This talk was delivered by Dr. Shashikiran Umakanth on 10 Jan, 2016 as part of CME on Infectious Diseases conducted by the Indian Medical Association, Udupi-Karavali branch, Karnataka, India.
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Dengue Fever - Rational Management
1. Dengue Fever
An Approach to Rational Management
Dr. Shashikiran Umakanth
Professor & Head, Department of Medicine
Dr. TMA Pai Hospital, Udupi
MMMC, Manipal University
2. Dengue - A Flavivirus
o Arboviral infection
• Aedes aegypti
o Incubation period
• 3-14 days
• average 7 days
o 2.5 billion people at risk (40% of world
population) in >100 countries
o Tropical and subtropical countries
o Other flaviviruses
• Yellow fever virus
• Japanese encephalitis
• West Nile virus
• St Louis encephalitis
3. Global burden
390 million cases/year
5 lakh admitted for severe dengue (DHF)
90% in children <5 years
4. Agenda
1) Clinical Phases of Dengue
2) Warning igns of impending complications
3) Classification of Dengue severity - Groups A, B C
4) Management of Group A, B & C Dengue fever
5) Advances in Prevention & Management
5. 1) Clinical Phases of Dengue
2) Warning signs of impending complications
3) Classification of Dengue severity - Groups A, B C
4) Management of Group A, B & C Dengue fever
5) Advances in Prevention & Management
6. Phases of Dengue
Illness
Day of Illness
Temperature
Potential
Clinical Issues
Lab Changes
Serology
& Virology
FEBRILE
1 2 3
CRITICAL
4 5
RECOVERY
6 7 8 9 10
Shock / Bleeding
Organ Impairment
Dehydration
Reabsorption /
Fluid overload
40 ºC
Platelets
Hematocrit
Viraemia IgM/IgG
1 2 3
7. 2) Warning signs of impending complications
3) Classification of Dengue severity - Groups A, B C
4) Management of Group A, B & C Dengue fever
5) Advances in Prevention & Management
1) Clinical Phases of Dengue
8. Onset of critical phase is
marked by plasma leakage
occurs around fever defervescence
Evidence of plasma leakage includes
Rising hematocrit >10% (early marker)
Hemodynamic instability
Fluid accumulation in extravascular space (late
marker)
hypoproteinemia
9. Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation
Mucosal bleed
Lethargy; restlessness
Liver enlargement >2cm
Lab: ↑ hematocrit (HCT) &
rapid ↓ of platelets
Warning signs of Impending Critical Phase
Co-existing conditions/
situations
o Pregnancy
o Infancy & Old age
o Obesity
o Diabetes mellitus
o Hypertension
o Heart failure
o Renal failure etc.
10. Clinical judgment is required regarding admission
However, essential to admit the following:
All patients with platelet count of ≤100,000/cumm
Platelet count 100,000 - 150,000/cumm if dropping rapidly
All patients with warning signs after day 3 of illness
Criteria for admission
11. 1. Severe plasma leakage (DSS)
2. Severe hemorrhage (DHF)
3. Severe organ impairment
without
Dengue ± warning signs Severe Dengue
with
warning signs
12. 3) Classification of Dengue Severity
4) Management of Group A, B & C Dengue fever
5) Advances in Prevention & Management
1) Clinical Phases of Dengue
2) Warning signs of impending complications
13. Severity of Dengue
Group
A
B
C
Features
No warning signs, esp. when fever subsides
Able to take orally; urine output every 6h
Near normal HCT and blood counts
Developing warning signs
Poor family/ social support
Increasing HCT, reducing platelets
Established warning signs
Critical phase
Severe plasma leakage
Hemorrhage
Organ impairment
Rx Setting
Home
Hospital
ICU
14. 4) Management of Groups A, B and C
5) Advances in Prevention & Management
1) Clinical Phases of Dengue
2) Warning signs of impending complications
3) Classification of Dengue severity - Groups A, B C
15. Manage at home
2.5 - 3.0 litres of oral fluids/day
ORS, fruit juices, soups, water
Avoid red/brown fluids (confusion with hematemesis)
Avoid NSAIDs!
Paracetamol is usual doses 500-1000mg q6h-q8h
Daily blood counts, watch for warning signs
Management of Group A patients
A
16. Hospital admission
If admitted due to lack of family support
Manage like Group A
If warning signs/ critical phase (plasma leakage)
IV fluids with normal saline or Ringer’s lactate
Close monitoring of vital signs, fluid balance, HCT,
platelets, urine output, LFT, RFT, coagulation profile
Management of Group B patients
B
17. Emergency management in ICU
Compensated or decompensated shock
IV crystalloids and colloids
Individualized fluid requirement
Colloids and blood transfusion in intractable shock
Usually recovery in few hours, if not - consider
acidosis, electrolyte disturbances, myocarditis,
hepatic necrosis, internal bleeding
Management of Group C patients
C
19. Calculate total fluid quota for 48 hours:
Maintenance + extra 5% fluid deficit
Impending or Early Critical Phase
Needs
IV fluids for 48
hours
Maintenance: 100-50-20 formula
100 mL/kg for first 10 kg of BW
+ 50 mL/kg for second 10 kg of BW
+ 20 mL/kg for every kg >20 kg up to 50 kg
5% fluid deficit (extra)
50 mL/kg of BW up to 50 kg
Example: 45kg BW
100x10 = 1000ml
50x10 = 500ml
20x2 = 100ml
50x45 = 2250ml
Total = 3850ml
20. Halliday-Segar formula for total fluid
requirement
4 ml/kg/hr for first 10 kg bw +
2 ml/kg/hr for next 10 kg bw +
1 ml/kg/hr for body weight >20kg
Alternative
Needs
IV fluids for 48
hours
Maintain at least
0.5ml/kg/hour
urine output
Strict I/O balance;
but does not help
in judging fluid
need
22. Prophylactic use NOT recommended
even if platelets are very low
Use only if there is active bleeding with
thrombocytopenia
Platelet transfusion
23. Indications
Significant overt bleeding
Suspicion of concealed bleeding
When HCT drops without clinical improvement
Severe metabolic acidosis and end-organ dysfunction despite
adequate fluid replacement
Use PRC at 5ml/kg once and repeat only if needed
PRC contraindicated if HCT > 45%, even if active bleeding
Blood transfusion (PRC)
25. Fluid intake
Same as for non-pregnant women
Pre-pregnancy body weight should be used in the formula
Detection of plasma leakage is difficult
early ultrasonography is preferred
Signs & symptoms may be confused with that of
HELLP syndrome
Dengue in Pregnancy
26. Corticosteroids
No major studies have shown efficacy in preventing
complications
Antiviral drugs
Many studies on Balapiravir
Not effective
Experimental treatments
28. Recognized by improvement in
Clinical variables
Patient’s wellbeing
Many patients develop diuresis
and hypokalemia
Rashes and pruritus common
during recovery
Convalescence
30. 5) Advances in Prevention & Management
1) Clinical Phases of Dengue
2) Warning signs of impending complications
3) Classification of Dengue severity - Groups A, B C
4) Management of Group A, B & C Dengue fever
31. A tetravalent dengue vaccine
Live attenuated genetically engineered Yellow Fever virus
Available in Mexico, Philippines and Brazil
Developed by Sanofi
Not yet approved in India
Dengue Vaccine