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Dengue in children where the Art and Science meet an Update-3 copy.pptx

  1. 1. Dengue in children where the art and science meet An update Dr.G.Sudhakar Professor Of Paediatrics (Rtrd) Consultant Paediatrician KIMS Hospitals Kurnool Andhra Pradesh
  2. 2. DENGUE • DNV 1-5 • Mostly children • Treatable yet potentially fatal • Primary and secondary infections • Prodrome/ Leaks/ Bleeds • Leukopenia/Thrombocytopenia/ Raised HCT • IgG IgM NS1 Ag • Notifiable • Preventable 2
  3. 3. Primary infection produce both Type specific neutralizing (TSNA) and nonspecific non-neutralizing antibodies(NSNNA). TSNA homologous complexes are non-infectious Nonspecific non-neutralizing antibodies of primary infection Complexes with heterologous virus of secondary infection which are infectious These infectious complexes enter more monocytes and macrophages where the virus replicates ie the viral multiplication is being enhanced or being augmented… that is why we call them as enhancing or augmenting antibodies
  4. 4. Endothelial dysfunction with capillary plasma leaks is the hall mark of Dengue pathophysiology behind the clinical picture • When fever subsides 90% become active and recover. • Around 10% become lethargic and enters “critical dengue” • Critical dengue is with plasma leaks resulting in 1. Warning signs 1.Abdominal pain and tenderness 2.Persistent vomiting 3.Clinical fluid accumulations 4.Mucosal bleeds 5.Lethargy/restlessness 6.Increase in HCT and fall in platelets 2. Intravascular volume depletion and bleeds resulting in Shock when volume loss is critical 3.Bleeds due to Decreased platelets Ischemic hepatitis with prolonged PT DIC Vasculitis with prolonged APTT
  5. 5. Clinical implications of pathophysiology… • Febrile period without warning signs and without signs of shock Non-Severe dengue without warning signs • Afebrile period with warning signs but without signs of shock Non-Severe Dengue with warning signs • Afebrile period with warning signs and with signs of shock Severe Dengue 1. Shock due to leaks and/or bleeds 2. Respiratory distress due to third spacing 3. Multiorgan disfunction Hepatitis Encephalitis Renal failure Myocarditis etc
  6. 6. Treatment implications of pathophysiology… • With onset of critical dengue warning signs secondary to plasma leaks and organ hypo-perfusion appear. Plasma leaks continue for 48 hours • With critical depletion of IV volume signs of shock appear... • After 48hrs the the leaked-out plasma re-enters circulation • Replacing intravascular volume to maintain organ perfusion is critical • But plasma re-entry during recovery plus the IV fluids given during critical phase may add-up resulting in circulatory overload and pulmonary oedema. • Under our control is only what we infuse but not re-entry plasma. • Attempts to correct raised HCT with IV fluids will inevitably result in third space accumulations and respiratory distress. • Replacement of volume should be restricted to 40-60% of maintenance to give space for re-entry fluid to get accommodated, otherwise it will be like tsunami with onset of recovery phase.
  7. 7. Therapeutic implications of pathophysiology… HCT EVV EVV EVV EVV EVV EVV EVV EVV IVV IVV IVV IVV 1.Normal IVV vs EVV Volume status after plasma leaks Volume status after IVF for shock Volume status after Re-Entry during recovery Plasma leaks Re-Entry of EVF + Rapid fluid infsion during recovery results in fluid overload Prodromal phase Critical dengue Warning signs and shock Fluids to improve tissue perfusion Tsunami
  8. 8. 6 years old Irfan with fever of 5days duration. Afebrile since morning, sick looking, generalized edema, abdomen distended and tender. Ns1Ag and IgM are non-reactive and IgG is reactive. Can this presentation be Dengue illness? • IgG +ve, IgM –ve, NS1Ag –ve suggests past infection in a febrile child • IgG +ve, IgM +ve, NS1Ag +ve suggests secondary infection • But in some secondary infections, IgM response is only transient or appears after IgG • IgG can appear very early in secondary dengue infections • NS1Ag has weak reactivity in IgG sero-reactive children • So IgG alone can be Positive and the other two being negative • False positives are zero with IgG index value of >6.00 and 0.19 for >3.00. With IgG IV of <3.00 false positives are likely( bacteremia, leptospirosis, Q fever, CGV, CMV, EBV, Varicella, Enteric fever, UTI etc.;) • Ref: Iran J of Microbiology 2016 Dec; 8(6): 395-400
  9. 9. NS1Ag +ve with or without IgM and IgG is confirmatory. Bu IgM alone is positive in Ramu with fever of 7days duration. 6cm non tender soft to firm liver and 1cm soft spleen present. No edema. No fast breathing. Diagnosis of Primary Dengue infection of more than 6days duration is made. What are your comments? • A single IgM report is not confirmatory • A weakly reactive IgM(<2.85 IV) may be false positive due to cross reactive CGV • A strong reactive IgM(>2.85 IV) can mean either Dengue of >6days • <2.85 IV indicative of recent past infection of 2 to 3 months back and may not be presently dengue. Detectable frequency was 68.2% and 35.9% at 6 & 12 months after primary infection. BMC Infct Dis. 2015; 15:167 • Suggestive clinical picture can favor Dengue in such situations • Clinical assessment in Ramu is not s/o Dengue and needs further evaluation like Blood for salmonella, leptospirosis, Rickettsia etc
  10. 10. A child with clinical picture s/o Dengue but Ns1Ag, IgM and IgG are negative. What should be our take on this issue? • Fever subsiding with when leaks appear and the child becoming more sleepy and lethargic favors clinical dengue even if all markers are negative. A convalescent serum sample can be tested for markers again (IgM and IgG). Previously -ve becoming +ve can be confirmatory. IgM/IgG ratio of >1.2 suggests Primary and <1.2 suggests secondary infection. NS1Ag of <9EU is read as –ve. • Fever increasing in intensity or continuing even after leaks appear should make us think of Rickettsia, Leptospira, Enteric fever and sepsis with plasma leaks. • With continuing fever coinfections/secondary infections and HLH complicating an infection too need consideration.
  11. 11. Please answer whether acute dengue is possible with following lab results? • NS1 Ag … Confirmatory of Acute dengue • IgG alone positive (past infection) … Acute dengue possible NS1Ag reactivity is poor in IgG reactive individuals IgM may appear after IgG appears • IgM alone positive (>6days)…. Need not be confirmatory probable dengue only recent past dengue (IgM may take up to 3-6months to disappear) • All markers Negative… Acute dengue Possible Ns1Ag sensitivity is 71-100% (0.5ug-2ug/ml) IgM sensitivity is 0-50% IgG sensitivity is IgG/IgM ratio >1.1 (100%) specificity is (97.4%) accuracy is (67.5%)
  12. 12. When to order FBC in a suspected dengue child? Can normal FBC rule out dengue? When to admit? • At the time dengue is suspected we should do FBC. • Earlier the FBC done more the chances for FBC to be normal. • It will not rule out Dengue. • But helps us know baseline HCT and to follow trends there after • To know the trends of falling WBC and platelets during febrile period • So an early clue to Dengue diagnosis • Admission in febrile period to those with co-morbids, infants and those with warning signs. • Ambulatory children with warning signs… admission is a must as rapid development of shock can ensue.
  13. 13. NSD without warning signs • Paracetamol • Oral rehydration • Watch for Warning signs 13 Presumptive Diagnosis Endemicity and Fever plus 2 of the following (1)Anorexia and nausea (2)Rash (3)Myalgias (4)Leukopenia (5)Torniquet test (6)Vitals signs normal (7)No warning signs Warning signs 1.Abdominal pain and tenderness 2.Persistent vomiting 3.Clinical fluid accumulations 4.Mucosal bleeds 5.Lethargy/restlessness 6.Increase in HCT and fall in platelets We do some minimum labs 1. Dengue kit test for NS1Ag. IgM, IgG 2. CBC on automated cell 3. SGPT, SGOT and Prothrombin time
  14. 14. NSD with warning signs •Admit if warning signs appear •Paracetamol •ORS/IV fluids •Watch for signs of severe Dengue 14 Multiple organ dysfunction ( Brain / Liver / Heart / Kidney ) Severe bleeds causing shock Plasma leaks leading to Shock and Respiratory distress
  15. 15. Severe dengue…Treatment of shock… • Fluid bolus 10-20ml/kg of Isotonic crystalloid over 1hr in compensated shock • Resuscitation fluids (10-20ml/kg within 20 min for Hypotensive shock • If responding, taper the fluids to maintain just enough circulation over next 12 hrs to 48 hrs ( follow WHO algorithms) • If still in shock, estimate HCT. If HCT is still high and not falling it is still plasma leaks and give colloids 10-20ml/kg over one hour. If HCT is falling, it is severe bleeds, give FWB 10-20ml/kg over 1-2hrs. ( falling HCT below normal never happens in Leaky phase and always indicates severe bleeds. • Low pulse volume + Low HCT = Bleeds • Low pulse volume + High HCT= Leaks • High pulse volume + Low HCT = Fluid overload
  16. 16. Treatment of Group C
  17. 17. Treatment of Group C
  18. 18. Monitoring a child on fluid therapy Pulse volume+ Pulse pressure Systolic BP Signs of RD Hematocrit Urine output Alertness Activity and interaction Clinical Impression Decreased Narrowing Normal or Less Fast breathing +/- RD Increased Decreasing Decreasing Decreasing NT/HT Shock due to leaks Decreased Decreasing Normal or Less Fast breathing +/- RD Decreased Decreasing Decreasing Decreasing NT/HT shock due to bleeds Increased Normal/ widening Normal or Increased Fast breathing +/- RD Decreased Increasing trends Improving improving Re-entry fluid overload Abdominal girth, Liver size and tenderness, VBG with Lactate, serum creatinine also need to be Monitored similarly Closely following the Trends or journey of all findings is critical for optimal outcome General condition
  19. 19. Some useful clues to clinicians… • Improving appetite, increasing urine output, increasing pulse volume, improving alertness, decreasing abdominal girth, physician’s assessment of improving general condition, inclination to play, improving interaction with parents and decreasing abdominal pain, all indicate onset of Recovery/re-entry phase. • Trends in respiratory rate should always be assessed in correlation with pulse volume and HCT values • Trends in WBC, platelets and alone are useless. • Trends in transaminases should be correlated with prothrombin time ( INR ) and well looking vs ill looking
  20. 20. Respiratory distress increasing… scenario 1 Child data • Breathing difficulty with fast breathing and chest retractions • Pulse volume high • Alert • Increased urine output • Accepting feeds well • Lactate normal • HCT low/normal/above baseline but significant fall • Stable circulatory status with fluid overload What we can do? • Stop IV fluids if plasma leaks are >48hrs and switch to ORS • Watch for 2 hrs and follow RR • If RR is falling and child is comfortable continue with ORS • If RD is rising despite stopping IV fluids and consider diuretic • Lasix 0.3 to 0.5mg/kg/dose 2- 4times a day or preferably 0.1mg/kg/hr as continuous infusion
  21. 21. Respiratory distress increasing… scenario 2 Child data • RD increasing • Child is hemodynamically stable • Alert • Urine output increased • Appetite improved • But still with in <48 hrs of plasma leaks • Acid base balance and lactate are almost normal What we can do • Reduce IV fluids or switch to colloids at 1-2ml/kg /hr until 48hrs of plasma leak stage is completed. • RD due to overload is unusual during plasma leak phase. • Thinking RD as due to overload and giving diuretic within plasma leak phase is hazardous as it may worsen shock state.
  22. 22. Respiratoy distress increasing… scenario 3 Child data • Plasma leak phase of <48 hours • Respiratory distress present • Signs of shock continuing with low pulse volume • HCT remains high • Third spacing is the cause of RD due to rapid infusions of hypotonic or crystalloid fluids What we can do? • IV fluids switched to colloids with carefully titrated bolus of 5- 6ml/kg over 1-2 hrs. • Reduce as per the need • Stop all fluids at or after 48 hrs of the critical period • Lasix may be needed if high pulse volume ensues with increasing RD after 48 hrs time
  23. 23. Fluid overload scenario 4 Child data • After fluid boluses Signs of shock continue with low pulse volume • HCT is low or normal • Excessive fluid accumulations • Most likely have severe occult bleeds What we can do • Further IV fluids are with poor outcome. Rather start dopamine if hypotensive too. • Early initiation of FWB 10ml/kg and titrate the rate based on clinical response, acid base status and lactate • Respiratory support may be needed
  24. 24. Respiratory distress increasing… scenario 5 Child data • Pulse volume is high • Abdominal girth increasing • Metabolic acidosis and high lactate is persisting s/o continuing shock • Suggests fluid overload of both extravascular and intravascular compartments. • Bleeds and leaks combined • Often due to bleeds treated with non-FWB What we can do? • FWB/PRBC and colloid infusions carefully can help child come out of plasma leaks with minimal worsening of respiratory condition • Dopamine if hypotensive • Watch for Respiratory failure and support accordingly.
  25. 25. Some common dilemmas… • 1. Can dengue shock occur during febrile phase? • Yes… Around 10 to 15% of severe dengue occur during febrile phase… or fever may sometimes get prolonged into critical phase too. • 2. If dengue is detected very early, can we prevent development of severe dengue with optimal care? • No… even with the best treatment modalities we can not prevent severe dengue , rather we can only treat severe dengue • 3.Is it the primary or secondary HLH that complicates Dengue infection? • Both can occur. Best dictum is HLH complicating Dengue in less than one year of age should be considered as primary HLH. Where as HLH in dengue after 2 years of age secondary hyper-ferritinemia with MODS is more common. To confirm, genetic testing for Primary HLH should be done
  26. 26. Dilemmas regarding platelets and FFP… • Platelet fall alone with out leukopenia is unusual in dengue that too with only IgM+ve, we need to rule out ITP and other thrombocytopenic disorders… • Severe dengue in leaky phase with platelets of less than 10k or <20k with bleeds can be indications for SDP. • In recovery phase of dengue with good appetite and and activity, the platelet count of even <10k does not warrant SDP. • Dictum is “Well child-well platelets and sick child-sick platelets” • INR of >1.5 is an indication for FFP at 10ml/kg run over 30 to 120min • But giving FWB in overt bleeding is better than giving SDP and FFP as correction of shock is of primary concern.
  27. 27. When the child is alert, BP is normal and accepting orally but warning signs are present. ORS? or IVF? Which is a better option? • Data is insufficient to decide • Being alert and having normal BP does not rule out circulatory instability. They remain normal in compensated shock which requires urgent fluid resuscitation to prevent hypotensive shock. • Hence assessment of circulatory status with at least the following four signs…. • Pulse volume, CRT, color and temperature of extremities to assess peripheral tissue perfusion. • Alertness, normal BP with no signs of shock… ORS • Alertness, normal BP with signs of shock… IV fluids
  28. 28. A well perfused child with persistently elevated HCT… to give or not to give fluids? • Well perfused child needs no fluid infusion • But Elevated HCT indicates ongoing plasma leaks and we incline to give fluids and never ever aim to correct HCT during 48hrs of leaky phase as it inevitably leads to more oedema and more third spacing. • This should be understood as “child is compensating well for ongoing losses” • Hence increasing IV fluids to correct HCT is likely to lead to fluid overload • Continue to monitor over next 2-3 hrs… if still stable we can even attempt stopping fluids… HCT usually resolves even without infusions as it is a balanced state • Lessons learnt is do not chase labs when child is stable.
  29. 29. A child with dengue with large pleural effusion and ascites on IV fluids enters recovery phase but refusing to take oral fluids. How to calculate IV fluids at this stage? • This child is already in a big positive fluid balance state with large pleural effusion and ascites and thirst is hampered • The only way for pleural effusion and ascites to get absorbed is to stop IV fluids • The child’s thirst mechanism will kick-in when once diuresis sets-in. • So best course of action at this point of time is to stop IV fluids and allow the child to take orally at his will
  30. 30. In the critical phase if the child is anuric with elevated creatinine a fluid bolus challenge followed by diuretic should be tried? • In the critical phase fluid challenge will invariably push fluids into third space and the diuretic will produce urine by depleting intravascular volume. So this procedure increases third spacing as well as worsens shock. It can also result in hypokalemia • When child is anuric urine output can’t be taken as a criterion to guide IV fluid therapy rather should be guided by other signs of perfusion.
  31. 31. When to advise antispasmodics and antacids for abdominal pain in children with dengue? • Never • Abdominal pain rather heralds the onset of warning signs or onset of shock due to plasma leaks at the time fever is turning into No-fever • Causes are acute liver enlargement due to leaks, ischemic hepatopathy and ischemic gastropathy • Last two respond only to fluid replacement not to antacids. Antispasmodics are useless and may contribute paralytic ileus and neurological complications
  32. 32. Worsening or persistent abdominal pain/tenderness after 24hrs of large volumes of fluid administration… do we need to stop IV fluids or continue IV flids? • Assessing intravascular volume status is the key. Peripheral perfusion, pulse pressure, pulse volume, urine output and acid-base status should be assessed. • If perfusion is still less consider colloid infusions • If perfusion is good consider stopping IV fluids • Further IV fluids will increase abdominal distension and respiratory distress
  33. 33. When to take help of nephrologist if renal failure is encountered in dengue? • RRT with CVVH during recovery phase is ideal and should not be attempted in critical phase • HD machine can’t draw blood effectively from hypovolemic shock child and can not correct metabolic acidosis and oliguria • Machine works well with volume repleted recovery phase and can prevent life threatening pulmonary edema. • Peritoneal dialysis can be an alternative if CVVH is not available
  34. 34. Metabolic disturbances seen with dengue management? • Metabolic acidosis with increased Lactate • Metabolic acidosis uncorrected by adequate fluids suggest bleeds • Metabolic acidosis with normal Lactate and hyperchloremia • Hyponatremia due to vomiting and hypotonic resuscitation fluids • Hyperkalemia due to renal failure and metabolic acidosis • Hypokalemia due to GI losses or stress induced hyper-cortisol state
  35. 35. Hyperglycemia and hypoglycemia in dengue… • Both can occur in the same child at different times in critical phase • Beware of spurious “good urine output” secondary to hyperglycemia • Osmotic diuresis can worsen shock in critical dengue • Hyperglycemia can result from stress induced hyper cortisol state or by using dextrose containing resuscitation fluids • Hypoglycemia can cause seizures and mental confusion • Hypoglycemia can be due to starvation young children, severe liver involvement etc
  36. 36. When to plan FWB transfusion? • overt bleeding with shock • Severe occult bleeds need to be identified… even severe bleeds may not result in fall of HCT below baseline if preceded by plasma leaks • Hence falling HCT needs to be assessed. Fall in HCT with isotonic crystalloids is usually negated by third spacing. • Hence during critical phase a fall in HCT with low pulse volume and narrow pulse pressure may indicate bleeds rather than effect of IV fluids • Persistent metabolic acidosis with adequate fluid therapy may point to occult bleeds
  37. 37. DIVC regimen for severe bleeding… • Decreased platelets, coagulopathy and DIC are the causes • FFP, SDP and cryoprecipitate transfusions… poor response • Bleeds and leaks continue resulting in severe third spacing • Hence urgent FWB transfusion can be life saving to prevent life threatening hemorrhagic shock and massive third spacing • Repeated blood transfusions for continued bleeding but not FFP/SDP • Bleeding usually stops after critical period
  38. 38. Refractory shock … • Refractory shock is usually a combination of plasma leaks and bleeding in uncorrected shock accompanied by Renal and Liver impairments • Usually the most common cause of death with 24-48 hrs after admission • Reassessment after every fluid bolus… if no improvement in hemodynamics, estimate HCT. A rising HCT/still high suggests plasma leaks … proceed with colloids… • If no improvement in hemodynamic status and HCT is falling think of bleeds and go with FWB transfusion
  39. 39. Pulmonary oedema and ARDS… • Pulmonary >ARDS • Both due to Rapid fluid infusions in critical phase. • Mechanical ventilstion indicated in 1.Child in Shock, confused, restless and combative 2. Respiratory failure due to Pulmonary edema/ARDS 3. Failed response to HFNC/CPAP • Sedatives, induction agents, muscle relaxants may cause hypotension and cardiac arrest. Conscious sedation is preferred . • Poor lung compliance and trauma to airway can increase pressure requirements. • FWB, Colloids, Inotropes, sedatives, circulatory and respiratory monitoring devices all should be readily available • Careful titration of FiO2 and PEEP are crucial. • Principle to remember is to maintain adequate oxygenation and ventilation to maintain Ph at 7.35 than to maintain normal PaCO2 to prevent metabolic alkalosis. • PEEP of <10cm of H2O and titrate FiO2 accordingly • If needed fine bore needle aspiration of ascites and pleural effusions. • Clinical, USG, Echo, ABG monitoring of circulatory status • Lactic acidosis/low or normal Ph/unable to lower inotropic support may warrant FWB.
  40. 40. What is abdominal compartment syndrome? • Massive ascites accumulated in a short time and hence is under tension. Precipitated by PEEP of >8cm of water if ventilated. • Pressure on retroperitoneal structures, kidneys, renal veins, inferior vena cava leads to decreased renal blood flow and oliguria even when peripheral perfusion is adequate • Hence in this situation oliguria can’t guide fluid management. • May be positioned in reclining or lateral posture to relieve pressure on retro-peritoneal structures. Stopping IV fluids with recovery can ease itra-abdominal pressure spontaneously and urine output improves… or diuretic can be tried during recovery if child is stable. • Avoid using diuretic to decrease abdominal distension before re-entry starts… it may worsen shock
  41. 41. How to differentiate from a surgical abdomen? • Trends in fever… • Trends in HCT • Trends in FBC • Effect of 5-10ml/kg volume bolus over pain abdomen • Abdominal wall oedema and other signs of generalized edema early • USG abdomen reveals GB wall oedema
  42. 42. When to stop iv fluids • Signs of cessation of plasma leakage • Stable BP, pulse and peripheral perfusion; • Hematocrit decreases in the presence of a good pulse volume; • Resolving bowel/abdominal symptoms • Improving urine output.
  43. 43. Iv fluids… Too much and too less are bad “Narrow therapeutic index” for iv fluid therapy. Recognizing the cues to discontinue intravenous fluid therapy is just as important as knowing when to start it.
  44. 44. Bleeding in SD • have profound/prolonged/refractory shock • have hypotensive shock and multi-organ failure or severe and persistent metabolic acidosis • are given non-steroidal anti-inflammatory agents Patients at risk of severe bleeding are those who:
  45. 45. Suspect bleeding in SD if … NT / HT pt + persistent or worsening metabolic acidosis + severe abdominal tenderness and distension. Fluid refractory shock A decrease in hematocrit after boluses of fluid resuscitation together with unstable hemodynamic status;
  46. 46. Treatment - Bleeding in SD… Give aliquots of 5−10 ml/kg of fresh -packed red cells or 10−20 ml/kg of fresh whole blood Consider repeating the blood transfusion if no appropriate rise in hematocrit after blood transfusion in an unstable patient.
  47. 47. Bleeding in SD… No evidence to support the practice of transfusing platelet concentrates and/or fresh- frozen plasma for severe bleeding in dengue For surgeries or invasive procedures, platelet transfusion can be considered
  48. 48. Inotropes in DSS • Limited role • As a temporary measure to prevent life threatening hypotension or during induction for intubation • Cardiogenic shock due to myocarditis • Concomitant septic shock
  49. 49. Urine output monitoring during both febrile and afebrile critical phase is essential. True or False? • During febrile phase a child passing urine for 4 to 6 times is adequate • But in critical phase measuring urine output is critical. • Goal of urine output of 0.5ml/kg/hour is optimum to maintain “just enough circulation” to avoid fluid overload • Urine output of >0.5ml/kg/hour is an indication to reduce IV fluid therapy. • IMPORTANT: avoid using diuretic for urine output of <0.5ml/kg/hour as it may produce some urine output but exacerbates shock. Oliguria is often pre-Renal in origin. So oliguria should be treated with IV fluid therapy until urine output reaches 0.5ml/kg/hour
  50. 50. When is the urine output not a good guide to fluid therapy in dengue? • RBG of >10mmol/Lit • AKI with elevated Creatinine • Underlying CRF, DM or uncontrolled hypertension • Moderately high PEEP >10cm of H2O • Intra abdominal hypertension >10cm of H2O • Diuretics or hypertonic fluid usage
  51. 51. Complications … • Renal failure – Most portant risk factor is shock • Other risk factors – Hepatic failure , prolonged Prothrombin time , obesity • J Pediatr. 2010 Aug;157(2):303-9. Epub 2010 Apr 1. • CVVH is mode of choice
  52. 52. Seizures or altered sensorium in a child with dengue should be treated like AES. True or false? • False • During febrile phase Febrile seizures is the most common cause and hence should be treated accordingly and rarely dengue viral encephalitis could be the cause • Less common cause is hyponatremia frequently seen in dengue, causing encephalopathy and seizures • Most common scenario is… Seizures and altered sensorium in critical phase are mostly due to decreased cerebral perfusion. Perfusion to brain is the last to decrease. So sudden collapse can occur if IV fluids are not give promptly. • Attempts to do procedures like LP, CT brain etc take away the valuable time and may delay critical step of fluid resuscitation.
  53. 53. Severe dengue with Hepatic dysfunction… • Infective hepatitis is rare • Ischemic hepatopathy is almost always the cause • Hence SGOT/SGPT ratio is always >1 • Transaminases can cross 10,000units • Increased prothrombin time with bleeds complicates critical dengue that is unresponsive to Vitamin K. • Measures to improve tissue perfusion usually results in resolution of hepatic dysfunction • Role of N-Acetyl cystine though controversial it is commonly used allover in PICUs. • Hepatic dysfunction coupled with seizures and hyper-ferritinemia more so in infants… consider Primary HLH
  54. 54. Take home points True/ False •IgM/Ns1Ag +ve is a must to say Dengue •IgG helps differentiating primary from secondary infection •Plasma leaks and bleeds are warning signs •Severe dengue is with Shock/RD/MODS •Guarded Fluids is the corner stone of therapy •Fluid overload is the most common cause of death •Platelet transfusions are life saving False True True True True True False
  55. 55. True/false….. •Trends in alertness , urine output , pulse volume , RR , Liver size , appetite is pivotal •Alert child with Increasing pulse volume and increasing RR is an indication for ORS / Lasix •Lethargy with decreasing PV and increasing RR being on fluids … a danger sign s/o contnuing leaks •Inotropes only with myocarditis/septic shock •Always refer children with ARF/ARDS. True True True True True
  56. 56. THANK YOU ALL

Notas del editor

  • A good clinical response includes improving haemodynamic status and acid-base balance.