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2. Fluid Management in Dengue Hemorrhagic Fever

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PowerPoint Presentation ... Pathogenesis Clinical Implications Key Points Monitoring Parameters Fluid Management Critical Phase Amount of Fluid? Ideal Body ... – PowerPoint PPT presentation

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Title: 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
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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
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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

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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

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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
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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
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