DISEASE MONITORING

Dr Mahiran MustafaChairman of CPG

Development Committee

CONTENTS

• Brief review on different phases in dengue infection

• Issues at different phases

• Clinical monitoring for each phase

• Laboratory monitoring for each phase

INTRODUCTION

• Monitoring dengue cases require the understanding that dengue infection is a systemic and dynamic disease.

• Its clinical, haematological and serological profiles changing from day to day and accelerate by the hour during the critical phase, particularly in those with plasma leakage

• Failure in recognising and interpreting the clinical and

laboratory manifestations can lead to delay in appropriate management thus cause intractable shock and death

CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS

OUTPATIENT MONITORING

Symptoms:1. Warning signals 2. Bleeding manifestations3. Inability to tolerate oral

fluids4. Reduced urine output5. Seizure

Signs:1. Dehydration2. Shock 3. Bleeding4. Any organ failure

Laboratory:1. HCT

2. Hb

3. Platelet

DISEASE MONITORING CARD

DENGUE DISEASE PROGRESSION CARDPatient’s name: ________________________________I/C No. : _______________________________Date of onset of fever : __________________________

Date Temp °C BP PR PCV/HCT

WBC Platelet Attending Clinic/ phone no.

Next Appointment

CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS

• Clinical deterioration often occurs during the critical phase because of marked plasma leakage

Evidence of plasma leakage includes: raised HCT haemodynamic instability fluid accumulation in extravascular space

• Vascular permeability leads to leakage

• Haemoconcentration

• Hypovolaemia leads to reflex tachycardia and vasoconstriction

• Inadequate perfusion of the tissue leads to increased anaerobic glycolysis and resultant lactic acidosis

• Shock that leads to DIC and bleeding

Pathophysiology

WARNING SIGNALS

• Vomiting

• Abdominal pain

• Restlessness or altered mental state

• Mucosal Bleed

• Sudden change of temperature to subnormal

• Raising HCT with rapid drop in platelet

CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS

SEVERE MANIFESTATIONS

• Acute abdomen

• Hepatitis and hepatic failure

• CNS manifestations

• Carditis or cardiomyopathy

Pathophysiological changes from normal circulation to compensated and decompensated shock

Normal Circulation Compensated shock Decompensated / Hypotensive shock

Clear consciousness Clear consciousness Change of mental state – restless, combative or lethargy

Brisk capillary refill time (<2 sec)

Prolonged capillary refill time (>2 sec)

Mottled skin, very prolonged capillary refill time

Warm and pink extremities Cool extremities Cold, clammy extremities

Good volume peripheral pulses

Weak & thready peripheral pulses

Feeble or absent peripheral pulses

Normal heart rate for age Tachycardia Severe tachycardia with bradycardia in late shock

Normal blood pressure for age Normal systolic pressure with raised diastolic pressure Postural hypotension

Hypotension/ unrecordable BP

Normal pulse pressure for age

Narrowing pulse pressure Narrowed pulse pressure (<20 mmHg)

Normal respiratory rate for age

Tachypnoea Metabolic acidosis/ hyperpnoea

 

Fluid Guidelines

Fluid Therapy: Non Shock

Recommendation • Encourage adequate oral fluid intake. (Grade C)• IV fluid is indicated in patients who are vomiting

or unable to tolerate oral fluids. (Grade C)• IV fluid is also indicated in patients with

increasing HCT (indicating on-going plasma leakage) despite increased oral intake. (Grade C)

• Crystalloid is the fluid of choice for non shock patients. (Grade C)

Indications for referral to Intensive

• Recurrent or persistent shock

• Requirement of respiratory support (non-invasive and invasive ventilation)

• Significant bleeding

• Encephalopathy or encephalitis

DISCHARGE CRITERIA

• Afebrile for 48 hours• Improved general condition• Improved appetite• Stable haematocrit• Rising platelet count • No dyspnoea or respiratory distress from pleural

effusion or ascites• Resolved bleeding episodes• Resolution/recovery of organ dysfunction

Summary:Principles of disease monitoring

1.Dengue is a systemic and dynamic disease. Therefore disease monitoring is governed by different phases of the disease.

2. The critical phase (plasma leakage) may last for 24-48 hours. Monitoring needs to be intensified and frequent adjustments in the fluid regime may be required.

3. Recognition of onset of reabsorption phase is also important because intravenous fluid regime needs to be progressively reduced/ discontinued