
Underlying diseases (1)
BleedingDiffuse bleedingPlatelet PT/APTT Hb Hb (g/dL) D1:18.9 - D4:10.5Plt: (/uL) D1:14K - D4:55KPT (Sec) D1:14.4 - D4:12APTT (Sec) D1: 48 - D4:46.7PRBC:10U FFP:38UPlt:7U Cryo.:20UCNSPain, agitation, deliriumSedation withdrawalFetanyl + Ativan + Nimbex
PIP < 35 cmH2O, FiO250%,PPEP 10cmH2O, GI work
Tramadol, Zyprexa zydis, Haldol,Ativan, Etumine, Mesyrel, Inderal
Underlying diseases (2)
CirculationCold peripheral perfusionElevated lactate levelD2:cold D4: warmLac.(mmol/L) D3: 7.9 D5: 2.0D1-3: + 22600 mlD2:GEDI/CI (626/4.27)D3:GEDI/CI (787/5.64)D4:GEDI/CI (766/3.89)LungAcute pulmonary edema, mixed typePO2/FiO2D2:76.6D3:119D4:66.3
Underlying diseases (3)
GIUGI bleedingIleusGastroparesisPPIProkinetics: promeran, moprideNJ tubeLiverAcute hepatitisJaundiceHyperammonemiaNutrition support (parenteral and enteral)Urso
Underlying diseases (4)
KidneyAcute oliguric renal failureFluid (Crystalloid firstly, colloid)DiureticsCVVHH/DRecirculation problemPancreasAcute pancreatitisSupportive carePain control + Nutrition support
Underlying diseases (5)
InfectionCommunity acquiredHospital acquiredAntibiotics ???Fever (adrenal insufficiency?)WBC/band%PltCRP/PCTEndocrineType 2 DMRelative adrenal insuffiiciencyInsulinSteroid
Hemodynamic support
&
Fluid status management
Everyday in ICU
Hemodynamic StatusFluid Status Evaluationhydrostatic pressure/permeability/oncotic pressurePerfusion pressure
Perfusion (Flow, Cardiac output)
Oxygen delivery (C.O, Hb, SaO2) Int. human bodyExt. human bodyPulmonary edemaPul. congestionPleural effusionAscitesBowel edemaScleraScalpTrunkLimbsInner side of thighGenital area
Fluid choice: Crystalloid or Colloid?
Hydrated status
Dehydrated
Normal hydrated
EdematousAlbumin level
Chemosis
Peripheral edema
PermeabilityNa+
K+
Cl-Crystalloid
0.9% N/S
Lactated Ringers
Colloid
Hemodynamic Status on Day 4
Adequate perfusion pressureBP: 113/75 mmHgMAP: 89 mmHg Adequate perfusion (cardiac output)Cold to Warm PerfusionSVI: 23 to 41 ml/m2CI: 2.72 to 3.81 L/min/m2Adequate O2 delivery (Q, Hb, SaO2)Lactate: 7.9 to 2.4 mmol/L(Lactate: 2.0 mmol/L D5)Adequate Intravascular VolumeGEDI: 569 to 766 ml/m2
Fluid Status Management (1)
Fluid Status Management (2)
Day 4
Day 15