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Dengue Fever & Dengue Shock Syndrome
07-May-18 PLES / SLCP 1
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Objectives
Early diagnosis
Pathophysiology of DHF
Proper management
How to avoid complications
Case
07-May-18 PLES / SLCP 2
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Febrile Phase
• High fever 2-7 days
• Facial flushing
• +ve TT
• Haemorrhaegic diathesis
• Enlarged liver
07-May-18 PLES / SLCP 3
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Early diagnosis of Dengue
• High fever, No coryza
• FBC in day 3• WBC < 5000• Platelet count <150000
• Hess’s test – positive
• NS1 Ag• Day 1-3
07-May-18 PLES / SLCP 4
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DF Vs DHF
DF
• No plasma leakage
DHF
• Evidence of plasma leakage
07-May-18 PLES / SLCP 5
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Febrile
RecoveryCRITICALFebrile
Recovery
Febrile
Febrile
Recovery
Recovery
07-May-18 PLES / SLCP 6
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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
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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
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DF – Critical Phase Identify the beginning of the capillary leak
• Platelets <100000
• 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
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Critical phase – Capillary leak
Fluid leak in to 3rd space (pleural space & ascites)
Hypovolaemia
Shock
MODS (poor organ perfusion)
Death 07-May-18 PLES / SLCP 10
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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
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Rate IV Fluid : Compare adult and children
07-May-18 PLES / SLCP 12
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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
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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
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Indications for urinary catheterization
•All high risk patients during the critical phase
• Patient with 1st shock
• Patient with complications
• Platelets <50,000
07-May-18 PLES / SLCP 15
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Case History – on Admission to Hospital @ 3 days
Clinical Scenario
• 4 years old child, weight-15kg
• WBC –3500, N-27%, L-62%
• Platelets – 98,000
• PCV – 36.3%
Commence Specific Treatment
•PCV monitoring
•Maintenance IV drip
1607-May-18 PLES / SLCP
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Child developing leaking while in the hospital
07-May-18 PLES / SLCP 17
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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 )
PLES / SLCP Compensated shock 07-May-18 18
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How do you adjust the drip rate
• 10ml/kg/hr
• 7ml/kg/hr
• 5ml/kg/hr
07-May-18 PLES / SLCP 19
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When the patient is not improving
Acidosis
Bleeding
Calcium & electrolytes
Sugar
07-May-18 PLES / SLCP 20
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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 PLES / SLCP 21Uncompensated shock
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Simulating natural course
Natural course Admitted with shock
07-May-18 PLES / SLCP 22
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Case History – 26 hrs after admission
Clinical Scenario
• RR-22/min
• Cold
• pulse was moderate
• CRFT – 3 seconds,
• BP 90/65.
• A V P U
• PCV – 35% (dropped)
Commence Specific Treatment & Monitoring
Pack cell transfusion 5ml/kg
↑ fluid to maintain urine output > 0.5ml/kg/hr
PLES / SLCP Acute Bleed07-May-18 23
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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
PLES / SLCP Fluid Overload 07-May-18 24
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07-May-18 PLES / SLCP 25
High risk patients
• Infants
•Obese patients
• Prolonged shock
•Bleeding
• Encephalopathy
•Underlying diseases
• Pregnancy
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07-May-18 PLES / SLCP 26
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Summary
Early diagnosis
Pathophysiology of DHF
Rational fluid management
How to manage complications
07-May-18 PLES / SLCP 27