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Management of Severe Dengue

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Management of Severe Dengue Definition Severe dengue: DHF grade 3 and 4 Dengue with severe organ impairment: Dengue with fulminant hepatitis Dengue with myocarditis ... – PowerPoint PPT presentation

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Title: Management of Severe Dengue


1
Management of Severe Dengue
2
Definition
  • Severe dengue
  • DHF grade 3 and 4
  • Dengue with severe organ impairment
  • Dengue with fulminant hepatitis
  • Dengue with myocarditis
  • Dengue with encephalitis
  • Dengue with respiratory distress

3
Clinical course of DHF
4
Clinical assessment for severe dengue and DHF
Grade 3 4
  • During critical phase
  • Plasma leakage around defervescence phase
  • Evidence of plasma leakage includes
  • raised HCT (early marker),
  • haemodynamic instability,
  • Skin- cool and pallor, delayed capillary refilled
    time
  • Reduced pulse pressure to lt 20 mmHg
  • Tachycardia
  • Hypotension SBPlt 90 mmHg
  • fluid accumulation in extravascular space (rathe
    late marker)
  • Pleural effusion
  • Ascitis
  • hypoproteinemia.

5
DHF Grade 3 4-clinical assessment
  • Intense thirst,
  • Abdominal pain, epigastric pain,
  • Vomiting,
  • Restlessness,
  • Reduced urine output
  • Altered conscious level,
  • Shortness of breath and tachypnoea,
  • Sudden change from fever to subnormal temperature

6
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7
Fluid management - When to initiate IV fluid
replacement?
  • Not taking orally
  • Dehydration and rising haematocrit level
  • Diarrhoea
  • Vomiting
  • Decreased sensorium
  • Compensated shock
  • Decompensated shock

8
Fluid management - maintenance
  • Calculations for normal maintenance of
    intravenous fluid infusion per hour
  • (Equivalent to Halliday-Segar formula)
  • 4 mL/kg/h for first 10kg body weight
  • 2 mL/kg/h for next 10kg body weight
  • 1 mL/kg/h for subsequent kg body weight
  • For overweight/obese patients calculate normal
    maintenance fluid based on ideal body weight
  • Ideal bodyweight can be estimated based on the
    following formula
  • Female 45.5 kg 0.91(height -152.4) cm
  • Male 50.0 kg 0.91(height -152.4) cm

9
Fluid management - general rules
  • Frequent adjustment of maintenance fluid regime,
  • 1.2-1.5 X Maintenance in critical phase,
  • If gt 1X Maintenance required, regime need to be
    reviewed 4-6 Hly.
  • Rising HCT- increase infusion rate
  • DSS fluid resuscitation algorithm
  • Stop fluid therapy once after critical phase and
    patient is stable (post defevercence).

10
Dengue Shock Syndrome DHF Grade 3 and 4 (DSS)
  • Medical emergency
  • Early and prompt management lead to better
    outcome,
  • Should be nursed in High dependency unit or ICU
  • Fluid resuscitation should be prompt,
  • Following initial resuscitation there maybe
    recurrent episodes of shock because capillary
    leakage can continue for 24-48 hours

11
Fluid management type of fluid
  • no clear advantage of using colloids over
    crystalloids in terms of the overall outcome.
  • colloid may be preferable in patients with
    intractable shock in the initial resuscitation.
  • The choice of colloids includes gelatin solution
    (e.g. Gelafusine) and starch solution (e.g.
    Voluven)

12
DSS Fluid resuscitation
  • 2 IV lines (largest branula possible)
  • 1st line for replacement/bolus
  • 2nd line for blood taking OR blood transfusion

13
DHF GRADE 3 4 (DSS) Fluid Resuscitation
Algorithm
14
After fluid resuscitation assessment for
improvement
  • Clinical parameters
  • Improvement of general well being/ mental state
  • Warm peripheries
  • Capillary refill time lt 2sec
  • BP stable
  • Improving pulse pressure
  • Less tachycardia
  • Increase in urine output
  • Less tachypnoea
  • Laboratory parameters
  • Decrease in HCT
  • Improvement in metabolic acidosis

15
If no improvement after the 1st bolus
16
If no improvement after the 2nd bolus
17
If improvement after the bolus(es)
18
After 1st bolus fluid IMPROVED?YES
  • Clinical parameters must be monitored every
    15-30 minutes during shock!
  • Fluid regime must be reviewed and readjusted
    every 30 -60 minutes.
  • Recurrent episodes of shock can occur after
    initial resuscitation (due to continuing plasma
    leakage) for 2nd bolus fluid resuscitation
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