Fluid Management in DHF Patients

1
Fluid Management in DHF Patients
Dr Rasnayaka M Mudiyanse Senior Lecturer in
Paediatrics Faculty of Medicine Peradeniya
2
Short Duration Fever - OPD
Treat and send home
Admit No resuscitation
Need Resuscitation

• Treat Fever
• Rest
• Fluid
• Specific drugs
• Warning signs
• DD
• Dengue ( group A)
• ( No warning signs )
• Viral fevers
• Other D

• Immediate attention
• Fluid
• Oxygen
• Observation
• DD
• Dengue (group B)
• ( with warning signs)
• Other infections
• Other D

1. Evaluate ABC care 2. Fluid boluses 3.
Oxygen 4. Hand over MO-MO DD Dengue ( group
C) (Sever dengue ) Septicemia Diarrhea
Anaphylaxis
3
Classification of Dengue
Old WHO classification New WHO classification
Classical Dengue Fever Probable dengue ( group A - OPD management)
Dengue Fever with hemorrhagic manifestations Dengue with warning signs ( Group B - inward observation and management) ( patients are admitted for social reasons and when they are in high risk category)
DHF grade one Dengue with warning signs ( Group B - inward observation and management) ( patients are admitted for social reasons and when they are in high risk category)
DHF grade two Dengue with warning signs ( Group B - inward observation and management) ( patients are admitted for social reasons and when they are in high risk category)
DHF grade three Severe Dengue ( Group C - resuscitation and management) With compensated shock With hypotensive shock With severe organ impairment
DHF grade four Severe Dengue ( Group C - resuscitation and management) With compensated shock With hypotensive shock With severe organ impairment
DHF with unusual manifestations Severe Dengue ( Group C - resuscitation and management) With compensated shock With hypotensive shock With severe organ impairment
4
Dengue Hemorrhagic Fever or Dengue Leaking
FeverEssential Feature In DHF is LeakingDF may
have bleeding but not leaking
5
The Cause of Shock in Dengue

• Plasma leakage
• Bleeding external and internal
• Hypocalcaemia
• Vascular involvement
• Inadequate fluid intake
• Myocarditis

6
What is the cause of Plasma Leakage

• Endothelial cell dysfunction rather than
  destruction

7
Evidence of Plasma Leakage

• Rise in HCT
• 20 children 35 ? 42 adults 40 ? 48
• Circulatory failure
• Fluid accumulation Ascites, Pleural effusions
• Albumin lt 3.5 gr/dl
• Cholesterol lt 100 mg

8
Evidences of plasma leakage in DHF
(Rt. lateral decubitus position)
A. Rising hematocrit 50
Rt pleural effusion
Ascites
9
Plasma Leakage ? Shock ? Prolonged shock

• Prolonged shock
• Organ hypo perfusion Organ impairment
• Metabolic acidosis DIC
• Severe Hemorrhage ( Drop HCT rise of WBC )

All these complications may develop without
obvious plasma leakage or shock
10
Rising HCT indicate plasma leakage

• 20-30 rise ? GIT ischemia including liver
• 30-40 rise ? Renal and brain ischemia

11
Patients at risk of major bleeding

• Prolonged/refractory shock
• Hypotensive shock renal or liver failure
• Severe and persistent metabolic acidosis
• Receiving NSAID agents
• Pre-existing peptic ulcer disease
• On anticoagulant therapy
• Any form of trauma( IM injection)

12
Flushing Tourquet test Leucopenia Liver enzymes
1st day 73 53 70 within 24 hrs pt will enter critical phase AST rise 90 AST gt 60 PPV 80 AST gt ALT (2-3 times)
2nd day 90 90 70 within 24 hrs pt will enter critical phase AST rise 90 AST gt 60 PPV 80 AST gt ALT (2-3 times)
3rd day 85 98 70 within 24 hrs pt will enter critical phase AST rise 90 AST gt 60 PPV 80 AST gt ALT (2-3 times)
13
Dengue is a Dynamic Disease
14
Febrile, Critical and Recovery Phase



53
105 51
104 140 49
103 47
102 120 45
101 43
100 100 41
99 39
98 80 37
35
60


1 2 3 4 5 6 7 8
1
2
3
Incubation period 5-8 days ( 3-14 days)
15
Rate of Fluid Leakage



53
105 51
104 140 49
103 47
102 120 45
101 43
100 100 41
99 39
98 80 37
35
60


1 2 3 4 5 6 7 8
1
2
3
M 5
Optimum volume of fluid
16
Calculation of M 5

• Calculation of M
• 1st 10 kg 100 ml/kg/day ( 4 ml/kg/hr)
• 2nd 10 kg 50 ml/kg/day ( 2 ml/kg/hr)
• Subsequent ..kg 20 ml/kg/day ( 1ml/kg/hr)
• Calculation of 5
• 5 50ml/kg/day ( 2ml/kg/hr)

Maximum Fluid for adult ( 50kg) 4600
M 5 for boy 60kg (IBW 50kg ) ?
17
Fluid Management in DHF patients
18

• Rational Use of Fluid Management of Dengue

Avoid Prolong Shock
Avoid Fluid Overload
19
Spectrum of Dengue

• DHF Grade 4 ( SD with hypotnsive shock )
• No pulse 20ml/kg rapid bolus
• Drop SBP (Pulse ) 10 ml/kg rapid bolus, Rpt
  sos
• DHF Grade 3 ( SD with compensated shock)
• 10 ml/kg/hr
• No circulatory failure ( D warning signs)
• DF /- Bleeding ( oral fluid ? M5)
• DHF in Febrile phase (1.5 ml/kg/hr)

20
DF DHF in Febrile Phase
21
DF DHF in Febrile Phase
1

• Parcetamole 15mg/kg 6 hrly
• Physical methods of controlling fever
• Dont use Aspirin and NSAID
• Fluid to maintain nutrition and hydration
• Oral between M and M5 ( 5ml/kg/hr)

Too much fluid during febrile phase can
contribute to fluid over load
22
Recognize the Time of Entry to the Critical Phase
( when blood vessels become leaky)

• Dropping platelet count below 100 000/dl
• Rising HCT Evidence of plasma leakage

23
Fluid management during Critical Phase not in
shock ( when blood vessels become leaky)

• Establish IV line IV fluid to KVO
• Limit total ( IV Oral) fluid to 1.5 ml/kg/hr
• Monitor UOP ( 0.5ml/kg/hr is OK)
• Rising HCT - Increase fluid- 3-5-7-10 ml/kg/hr
• Monitor for circulatory failure Fluid boluses

HCT monitoring 4-6 hrly initially then hrly
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Fluid Allocation for Non Shock Patient



53
105 51
104 140 49
103 47
102 120 45
101 43
100 100 41
99 39
98 80 37
35
60


1 2 3 4 5 6 7 8
20-10 ml/kg
10-20 ml/kg
1
2
3
10-5 ml/kg
5-10 ml/kg
5-3 ml/kg
3-5 ml/kg
3-1 ml/kg
1-3 ml/kg
KVO
1.5 ml/kg
M 5 48 hrs
25
Fluid Allocation for Non Shock Patient



53
105 51
104 140 49
103 47
102 120 45
101 43
100 100 41
99 39
98 80 37
35
60


1 2 3 4 5 6 7 8
20-10 ml/kg
10-20 ml/kg
1
2
3
10-5 ml/kg
5-10 ml/kg
5-3 ml/kg
3-5 ml/kg
Fluid over load and shock
3-1 ml/kg
1-3 ml/kg
KVO
1.5 ml/kg
M 5 48 hrs
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Fluid Allocation for Non Shock Patient



53
105 51
104 140 49
103 47
102 120 45
101 43
100 100 41
99 39
98 80 37
35
60


1 2 3 4 5 6 7 8
20-10 ml/kg
10-20 ml/kg
1
2
3
10-5 ml/kg
Shock and Fluid Over Load
5-10 ml/kg
5-3 ml/kg
3-5 ml/kg
3-1 ml/kg
1-3 ml/kg
KVO
1.5 ml/kg
M 5 48 hrs
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Prolonged shock
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Prolonged Shock

• Detecting absent pulse is too late
• Drop in SBP is too late
• Drop in pulse pressure, CRFT, Cold extremities ..
  can detect early shock
• We can prevent shock !

Rise in HCT loss of IV compartment 20 -
compromise GIT blood supply 40 - compromise
renal and brain
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Prevent Shock Manage PCV



53
105 51
104 140 49
103 47
102 120 45
101 43
100 100 41
99 39
98 80 37
35
60


1 2 3 4 5 6 7 8
20-10 ml/kg
10-20 ml/kg
1
2
3
10-5 ml/kg
5-10 ml/kg
5-3 ml/kg
3-5 ml/kg
3-1 ml/kg
1-3 ml/kg
KVO
1.5 ml/kg
M 5 48 hrs
30
Cause of Prolonged Shock in Dengue

• Failure to detect shock is rare in SL
• Clinicians thought prolonged shock is due to
  bleeding as a result of low platelets
• Clinicians did not appreciate that shock
  precipitate bleeding and other organ damage
• Clinicians did not monitor/manage PCV ( instead
  they managed platelet count )
• personal opinion

WHY ?
Lack of knowledge and training
WHY ?
Failures in teaching/training programs
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(DHF grade 4) Severe Dengue with Hypotensive
shock
5 year old boy fever 5 days, cold extremities
and prolonged CRFT. HCT 48, Plt 45 000/dl SBP
60/40.
1-10 yrs - 5th Centile SBP 70 (agex2)
Adults SBP lt90 mm Hg or MAP lt70 mm Hg or Drop
of SBP gt40 mm Hg
32
Management of DHF Grade 4Severe Dengue with
Hypotensive shock

• Oxygen,Keep flat /- Head low
• IV canula Blood samples
• Rapid Fluid bolus Rpt SOS
• Monitoring ABCS
• Consider other possibilities
• Record keeping Communication

33
Investigations for DHF patients

• FBC
• Blood grouping and cross matching
• Blood sugar
• Blood electrolytes ( Na,Ca,K,HCo2)
• Liver Function tests
• Renal Function tests
• Blood gases
• Coagulation profile ( PTT,PT,TT)

34
Management of DHF Grade 4Severe Dengue with
Hypotensive shock
Fluid bolus 10-20 ml/kg Normal Saline / 15 mt
Improving , HCT coming down gradually , good UOP

• Slow bolus 10 ml/kg Crystalloid/colloids over
  one hour
• Infusion 5- 7 ml/kg/hr for 1-2 hrs ( Hartmann)
• Infusion rate 3- 5ml/kg/hr for 2-4 hrs
• Infusion rate 3ml/kg/hr for 2-4 hrs
• Stop fluid in 48 hrs

No improvement HCT dropping Blood transfusion
No improvement HCT Rising Colloid transfusion
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Management of DHF Grade 4(Severe Dengue with
Hypotensive shock )
Fluid bolus 10- 20 ml/kg Normal Saline / 15 mt
Rpt fluid boluses 2 crystalloids' ? colloids
NO IMPROVEMENT
Check HCT before fluid bolus or after fluid bolus
If HCT is dropping lt 40 for Children and
female lt 45 for adult male
Rising HCT

• 2ndBolus - Colloids
• 10 20 ml/kg/ ½-1 hr

Blood transfusion whole blood 10 -20 ml/kg Packed
RBC 5-10 ml/kg

• 3rd bolus - Colloids
• 10 20 ml/kg/1 hr

36
DHF Grade 3Dengue with Compensated Shock
10 year old boy fever 5 days. Cold extremities.
Tender Hepatomegaly. PCV 52, Platelets 50 000/dl
CRFT 5 sec. SBP 100/85.
5th Centile SBP 70 (agex2)
37
Management of DHF grade 3(Severe Dengue with
Compensated shock)
Fluid bolus 5-10 ml/kg Normal Saline / 1hr
Improving , HCT coming down gradually , good UOP

• Hartmann - 5- 7 ml/kg/hr for 1-2 hrs
• Hartmann - 3- 5ml/kg/hr for 2-4 hrs
• Hartmann - 2-3 ml/kg/hr for 2-4 hrs
• Stop fluid in 48 hrs

38
Management of DHF grade 3(Severe Dengue with
Compensated Shock)
Fluid bolus 5-10 ml/kg Normal Saline / 1hr
Rpt fuid bolus 5-10 ml/kg Normal Saline / 1hr
NO IMPROVEMENT
HCT rising
If HCT is dropping
lt 40 for Children and female lt 45 for adult male
Blood transfusion Packed RBC 5-10 ml/kg Whole
blood 10-20 ml/kg
Fluid bolus saline /colloids 10 -20 ml/kg for
1hr
However, a rising or persistently high HCT
together with stable haemodynamic status and
adequate urine output does not require extra
intravenous fluid.
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Patients not responding to usual fluid boluses

• Massive plasma leakage rising PCV
• Concealed hemorrhage Drop of PCV
• Hypocalceamia
• Hypoglycaemia
• Hyponatremia
• Acidosis

40
Fluid Management During Critical Phase DONT
OVER LOAD LEAKING VESSELES

• Manage PCV and shock use monitoring chart
• Fluid quota for leaking phase is M5
• Pre shock in 48 hours , Grade 3 4 in 24 hours
• Use colloids to retain longer
• UOP 0.5 ml/kg /hr is OK (Void volume chart)
• Cut down fluid at recovery phase
• Eg - 10ml/kg/hr ? 1.5 ml/kg/hr
• Give blood when indicated

41
Fluid Allocation for shocked Patient



53
105 51
104 140 49
103 47
102 120 45
101 43
100 100 41
99 39
98 80 37
35
60


1 2 3 4 5 6 7 8
20-10 ml/kg
1
2
3
10-5 ml/kg
5-3 ml/kg
3-1 ml/kg
KVO
M 5 24 hrs
42
Fluid Allocation for Non Shock Patient



53
105 51
104 140 49
103 47
102 120 45
101 43
100 100 41
99 39
98 80 37
35
60


1 2 3 4 5 6 7 8
20-10 ml/kg
10-20 ml/kg
1
2
3
10-5 ml/kg
5-10 ml/kg
5-3 ml/kg
3-5 ml/kg
3-1 ml/kg
1-3 ml/kg
KVO
1.5 ml/kg
M 5 48 hrs
43
What is M5 in management of DHF (MCQ)

• Fluid volume to be given during critical period
  after excluding boluses
• Fluid volume to be given during critical period
  after including boluses
• Upper limit of fluid volume for critical period
• Upper limit that should never be exceeded

M 5 is only a guide to understand the risk for
fluid over load
44
Fluid Management in Recovery Phase
45
Fluid Management in Recovery Phase

• Dengue patients have accumulated fluid within
  his/her body
• Cut down fluid
• Give oral fluid if tolerating
• Dropping HCT is not bleeding
• Rising HCT in stable child manage with oral fluid

DHF grade 3 recovery phase nurse inform that
child has massive meleana HCT dropped to 35 !
Dont panic if the child is stable, hematocrit 35
is because he is recovering child is passing what
he bled yesterday
46
6 yr old boy DHF grade 4 recovered after 3 fluid
boluses. His HCT dropped from 48 to 39. However
he again developed circulatory failure with
reduced pulse pressure.
47
Management of severe bleeding

• Probably he has internal bleeding
• Manage with
• 10 ml/kg whole blood
• 5 ml/kg Packed RBC

48
Indications for Blood Transfusions
only 10-15 patients need blood

• Overt bleeding ( more than 10 or 6-8ml/kg)
• Significant drop of HCT lt 40 ( lt 45 for males)
  after fluid resuscitation
• Hypotensive shock low/normal HCT
• Persistent or worsening metabolic acidosis
• Refractory shock after fluid 40-60 ml/kg

Circulatory failure with high HCT should be
managed with colloids ( Lasix if fluid
overloaded) before blood
49
Why do you do platelet counts ? (Answer this MCQ)

• To decide on platelet transfusion
• To recognize the beginning of critical stage -
• As a prognostic indicator-

50
Why do you do platelet counts ?

• To decide on platelet transfusion - X
• To recognize the beginning of critical stage -
• As a prognostic indicator-

51
Fluid Over Load
52
Causes of Fluid Over Load

• Too much fluids in febrile phase
• Excessive and/or too rapid IV fluids
• Use of hypotonic crystalloid solutions
• Inappropriate IV fluids for severe bleeding
• Inappropriate - FFP, platelet cryo
• Continuation of IV fluids after Critical phase
• Co-morbid conditions
• congenital or ischaemic heart disease
• chronic lung and renal diseases
• Obesity Fluid not calculated for IBW

53
Early Clinical Features of Fluid Overload

• Respiratory distress
• Difficulty in breathing
• Rapid breathing
• Chest wall in-drawing
• Wheezing (rather than crepitations)
• Large pleural effusions /or Tense ascites
• Increased jugular venous pressure (JVP)

54
Management of Fluid over load

• Minimize fluid
• Stop if in recovery phase
• Minimize in critical phase
• Nurse in the R lateral position
• Maintain oxygen saturation above 95
• IV Furosemide 10 Dextran (40) 10 ml/kg ?
• Correct hypokalaemia
• Assess ABCS

55
How to prevent fluid over load
Leaking Blood vessels ! Give only minimal
essential

• Try to manage within the fluid quota (M5)
• For 48 hrs for non shock patients
• For 24 hrs for shocked patients
• Expected Urine out put is only 0.5 ml/kg/hr
• Calculate oral fluid also
• Monitor fluid intake regularly during critical
  period Use a fluid monitor

56
What to do in practice
3 yr old mucus diarrhea mild dehydration had HCT
55
57
8 year old 30 kg girl Fluid for 48 hrs
30 kg IBW - 25 kg
M 1700 1600
M5 3200 2850
5 ml/kg 7200 6000
3 ml/kg 4320 3600
1.5 ml/kg 2160 1800
58
Fluid balance in health and dengue
Health Ml/kg/hr Dengue Ml/kg/hr
Total intake 3 3
UOP 2 1
Insensible loss 1 1
Leaking ( ve balance) 0 1
Water for growth was not taken in to consideration
59
Fluid balance in health and dengue
Health Ml/kg/hr Dengue Ml/kg/hr
Total intake 3 5
UOP 2 2
Insensible loss 1 1
Leaking ( ve balance) 0 2
Water for growth was not taken in to consideration
60
Fluid balance in health and dengue
Health Ml/kg/hr Dengue Ml/kg/hr
Total intake 3 1.5
UOP 2 0.5
Insensible loss 1 1
Leaking ( ve balance) 0 0.25
Water for growth was not taken in to consideration
61
Monitoring Charts
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22 kg HCT/plt HR BP RR UOP CRFT Coldness Fluid Ml/kg
11.00 am 38 146 90/80 47 5 ml 8 Mid calf 10 ml/kg bld
12.00 noon 48 100 110/80 49 SOB 10 2 ankle 10 ml/kg HS Laxis 20 mg
1.00 pm 41 100 100/70 40 Acitis effusions 100 2 - 3 ml/kg NS
2.00 pm 110 100/70 38 Effusions 60 2 - 1.5 ml/kg
?
3 ml/kg NS /one hr
2222/2640
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47
63


10
9
8
7
6
5
4
3
2
1
0
1 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48
PCV 52 45 51 46 49 40 48 35 42
UOP 00 00 20 45 30 30 15 65 65 10 10 95 60 60 75 60 45 45 60 85 100 100 40 50
HR 140 140 140 110 110 110 160 120 120 160 100 110 100 100 100 110 100 110 100 100 100 100 100 98
RR 35 30 35 35 35 30 38 32 34 38 45 35 35 30 25 25 25 20 20 20 20 20 20 20
BP 90/80 90/80 90/80 95/70 95/70 95/65 80/70 90/80 90/80 65/50 100/70 95/70 100/75 95/70 95/70 95/70 95/70 95/70 100/70 100/70 95/70 95/70 95/70 100/70
64
Fluid over load

• Why?

65
Causes of fluid over load

• Clinicians gave too much fluid - eg 3-5 ml/kg/hr
• Clinicians thought that extra fluid in the
  febrile can prevent shock
• Clinicians thought giving blood can be dangerous
• Personal opinion with no proof

WHY ?
Lack of knowledge and training
66
Condition of the patient HCT Rising HCT Dropping
Deteriorating Colloids Blood transfusion
Improving Observe Increase fluid rate during early critical phase Improving ! Encourage normal feeding
67
Use Void Volume Chart
68
7 year old (20 kg ) boy passed 100 ml of urine at
12 MN. He passed urine at 5 pm soon after coming
to the ward. Interpret his UOP

• UOP is 0.74 ml/kg/hr

69
He was given 100 ml/hr of Hartmann solution from
MN up 6 am when he passed 400 ml of urine.

• UOP is 3.3 ml/kg/hr
• ?

His blood counts done on admission total 5.6 ,
Platelets 50 000/dl, PCV 45
70
Same fluid rate was continued. At 12 noon he
passed 40 ml of urine.

• UOP is 0.3 ml/kg/hr
• ?

Blood counts done at 6 am Platelets 50 , HCT 42
Circulation HR 120, cold limbs CRFT 5 sec
71
Patient develop massive fluid over load. After 30
hours in critical phase, he is on fluid 15
ml/kg/hr. He passed 300 ml of urine in 4 hrs.

• UOP is 3.75 ml/kg/hr
• ?

Blood counts done at 6 am Platelets 60 , HCT 36
Circulation HR 98, no cold limbs CRFT 3 sec
72
Use monitoring chart

• Chart one Suspected dengue patient not in
  critical stage
• Chart two Start once patient enter the critical
  stage

Knowing the stage of the illness by everybody in
the team is very important in management of
dengue patients
73
Unusual Manifestations of Dengue

• Encephalopathy
• Hepatic failure
• Renal Failure
• Dual infections
• Underline conditions

74
Ward round presentation by ho/sho

• This 7 yr old IBW 20 kg child came to the ward 3
  days ago, entered the critical phase yesterday
  morning. Now 24 hrs in critical phase. On 5
  ml/kg/hr of Hartmann.
• Stable circulation. Warm limbs, CRFT 2 sec, BP
  100/60
• UOP for last six hours 0.8 ml/kg/hr
• Last HCT 48 ( it has gone up from 42)
• So far We have given 1200 ml out of 2500 ml 48 hr
  fluid quota
• We thought of increasing fluid to 7 ml/kg/hr

75
Diagnosis Card of DHF Patient
Diagnosis Dengue Hemorrhagic Fever Grade
4 (Severe Dengue with hypotensive shock)

• Management
• Total fluid during critical period
• 1850 / 1900
• Crystalloid boluses 3
• Colloid boluses 1
• Blood 10ml/kg x1

• Patient entered critical phase 24 hrs after
  admission to ward
• HCT - Maximu 52, minimum 32
• Platelets Max 120, Mini 40
• Blood pressure min 40/ ?

• Complications
• Fluid over load Wheezing, Pleural effusions
  and ascites. Lasix 20 mg x2
• Bleeding ( HCT 32, need blood 10ml/kg)
• Hypocalcaemia Serum Ca 1.8 ( treated with 10
  ml 10 ca Gluconate)

76
Initial fluid for following DHF patients

• DHF with no palpable pulse
• 10-20 ml/kg/15 mt normal saline
• DHF palpable pulse but low BP
• 10ml/kg/15 mt NSS or colloids
• DHF normal BP, cold limbs CRFT 4 sec
• 10ml/kg/hr NSS 10 Dextrose
• DHF no shock just entered the critical phase
• 1.5 ml/kg/hr
• DF/DHF in febrile phase Oral fluid ?5 ml/kg/hr

77
Thank You