Management of Severe Dengue

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Management of Severe Dengue
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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

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Clinical course of DHF
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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.

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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

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Fluid management - When to initiate IV fluid
replacement?

• Not taking orally
• Dehydration and rising haematocrit level
• Diarrhoea
• Vomiting
• Decreased sensorium
• Compensated shock
• Decompensated shock

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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

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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).

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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

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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)

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DSS Fluid resuscitation

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

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DHF GRADE 3 4 (DSS) Fluid Resuscitation
Algorithm
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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

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If no improvement after the 1st bolus
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If no improvement after the 2nd bolus
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If improvement after the bolus(es)
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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