DENGUE FEVER

DENGUE FEVER

TO FIGHT THE ENEMY IS TO UNDERSTAND ITDilemma THINGS ARE COMPLICATED!

VERY ATYPICAL PRESENTATION

2RATHERTO SUMMARISE WHAT YOU AND I ALREADY KNOWN

COMPLICATION/warning signs?HistoryTakingPhysicalExaminationLabTestManagement-increase @reduce drip?3For a disease that is sooooo dynamic senang je management give enough fluids not too much and not too little

5Febrile Phase 2 7 daysFever is often accompanied byFacial flushing, skin erythema, generalised body ache, myalgia, arthalgia and headacheAnorexia, nausea and vomiting (warning sign for dengue) are commonMild hemorrhagic manifestations may be seenThis may include positive tourniquet test, petechiae or mucosal bleedingEarliest abnormality in FBC is a progressive decrease in total WBC count

5Bleeding: give bolus fluid artificial leak in febrile phase then will leak more in critical phase. Shock fluid: large 30cc/kgDengue fluid: 25 cc/kg crystalloidsPetechiae mucosal haemorrhage mainly platelets less than 20,000.

Neurological manifestationEncephalopathyEncephalitisRarely myelitis, GBSAcute AbdomenAcalculous Cholecystitis (epigastric pain worries of dengue gastropathy do ultrasound see gall bladder distended typical of dengue)Liver Failure (fulminant hepatitis)KKM UMMC 2006Unusual presentation6Bangladeshi patients have bradycardia and fever (should be typhoid but is dengue) check for myocarditis.Acute cholecystitis needs immediate ultrasound and surgery.Q:WHY IS CRITCAL PHASE IMPORTANT?

7Critical PhaseUnlike other viral infection afebrile means RECOVERY.

But in dengue it may mean the beginning of PROBLEMS

Critical phase =leakage.- in certain gp of patients.Some recover without complication ( no capillary leakage)89Critical Phase Occurs eitherTowards the late febrile phaseOften after 3rd day of feverorAround defervescenceUsually between 3rd day to 5th day of fever; but may go up to the 7th day of fever.This phase lasts for 24- 48 hours9Lasts for 48 hours (time patients)Problem to look at temperature patients go to GP given analgesics interrupt the fever pattern (must always ask patients what medication they are on)NSAIDs predisposes patients to peptic bleeding

Understand the terminologiesLEAKAGEMarked by the evidence of warning signs (vomiting)Usually accompanied by rise in HCT, preceeds the onset of tachycardia and hypotensionLasts 48 hrs (can be early as 24 hours)

DEFERVERSCENCEMay nor may not leakUsually when temp < 38

10Its a dynamic processDegree of HCT increase may be diminished by early fluid therapyWe need frequent hct determination.Free fluid determined by presence of Ascites---- by usgPleural effusion by usg Gallbladder edemaHemorrhagic manifestation11

AST >500 start patients on N-acetylcysteine (dengue and hepatitis) evidence: start early, the recovery is good.AST is usually higher than ALT in dengueLactate level increase unable to function make sure liver is functioning

12Recovery Phase Follows the critical phaseGradual resorption of the extravascular fluid takes place next 48-72hrs.Improvement of symptomsRash may appear, pruritic/ classical islands of white in a sea of red.HCT-back to baseline or may even be lower ( reabs)BUT MAY BE A NIGHTMARE if overzealous with fluidsSea of red (pathological) and islands of white (patients skin)HCT: reabsorption happens 13Complications that may encounter at different phases

14Severe dengueOne or more of the following(i) severe plasma leakage that leads to shock (dengue shock) and/or fluid accumulation with respiratory distress;(ii) severe bleeding;(iii) severe organ impairmentClinical examination- recognise early shock pleaseTachycardia in the absence of fever Quiet tachypnoea without the effortCompromised CRT (capillary refill time)Rising diastolic, pulse pressure less than 20mmhgA low bicarbonate, higher lactate, compensated metabolic acidosis A relatively normal or low HCT in the presence of shock.. Think of dengue shock with occult bleeding.Intravascular volume depleted due to bleed or leak tachycardia.Diastolic blood pressure increase, then patient goes to shock. It is an early sign of compensated shock.Venous blood test: look at bicarbonate and lactate (increase in shock)

16History Taking

Physical Examination

CRT, pulse rate and blood volume imprtant Collection of fluid in lung and abdomenRashDont do tourniqet test consume platelets18Whats the next stepCommit to a diagnosis----Which phase of illnessLeaking or notDeferversced or notGet all the information needed and available and make a decision --- dont jump on one parameter.NotifyLeaking stage: monitor 4 hourly

19Whom to admit group BWarning signsSevere comorbidity: elderly, obesity, infancy, pregnancy, heart failure, renal failure etcPoor social circumstancesWarning signs (definitely!)Manage fluids adequately

Pregnant women with dengue definitely admit! Very cautious when dealing with pregnant women.

20Group C patientsSevere plasma leakage with shock and?or fluid accumulationSevere BleedingSevere organ impairmentManagement: divided into compensated shock or decompensated shock

22Estimated Ideal Body Weight Based on Height and Estimated Normal Maintenance Fluid Regime for FemaleHeight ( )Height (cm)Estimated IBW (kg)Normal Maintenance Fluid Regime (ml/hr)5 15245855115547875316052925 5 16556965717061101591756610651118070110611857511523Dehydrated patients do not give bolus but maintenance fluid regime In obese patients, do not use their weight but use the ideal body weight (do not want to give them excessively)

Estimated Ideal Body Weight Based on Height and Estimated Normal Maintenance Fluid Regime for MaleHeight ( )Height (cm)Estimated IBW (kg)Normal Maintenance Fluid Regime (ml/hr)5 15250905115552925316057975 5 1656210257170661065917571111511180751156118580120631908412424Pearls of Management USE IDEAL BODY WEIGHT---- train yourself to do it not when only asked!!!!!!Get HELP: Anaes, ID, specialist oncallIts a judgement call that needs to be made AT THAT TIME not sometime today/tomorrow At every review: commit to the following: peripheral warmth, CRT, pulse volume( not just rate) and bp, lab ix, presence/reduction/ absence of warning signs, intake output charting. ---------- MAKE A HOLISTIC DECISION!!!!!!!--------------Pearls of Management - contsTry and use the guidelines as a guide alone ( but its pretty cool and comprehensive)Obtain referrence hct before and after fluid resuscObtain vbg, rp, lactates regularly, fbc 2 hrlyIf HCT improves--- cut down!If HCT does not improve:If increased repeat the bolus either 10- 20 mls/hrIf reduced and hemodynamically unstable--- occult bleeding26

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Do not write query denguePatient is leaking have to monitor 4 hourly29

Hypertensive patients mean arterial pressure targeted is 100.Normal is 70. 30

When there is improvement, step down slowly ; need to do FBC every hour.Colloid is larger can stay in intravascular space longer

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Decompensated shock we give blood early34Choice of fluidsNo advantage of using colloids or crystalloidsColloids better at restoring Bp urgently , reducing HCT faster ( best data with voluven)Most have their own limitationsCrystalloids 0.9% normal salineBest for resuscitation intiallyNormal anion gap hyperchloraemic acidosisRingers lactateGood alternative if the cl is increasing trend--- caution in liver failure and metformin (stop).35Choice of fluidsColloids Dextran based, gelafusinBinds to vonWF as well as factor 8 and impairs coagulationAllergic reactionGelafusin has the highest allergic reaction but least impairment in coagulationCan be used if there is elevation in HCT despite normal saline boluses( stable or unstable pt)How much blood to giveIf blood loss can be quantified, this should be replaced. 510 ml/kg of fresh -packed red cells or 1020 ml/kg of fresh or fairly fresh wholeblood (FWB) at an appropriate rate and observe the clinical responseOxygen delivery at tissue level is optimal with high levels of 2,3 diphosphoglycerate (2,3 DPG). Stored erythrocytes lose 2,3 DPG, oxygen-releasing capacity of haemoglobin, resulting in functional tissue hypoxia. improving haemodynamic status and acid-base balance.

Sometimes it just does not make sense..Pt seems to be improving and there is acidosis.Could be due to the normal saline infusion given causes normal anion gap acidosisSometimes parameters are improving but Bp is lowis it sepsis wide pulse pressure, bounding pulsePresented with UGIB coffee ground vomitus, history of hematemesis, but pt stable nowReevaluate the case from scratch, does he really need transfusion! We will lose HCTImproving but HCT keeps going upThe volume given sometimes becomes malignantTry colloids.In recovery phase, patients can get nosocomial infectionIncreased risk of soft tissue infection as a result of thrombophlebitis 39Interpretation of blood results

Incubation Period: 4-10 daysviraemia detected from the time symptoms occur to absence of feverDengue IgM is detected usually when no fever( about 6-10 days.Dengue IgG usually by day 9Ns1 detected from day 2 to day 9But in secondary infection: dengue IgG rapidly high( 30-40 days) and detectable for decades.IgM too low to be detected so you send for IgGLow levels of viraemia and higher peaks of IgG in secondary infection41

1. Virus detected during febrile period and the ag and ab will be detected in the convalescent period2. Acute dengue infection is diagnosed if the reverse transcriptase and real time pcr and Ns1 detection is positive

3. Serological response can beseen via 2 ways : as a single serum specimn taken at day 5 of fever, or as paired sera looking for rise in titre

4, in the signle sera the igm is high in primary infection then the IgG is low levels but in secondary samples the igM is low and the IgG is very hihg titre ( 1: 1280)

5. Neutralization Test is the method of choice for determination of specific serotype

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Unrecognised disease (not anymore)Unrecognised shockUnrecognised occult haemorrhageOverzealous fluid therapy Nosocomial sepsis

KKM UMMC 20064343SUMMARYAll aspect-clinical phase, warning signs,lab ix (HCT) and haemodynamic status.

Not one of this aspect can stand on its own!

Careful observation and monitoring after each correction must be done and further plan based on this.44THUSMANAGE DENGUE COMPREHENSIVELY

AND PREVENT COMPLICATION AND MORTALITY

45SO THAT ..

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Case Presentation Case presentation26 year old presented with 5 day history of feverStays in outskirts of temerlohAbdominal pain on day 3 of feverVomitted twice on presentationHx of coffee ground vomitus on day of presentationFever settled that morning, no PCMOn examination at 9pm on day1 lethargic, afebrile ,tachycardic, lungs are clear, abdomen tender on palpation more of centra abdominal pain , no rash seen

Investigation Hb- 12, hct- 47, plt 87, Rp- normalLft alt- 413, ast-546Inr- normalBp- 110/76Pr- 101Abg normal ph and hco3Questions Raised?Is it dengue?What phase of illness do you think he is?What is your diagnosis?How much of fluid will you give?What will you do next?In ED1. run 10 mls per kg over 2 hrs2. inserted cbd3. repeated a fbc- 2hrs later4. urine output- 100cc/hr5. repeated fbc 10pm hb 11.1, hct-42, plt- 76,wcc-2.06. rp normal 7. vbgph- 7.38, hco3 198. bp remains 100-110/80-70mmhgUrine output- 100cc/hrCxr at 10pm: small pleural effusion over the rightAdmitted to icu and the following happensStable throughout the nightHaving reduction in abdominal pain but still thereBp ranges from 110/70Pr- 60 70 bpmUrine output 90 to 100 cc/hrFluid cut to 7mls/hr11pmHctHbPltWccBpPrFluidsUrine outputAction 11pm2am4am7am10am4pmHct42.741.04549.754.759.7Hb11.711.712.412.413.416.7Plt766553343865wcc3.23.53.63.74.54vbgPh-7.36. hco3-17.6Ph-7.35 hco3-16.67.36, 16.77.37, 17.67,42, 17.67.45, 17.6Bp100/70100/7090/50100/70110/60100/70Pr807668708056Fluids7-5-3 mls/kg-10mls/kg5mls/hr3mls/hr2mls/hr2mls/hrUO80mls/hr100mls/hr90,\mls/hr90mls/hr70mls/hr110mls/hreventWS nilAscitee/PESM, WS nilStale malenaLeak- 12 hrsLeak- 18hrsAction i/o: 2350/ 540 mlsTransfused 2pints pack cell

Further eventsMantained by 2mls /hr and at 10pm at night stopped the dripThe hct remained elevated and started coming down by the next moring at 6amDid not have any evidence of bleed after thatDischarged well

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