3. Documentation and

Monitoring of Dengue Patients

Dengue Expert Advisory Group

WHY MONITOR DENGUE PATIENTS?

• 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

BASIC MONITORING

ALL PATIENTS

• 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

FEBRILE PATIENT

• Dengue or not?

– Clinical

– FBC

• Leucopaenia + thrombocytopaenia

• DF or DHF ?

– Plasma leakage + or –

• If DHF – what is the phase ?

WHEN PATIENT AFEBRILE

• 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)

CRITICAL PHASE FACTS

• Dropping Platelets

• HCT rise of more than 20% of base line

Conforms 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).

RECOGNIZE THE STAGE OF THE

DISEASE

• Febrile phase

• Critical phase

• Convalescent phase

• Day of the illness ?

• Evidence of plasma leakage ?

• Convalescent rash ?

Assess

MONITORING & DOCUMENTATION

CRITICAL PHASE

• 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

WARNING

•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.

MONITORING CHART I - FOR MANAGEMENT OF

DENGUE PATIENTS – FEBRILE PHASE

D4 without

Fever

D3 with Fever

WBC

<5000/mm3

N-40% L-58%

TT + ve

Hct

%

D4 with

Fever

TT + ve, WBC

<5000/mm3

N-40% L-58%

Tender Liver

HOW TO TIME THE ONSET OF CRITICAL

PHASE?

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 25200

0

12100

0

11000

0

61000 22000 18000 12000 8000 19000

Onset End

MONITORING IV FLUID THERAPY

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 overloading Respiratory rate > 20/mt

• Lung bases

• SaO2 < 92%

• CXR Shift

ICU

CLINICAL PARAMETERS

HCt

Urine output

(based on IBW)

General condition

Appetite

Vomiting

Bleeding

Peripheral Perfusion

Pulse volume

Skin colour

Skin Temp.

CRFT

Fluid Therapy

PR

RR

BP/PP

CLINICAL SCENARIO

• 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

SCENARIO

• Afebrile

• Restless

• Confused

• Pulse volume poor

• Skin pale

• CRFT>2 sec

• Urine output < 0.5ml/kg/hr

• PR

• BP

• PP

• HCt

Decision

Blood Transfusion

SCENARIO

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

WARNING

• 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 )

PEARLS

• 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.

PEARLS

• 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.

PEARLS

• 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.

PEARLS

•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