3. Documentation and Monitoring of Dengue Patients

Dengue Expert Advisory Group

• To differentiate DHF from DF

• Assessing onset of Critical Phase of DHF

• Smooth manipulation of fluids averting prolonged shock and fluid overload

• Early detection of complications

• Recognition of unusual presentations

• Pulse rate• Pulse pressure• CRFT• Respiratory rate• FBC - HCT• Intensity of monitoring depends on

• Phase of the illness• Severity• Aggressiveness of fluid therapy

• Accurate fluid balance charts

Ministry of Health Sri Lanka

• Dengue or not?– Clinical– FBC

• Leucopaenia + thrombocytopaenia

• DF or DHF ?– Plasma leakage + or –

• If DHF – what is the phase ?

• Critical phase– Time of entry– Predicted time of end

• Aggressive monitoring

• Calculate the fluid quota

• Dynamic approach to fluid therapy

• Final diagnosis – precise (DF or DHF & grade)

• Dropping Platelets • HCT rise of more than 20% of base lineConforms DHF as it signify leak.Even If HCt rise less than 20% but pleural

effusion/ascites present conforms diagnosis of DHF/DSS( it is mostly due to early volume replacement or bleeding).

• Febrile phase

• Critical phase

• Convalescent phase

• Day of the illness ?

• Evidence of plasma leakage ?

• Convalescent rash ?

Assess

• Detection of shock• Pulse pressure < 20 mm Hg• CRFT > 2 secs• HCT increase of 20% or more from baseline

• Efficacy of IV fluid therapy• Pulse pressure, capillary refill time, hypotension• To keep urine output at least 0.5 – 1.0 ml/kg/hr

• Early detection of Fluid overload• Respiratory rate > 20/mt • Lung bases• SaO2 < 92% • CXR

•Misjudging of critical phase which could begin as early as day 3 (if fever drop on day 3). • Delay in doing the WBC, platelets and Hct determinations. which help predict the critical stage/shock Lead to misdiagnosis and/or delay until shock

occur.

Dengue

FeverD4 without Fever

D3 with FeverWBC<5000/mm3

N-40% L-58%TT + ve

Hct%

Entry in to critical phase D4 with FeverTT + ve, WBC<5000/mm3

N-40% L-58%Tender Liver

17th 8 am

D3

18th

8 am

D4

18th 8 pm

D4

19th

8 am

D5

19th

8 pm

D5

20th 8 am

D6

20th 8Pm

D6

21st

8 am

D7

21st

8 pm

D7

WBC 3200 2800 1900 2900 3700 4500 6000 7000 7300

N % 53 41 31 26 25 31 33 43 58

L % 44 56 68 71 73 67 66 55 41

PCV %

39 36 39 42 43 39 44 43 38

Plt 252000

121000

110000

61000 22000 18000 12000 8000 19000Onset End

Phase of the illness – be fully aware• Adequacy of fluid therapy

• Pulse Pressure >20 mmHg• CRFT <2 sec• Pulse Rate <80/mt• UOP > 0.5 ml/Kg/hr• HCT

• Early detection of fluid overloadingRespiratory rate > 20/mt

• Lung bases• SaO2 < 92% • CXR

Shift ICU

HCtUrine output

(based on IBW)

General conditionAppetiteVomitingBleeding

Peripheral Perfusion Pulse volume Skin colour Skin Temp.

CRFT

Fluid TherapyPRRR

BP/PP

• If Afebrile Pt.• Restless• Irritable• Pulse rate• Pulse volume poor• CRFT>2 sec• Skin cold• Pulse pressure<20• HCT• Urine output<0.5 ml/kg

Decision

IV Fluid Bolus

• Afebrile• Restless• Confused• Pulse volume poor• Skin pale • CRFT>2 sec• Urine output < 0.5ml/kg/hr• PR• BP• PP• HCt

Decision

Blood Transfusion

Afebrile patient•Puffy eyelids •Distended abdomen•Tachypnea•Dyspnoea•orthopnea•Respiratory distress

Vital Signs •Pulse volume good•Skin colour normal•Skin temp. normal•Pulse pressure• wide•Urine output > 1ml/kg/hr•CRFT< 2 sec•PR•BP•HCt

Decision

Dextran 40 with

frusemide

• Be vigilant to recognize DSS as most of the patients remain in good conscious and have narrow pulse pressure with increased diastolic pressure(e.g.BP=110/90, 100/80mm Hg) without hypotension.

• Avoid misdiagnosis of DHF in Infants(<1 year) with fits as sepsis/infection followed by LP leading to bleeding/ hematoma(platelets )

• Your initial timing of critical phase may prove to be sometimes wrong

Be prepared to change what you decided earlier or shift the timing based on more information you receive while Mx.

• Try to Master the ways of giving

‘ THE SMOTHEST AND THE MOST UNEVENTFUL RECOVERY’ for the patient.

• Avoid both shock and fluid overload.

• Keep ‘CHECKING ON A TIME SCALE’… R u heading for fluid overload? If so, switch to a colloid.

• At ‘END OF LEAKING PHASE’ even if PCV is high but patient is well, pulse, BP is OK

• Don’t try to correct PCV as re absorption will start soon and PCV will come down so..

WAIT.

•About 60% of DSS can be successfully resuscitated by using crystalloid solution only, 20% need colloidal and 15% need blood transfusion (+blood components). •With rapid recognition of shock and proper treatment rapid and dramatic recovery is the rule