2. Fluid Management in Dengue Hemorrhagic Fever

1
2. Fluid Management in Dengue Hemorrhagic Fever

• Dengue Expert Advisory Group

2
Dengue Virus Infection

• Asymptomatic
• Symptomatic
  Undifferentiated
  Febrile Illness
  Dengue Fever
  Dengue
  Hemorrhagic Fever
  ? Non Shock
  ? Shock

3
Dengue Hemorrhagic Fever

• Febrile Phase
• Critical phase characterized by plasma leak
• Convalescent Phase

4
Dengue Leak Fever

• Plasma leak during critical phase is the hall
  mark
• Leading to 3rd space losses
  peritoneal cavity
  
  pleural cavity
• Variable in magnitude and exact timing

5
(No Transcript)
6
Pathogenesis of leak

• Infection with a virulent dengue virus
• Presence of antibodies that enhance dengue virus
  infection (ADE)
• Intense immune activation

7
Pathogenesis

• Rapidly elevated cytokines (TNF-a, IL-2, IL-6,
  IL-8, IL-10, IL-12, and IFN-g)
• Malfunction of vascular endothelial cells
• Plasma leakage from intra to extravascular space

8
Pathogenesis

• In severe DHF the loss of plasma is critical
• Patient becomes hypovolaemic
• Signs of circulatory compromise
• Progress to shock, organ failure, death

9
Pathogenesis

• Cytokine Storm
• Self limited
• Ends after 48 hours

10
Clinical Implications

• Extravascular fluid loss at variable rate that
  has to be matched ml for ml
• Lasting 48 hours
• Resorption of fluid during convalescent phase

11
Key Points

• Manage critical phase with appropriate volume
  
  Dont under transfuse
  Dont over
  transfuse
• Meticulous monitoring during critical phase to
  match rate of fluid infusion with rate of leak

12
Monitoring Parameters

• Clinical
  Pulse Rate
  
  Blood and Pulse Pressure
  Capillary
  Refill Time
  Urinary Output
• Lab
  Hematocrit

13
Fluid Management Critical Phase
14
Amount of Fluid?

• Based on weight
• Adults
  If less than
  50kg use actual weight
  If more take weight as 50 kg
• Paediatrics
  Current OR
  Ideal body weight whichever is lower

15
Ideal Body Weight

• Weight for height using a growth chart
• Weight for age
• Formulae in emergency

16
Growth Charts
17
(No Transcript)
18
Formulae

• lt1 year Age (in Months) 9/2
• 1-7 years (Age x 2) 8
• gt7 years Age x 3
• APLS (Age in years 4) x 2

19
Fluid Quota

• M 5 Maintenance 5 of body weight
• Over 48 hours if patient presents in the
  beginning of critical phase (without shock)
• Over 24 hours for patients coming in shock

20
(No Transcript)
21
(No Transcript)
22
M 5 - Adults

• Maintenance
  1st 10 kg 1000
  mls
  2nd 10 kg 500 mls
  Remaining 30kgs
  600 mls
  Sum 2100 mls
• 5 deficit 50 x 50 2500 mls
• Total 4600 mls

23
Child 22 kg

• Maintenance
  1000 500 40
  1540 mls
• 5 Deficit 50 x 22 1100 mls
• Total 2640 mls

24
Types of Fluid

• Crystalloids
  0.9 Saline
  
  5Dextrose 0.9 Saline
  5 Dextrose ½
  saline

25
(No Transcript)
26
Monitoring Critical Phase

• Vital parameters - hourly
• Fluid balance chart - assess three hourly
• HCT - six hourly

27
Fluid Management in Dengue Shock Syndrome
28
Compensated

• Body compensates for fluid loss
• Tachycardia
• Pulse Pressure narrows
• Prolonged CRT
• Fall in urine output to 0.5 mls/kg/hr

29
Decompensated

• Pulse pressure narrows further leading to
  unrecordable pulse and BP
• Urine output falls less than 0.5 mls/kg/hour

30
Fluid Resuscitation

• Crystalloids N Saline
• Colloids
  Dextran 40 in N.
  Saline
  6 Starch
• All boluses part of fluid quota

31
Indications for Colloid

• Failure of crystalloid boluses to normalize pulse
  /BP
• Development of shock
  with fluid overload
  
  amount of fluid exceeding M 5 deficit
• 10 ml/kg over 1 hour

32
Colloids

• Dextran may sometimes interfere with grouping and
  cross matching
• 3 doses of Dextran 40 during a 24 hour
• 5 doses of 6 Starch during 24 hour
• Remain in circulation for much longer

33
(No Transcript)
34
(No Transcript)
35
Refractory Shock - ABCS

• Blood
  packed cells
  
  whole blood
• Bicarbonate
• Glucose
• Calcium

36
Monitoring During Shock

• 15 minute monitoring of vital signs
• HCT immediately before and after each fluid bolus
  and then at least two to four hourly

37
Key Points Managing DHF

• Recognizing the start of critical phase of DHF
• Predicting the rate of leak which may vary from
  patient to patient and within the same patient
• Matching the rate of infusion to rate of leak
• Being cognizant of the end of critical
  phase

38
Key Points Managing DSS

• Meticulous monitoring
• Switching appropriately from crystalloids to
  colloids
• Recognizing need for blood transfusion