09 lec - changing trends in dhf

8/8/2019 09 Lec - Changing Trends in DHF

1/71

Professor Siripen Kalayanarooj

Director, WHO Collaborating Centre forCase Management of Dengue/DHF/DSS,Queen Sirikit National Institute of Child Health,

Department of Medical Services,

Ministry of Public Health,Bangkok, Thailand.


2/71

Thailand Successful Story

DHF since 1958

2008: 90,322 Cases with 98 deaths,

CFR = 0.11%

Number of cases Case Fatality Rate

180,000 Cases


3/71

Dengue viruses isolates from

The Childrens Hospital1973 - 2004


4/71


5/71

Asymptomatic Sympto

Acute febrile illness Dengue fever Dengue hemorrhagic feve(Viral syndrome) (DF) (DHF)

no shock

Dengue viral infections

Plasma leakage

10,000

50 DF, 50 DHF

100400500

1,0009,000

1-248


6/71


7/71

Natural Course of DHF

Fever 2 7 Days Critical Period 24 48 hrs

Plasma leakage Abnormal hemostasis

Convalescence 3 7 Days


8/71

Virus isolationMosquito inoculation (intrathoracic)

Toxorhynchites splendensMosquito cell culture

C6/36 (Aedes albopictus)

Molecular techniques

Polymerase chain reaction(PCR)

Taqman

NS1 Ag

Day of Fever 2 4 6 8 10 12 14Days after infection

Shock

Hemorrhage

Hemagglutination Inhibition

Plaque Reduction Neutraliz

IgM and IgG ELISARapid tests: Dot blot, Im

Dipstick, Immunochromato

Anti-dengue IgM

Dengue Diagnosis

Manifestations:

ViremiaFever


9/71

Sensitivity in the febrile phase(First few days of fever)

PCR: >95% - expensive, not available inmost places

ELISA : 60% on the day of shock

30-40% one day before shock

100% one day after shock NS1Ag: 60-70%


10/71

Dengue diagnosis :

in death case

Armed Forces Research Institute of Medical Sciences


11/71

Early Diagnosis :

simple clinical & lab. Tourniquet test

CBC

At least day 3 of fever

CBC everyday if possible

Close follow up until 24 hours ofdefervescence

Tourniquet test positive + leucopenia*

= Dengue infection*Leucopenia = wbc 5,000 cells/cumm.


12/71

Tourniquet test

Fever day 150%

Fever day 2 70%

Fever day 3 > 90%False negative TT

Obese patients

Thin patients

Not good technique

During shock


13/71

Systolic + Diastolic

2 = 5 mins.

Tourniquet test


14/71

WBC 5,000 cells/cumm.

Early diagnosis Indicates: no fever within

the next 24 hours If DHF :oEntering critical stageoBeginning of plasma leakageoIf severe : aware/ prevent

shock? Is possible


15/71

Duration of fever in DHF patients

4,595 DHF patients, QSNICH

Duration of fever(day) %

2 2.16

3 10.074 41.01

5 30.946 11.51

7 2.16

>7 1.44


16/71


17/71


18/71

Prolonged shock > 10 hours untreated - Death!!!

> 4 hours untreatedLiver failure- prognosis 50%

Liver + Renal failure - prognosis10%3 organs failure (+respiratoryfailure) Prognosis is a miracle!!!


19/71

Day 1 2 3 4 5 6 7 8 9

Fever

WBC

WBC 7,900 5,000

Platelet count 230,000 100,000

Hct 40 46 50%

Albumin 3.5 gm%

Cholesterol 100 mg%

Hematocrit

Plasma leakage Stop leakage

Pleural effusion,Ascites

Reabsorption

Shock

IV fluid: NSS, DAR, DLRColloid: 10%Dextran,

10%Haes-sterilM+5% Deficit

(= 4,600 ml in adult)

Natural course of DHF



20/71

Indications for admission Shock Platelet 100,000 cells/cumm. c nogood clinical conditions; poor

appetite..o High risk patients: Obese, infants,bleeding, underlying diseases,

consciousness changeo No care-taker

o Live far away

o Mass-media families


21/71

Warning signs of shock

Clinical deterioration/ notimprove when no fever/ lowgrade fever

Abdominal pain

Vomiting Restless, shortness of breath,

persistent crying in infants Sweating, cold clamy skin Behavior change, drowsy No urine 4 6 hours


22/71

Early diagnosis of

dengue infections :

Tourniquet test and

CBC with follow-up

Advise warningsigns of shock inall patients with

suspected dengueinfections

Tourniquet test

CBC


23/71

Detection of shock : Difficult

Good consciousness

No fever and rapid pulse:Impending shock?

Narrowing of pulse pressure, e.g.

100/80, 110/90 mmHg Rapid/ weak pulse

Delay capillary filling time (>2 sec) Restlessness/ irritable

Speak fowl language, rude behavior


24/71

Delayed capillary refill time


25/71

Tender

Hepatomegaly


26/71


27/71

A 13-year-old girl, 70 kgs

Seen in an ER with no BP, confused,Had history of fever for a few days

and no fever today. Mom just found

her sleeping in her bed with cold,clammy skin.

Diagnosis???

Management???

21.00 PM


28/71

Chest film

Upright Right lateral decubitus


29/71

Rising Hematocrit ( 20%)

Problems :

No baseline Hematocrit known Not done frequent enough

Blood loss :

internal/ concealed bleeding

Hemolysis : thalassemia, G-6-PD


30/71

Ratio of Children : Adult Dengue

1997 - 2005

BoE, DDC, MOPH

Child < 15 years


31/71

C t it ti i


32/71

Current situation in

Thailand Adult dengue 60%

Oldest age 84 years (92 years?)Youngest age 16 hours (9 hours?)


33/71

IV fluid in critical period

(Platelet

100,000 cells/cumm.)

Start Isotonic salt solution

Amount = Maintenance + 5%Deficit in24-48 hours

Shock - 24 hours Non-shock 48 hours


34/71

Calculation of M + 5% Deficit

Maintenance: 10 kg. = 100 ml/ kg

10 kg = 50 ml/kg > 20 kg = 20

ml/kg5% Deficit = 50

ml/kg

Example: adult 50 kgs

M = (10 X 100 ml) +

(10 X 50 ml) +

(30 X 20 ml)

= 1,000 + 500 + 600

= 2,100/day = 87 ml/hr

5% D = 50 X 50 ml= 2,500

M+5%D = 2,100 + 2,500

= 4,600/day= 4,600/24 hr = 191.67 ml/hr

= 191.67/50 kg = 3.83 ml/kg/hr

Rate IV Fluid :


35/71

Rate IV Fluid :

Compare adult and childrenChild

(ml/kg/hr)

Adult

(ml/hr)

M/2 1.5 40

M 3 80

M +5%D 5 100-120

M +7%D 7 150

M + 10%D 10 300 - 500

Natural course of DHF


36/71

Day 1 2 3 4 5 6 7 8 9

Fever

WBC

WBC 5,000

Platelet count 100,000

Hct rising 20%

Albumin 3.5 gm%

Cholesterol 100 mg%

Hematocrit

Plasma leakage Stop leakage

Pleural effusion,Ascites

Reabsorption

Shock

IV fluid: NSS, DAR, DLRColloid: 10%Dextran,

10%Haes-sterilM+5% Deficit

(= 4,600 ml in adult)


Monitoring parameters


37/71

Monitoring parameters

clinical

Vital signs q 2 hours

Hct q 4-6 hours

Urine output(0.5 ml/kg/hr)


38/71

High risk patients

Infants

Obese patients Prolonged shock

Bleeding

Encephalopathy

Underlying diseases


39/71

Rate of IV Fluid in

Dengue Shock Syndrome

0

2

4

6

8

10

0 6 12 18 24

Rate

10- 5 ml/kg/hr (300-500 ml/hr)

5 ml/kg/hr (100-120 ml/hr)

3 ml/kg/hr (80-100 ml/hr)

3- 1 ml/kg/hr (40-80 ml/hr)

Hours after shock

Rate of IV

Shock (Rate in adult)


40/71

When not response to


41/71

When not response to

conventional IV fluid treatment

Hct:o Increase use Dextran

oDecrease Blood transfusion

Electrolyte Hypo Na, Hypo Ca Blood sugar - Hypoglycemia

Blood gas - Acidosis


42/71


43/71

Indications for colloidal solution

Signs of fluid overload : puffy

eyelids, distended abdomen, dyspnea/tachypnea, positive lungs signs(crepitation, rhonchi, wheezing)

Continue rising Hct/ persistent highHct or cannot reduce the rate of IVfluid in spite of adequate volume

replacement (R/O ASC and considerconcealed bleeding?) TOO MUCH IVFLUID AS CALCULATED as M+5% D


44/71

Choice of colloidal solutions in DHF

with massive plasma leakage

Plasma Expander only(Hyper-oncotic->300 mosm) :

o10% Dextran-40 in NSS (2.7 times)o10% Haes-steril (1.5 times)

Ch f ll d l l


45/71

Plasma Substitute : (can be used as initial

fluid resuscitation but not for massiveplasma leakage)

(Iso-oncotic 280 mosm) :

o FFPo Hemaccel

o 6% Haes-steril

o Gelefudin

o Voluven

Choice of colloidal solutions


46/71

Colloidal solution in DHFwith massive plasma leakage

rate 10 ml/kg/hr at a time

o Hct will drop 10

points Maximum dose 30 ml/kg/day

C t ll id C ll id


47/71

Colloid

15 USD/ 500 ml

Crystalloid

1 USD/ 500ml

Crystalloid v.s. Colloid

Albumin

50 USD/ 50 ml

(Not recommend becauseoften report of acute

pulmonary edema/ heart

failure)


48/71

Rate of IV Fluid in

Dengue Shock Syndrome

0

2

4

6

8

10

0 6 12 18 24

Rate

10- 5 ml/kg/hr (300-500 ml/hr)

5 ml/kg/hr (100-120 ml/hr)

3 ml/kg/hr (80-100 ml/hr)

3- 1 ml/kg/hr (40-80 ml/hr)

Hours after shock

Rate of IV

Shock (Rate in adult)


49/71

0

2

4

6

8

0 6 12 18 24 30 36 42 48

Rate

Rate of IV Fluid in

Dengue Hemorrhagic Fever grade I & II

Hours after

leakage

7 ml/kg/hr

1.5ml/kg/hr 3- 5 ml/kg/hr

Plt < 100,000 cells/cumm.Hct rising 10-20%

0

2

4

6

8

0 6 12 18 24 30 36 42 48

Rate

Rate of IV Fluid in

Dengue Hemorrhagic Fever grade I & II

Hours after

leakage

7 ml/kg/hr (100-120 ml/hr)

1.5 ml/kg/hr (40 ml/hr) 3- 5 ml/kg/hr (80-120 ml/hr)

(Rate in adult)

Plt < 100,000 cells/cumm.

Hct increase


50/71


51/71

ICD obtained effusion1860 ml =42 ml/kg(maintained for 3 days)

Blood transfusion


52/71

Blood transfusion

10-15% of DHF cases

Prefer whole blood (WB) if no sign offluid overload and pack red cell (PRC)in cases with fluid overload

Give equal to the amount estimated If cannot estimate: give WB 10 ml/kg

or PRC 5 ml/kg to increase Hct by 5points at a time (adult give 1 U ofWB or PRC to increase Hct by 3-4

points at a time)

Platelet (plt ) transfusion


53/71

Platelet (plt.) transfusion

0.4% in DHF cases who need bloodtransfusion

No prophylaxis plt. transfusion inchildren, no matter how low is the plt.count

In adult age >35 years, especially thosewith underlying hypertension, coronary

heart diseases give plt. tranfusion ifplt. < 10,000 cells/cumm.

Plt. 1 Unit = 50 ml

Recombinant factor VII


54/71

Recombinant factor VII

1 dose = 1,500 USD in a 10-kgspatient

No use in cases with prolonged shockand multiple organs failure

Consider in cases with bleeding causesis not from prolonged shock: pepticulcer, trauma

Convalescent rash


55/71


56/71

Plasma leakage :Natural course in sever cases

0 24 48 72 hours

Reabsorption

Shock

Start

Equilibrium

Plt < 100,000 cells/cumm

Hct

Stop


57/71

Causes of death in DHF


58/71

Aug 07-Mar 08 32 cases:

o

Adults 18 (56.25%)o Children 14 (43.75%)

Overweight: 19 (59.4%)

Delayed Diagnosis: 22 (68.75%)o Fluid overload 24 (75.0%) - IPD

o Prolonged shock 8 (25.0%) OPD

o Massive bleeding (initially) - 0

Major causes of death in DHF


59/71

Major causes of death in DHF

Bleeding


60/71


61/71

Dengue Fever Headache Retro-orbital pain

Myalgia Arthralgia/ joint pain

Rash Bleeding manifestations: petechiae, TT+ve Leucopenia (wbc 5,000 cells.cumm.)

Diagnosis :Tourniquet test positive +Leucopenia

PPV 80%


62/71

DHF severity


63/71

Plasma leakage

Grade I - Only positive tourniquettest

Grade II With spontaneous bleeding

Grade III - Shock/ impending shock

Grade IV Prolonged shock (no pulseor BP measureable)

DENCO Partners


64/71

Venezuela

Antwerp,

Belgium

Philippines

Heidelberg,

Germany

Vietnam

Malaysia

Thailand

TDR/WHO,

Geneva

Europe

Latin America

Asia

Cuba

Liverpool

,UK

Nicaragua

Brazil

SEVERE DENGUEDENGUE

Revised Dengue Classification

Warning Signs


65/71

SEVERE DENGUE

1.Severe plasma leakage2.Severe haemorrhage3.Severe organ impairment

WithoutWithWARNINGSIGNS

Warning Signs* Abdominal pain or tenderness Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy; restlessness Liver enlargement >2cm Laboratory:Increase in HCT

concurrent with rapid decreasein platelet count

1. Severe plasma leakage leading to Shock (DSS) Fluid accumulation withrespiratory distress

2. Severe bleedingas evaluated by clinician

3. Severe organ involvement Liver:AST or ALT>=1000

CNS:Impaired consciousness Heart and other organs

Probable DengueLive in / travel to dengueendemic area. Fever and 2

of the following criteria: Nausea, vomiting RashAches and painsTourniquet test +ve LeucopeniaAny warning sign

* Requiring strict observation and medical intervention

g g

Lab. confirmed dengue(important when no sign of plasma leakage)

Hotline DHF:


66/71

+6689-2045522 M.D.+6689-2042255 GN.

2008 200+ casesconsulted and 90%were saved

Outcome Measures


67/71

Decrease case fatality rate of DHF/DSS

Decrease severity/ complications inDHF/DSS patients

(Shock/ Fluid overload)

DHF Patient CareTeam


68/71

: .() .. .. .. ..() .. :

: .() .. : : :

..

International Training Course


69/71

MD. & GN. 2-week Course : Lectures, casediscussion & lab. practicals

Include: visit vaccine center & one-day field trip

29th June 10th July 2009 Apply thru WHO country office orother Institutions

Course fee 1,200 USD perparticipants


70/71


71/71

Best Center of Excellence :DHF 2006

Extreme Award forNetworking 2007

Best Woman Doctor2006

09 lec - changing trends in dhf

Documents