Lessons from Dengue mortality

Dr Suresh Kumar

Hospital Sungai Buloh

Suresh

2

Warning signs

Adult CPG; revised 2nd edition; 2010

Suresh

Look for warning signs

25 year old chinese female

Day 6 fever

Temp 37.8

Started having vomiting since yesterday

24 hours earlier Current

WCC 1,600 1,500

HCT 37 38

PLT 114,000 87,000

WHO proposed new Dengue case classification

Withoutwith

warning signs

1.Severe plasma leakage 2.Severe haemorrhage3.Severe organ impairment

Severe dengueDengue ± warning signs

Probable dengueLive in/travel to dengue endemic area. Fever and 2 of the following criteria:• Nausea, vomiting• Rash• Aches and pains• Tourniquet test positive• Leucopenia• Any warning signLaboratory confirmed dengue(important when no sign of plasma leakage)

Warning signs*• Abdominal pain or tenderness• Persistent vomiting• Clinical fluid accumulation• Mucosal bleed• Lethargy; restlessness• Liver enlargement >2cm• Laboratory: Increase in HCT concurrent with rapid decrease in platelet count

* Requiring strict observation and medical intervention

1. Severe plasma leakageleading to:• Shock (DSS)• Fluid accumulation with respiratory distress

2. Severe bleedingas evaluated by clinician

3. Severe organ involvement• Liver: AST or ALT>=1000 • CNS: Impaired consciousness • Heart and other organs

Criteria for dengue ± warning signs Criteria for severe dengue

WH

O/T

DR

20

09

Suresh

Case study 1

26 yr malePresented with fever for 6 days, high grade fever+headache and dizzienss+nausea+vomiting-after every meal-->food particle, non projectile+no abd pain+had diarrhea since yesterday

currently afebrile for the past 2 days

Suresh

FBC from GPwbc 2.1, plt 37 , pcv 51.5

no bleeding tendenciesno SOBno chest pain

no hx of jungle trekking,swimming in the lake,fishing,camping

stays and works in Saujana Utamaowns a grocery storeno recent fogging historyno recent travelling history

Suresh

Do you agree with the managmentWhat is the complete diagnosis?

BP-130/80

PR70/min

CRT<2 secs

Good volume pulse

FBC in ED pre bolus:wbc: 1.7, Hb: 18.9, HCT: 52.1 plt: 1

given bolus 10 mls/kg normal saline in EDpost bolus fbc:twc: 2.3Hb: 17.1HCTT: 48.1PLT: 1

Suresh

Complete diagnosis

Management of Dengue infection involves

Making a complete diagnosis

Phase of the disease – febrile, defervescence (critical), recovery

Warning signs

Compensated shock / decompensated shock

Evidence for severe dengue

Plasma leakage

Liver impairment

Hemorrhage

Suresh

Case study 1

26 yr malePresented with fever for 6 days, high grade fever+headache and dizzienss+nausea+vomiting-after every meal-->food particle, non projectile+no abd pain+had diarrhea since yesterday

currently afebrile for the past 2 days

Suresh

FBC from GPwbc 2.1, plt 37 , pcv 51.5

no bleeding tendenciesno SOBno chest pain

no hx of jungle trekking,swimming in the lake,fishing,camping

stays and works in Saujana Utamaowns a grocery storeno recent fogging historyno recent travelling history

Suresh

BP-130/80

PR70/min

CRT<2 secs

Good volume pulse

FBC in ED pre bolus:wbc: 1.7, Hb: 18.9, HCT: 52.1 plt: 1

given bolus 10 mls/kg normal saline in EDpost bolus fbc:twc: 2.3Hb: 17.1HCTT: 48.1PLT: 1

Suresh

Complete diagnosis

Management of Dengue infection involves

Making a complete diagnosis

Phase of the disease – febrile, defervescence (critical), recovery

Warning signs

Not in shock / Compensated shock / decompensatedshock

Evidence for severe dengue

Plasma leakage

Liver impairment

Hemorrhage

Suresh

Fluid regime for Dengue with warning signs

Start with 5–7 ml/kg/hour for 1–2 hours,

then reduce to 3–5 ml/kg/hr for 2–4 hours,

then reduce to 2–3 ml/kg/hr or less according to the clinical response

WHO 2009

Suresh

Fluid resuscitation in Dengue

Plasma loss must be immediately replaced

The volume of fluid

Just enough to maintain an effective circulation during the period of leakage

Too rapid intravenous fluids can lead to fluid overload, increased pleural effusion and ascites

Suresh

Fluid regime in compensated shock

5-

10

5 - 7

3 - 5

2 - 3

1.5 – 2

Aim to stop

1 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 24-48

Suresh

Intermittent boluses

5-

10

2-3

2

10

2 - 3

20

2 - 3

1 2 3 4 5 6 7 8 9 10 12 13 14 15 161

718

19

20 21 22 23 24 24-48

Suresh

Causes of fluid overload

excessive and/or too rapid intravenous fluids

incorrect use of hypotonic rather than isotonic crystalloid solutions;

inappropriate use of large volumes of intravenous fluids in patients with unrecognized severe bleeding;

inappropriate transfusion of fresh-frozen plasma, platelet concentrates and cryoprecipitates;

continuation of intravenous fluids after plasma leakage has resolved (24–48 hours from defervescence);

co-morbid conditions such as congenital or ischaemicheart disease, chronic lung and renal diseases.

WHO 2009

Suresh

Fine tuning the fluid regime

• The fluid regime will depend on

• Stage of disease

• Presence or absence of warning signs

• Hemodynamic status

• BP, PR

• Peripheral circulation

• Fluid regime when the blood was taken

Suresh

Fine tuning the fluid regime

• The fluid regime will depend on

• Stage of disease

• Presence or absence of warning signs

• Hemodynamic status

• BP, PR

• Peripheral circulation

• Fluid regime when the blood was taken

Suresh

WHO 2009

“The period of clinically significant plasma leakage usually lasts 24-48 hours”

Suresh

Critical phase

Usually at day 3-7 of illness

Around the time of defervescence

Temperature drops to 37.5 – 380C

Some patients can progress to the critical phase without defervescence

Changes in FBC will help in identifying the onset of critical phase

WHO 2009

Suresh

Evidence of plasma leakage

Haemoconcentration (20% above baseline)

A drop in haematocritfollowing fluid replacement

Adult male

Hct >46%

Adult female

Hct >40%

3rd space fluid accumulation

Pleural effusion, Ascites

Suresh

Picking up plasma leakage

“Progressive leukopenia followed by a rapid decrease in platelet count usually precedes plasma leakage”

“Chest x-ray and ultrasound abdomen can be useful tools for diagnosis”

WHO 2009

Suresh

“The period of clinically significant plasma leakage usually lasts 24-48 hours”

We need to estimate the onset of leakage and start

counting the hours since the onset of leakage

Potential pitfallsClinically significant leakage starts early if we give too much bolus fluids early on.

If we use only changes in HCT as the marker of plasma leakage, correction of dehydration will make us assume that the leakage has started

Suresh

Suresh

Fine tuning the fluid regime

• The fluid regime will depend on

• Stage of disease

• Presence or absence of warning signs

• Hemodynamic status

• BP, PR

• Peripheral circulation

• Fluid regime when the blood was taken

Suresh

Suresh

09/05;03.20AM: WBC 2.10, Hb 15,0 Hct 46.0, Plt 118 (LAB)500CC - NS

09/05; 04.30AM: WBC 1.4, Hb 12.9 Hct 34.8, Plt 6 (ED)1000CC - NS

09/05; 06.00AM: WBC 1.58 Hb 13.5 Hct 39.8 Plt 58 (LAB)500cc gelafundin

09/05; 07.29AM: WBC 1.55 Hb 10.6 Hct 31.1 Plt 62

Suresh

Photo gxm form

Suresh

Role for red cell/whole blood transfusions

WHO 2009

Suresh

Suresh

1qw

Suresh

Decision making in dengue

• Pulse rate

• Peripheries

• Capillary return

• Most useful

• HCT & WBC count

• Warning signs

• Evidence of plasma leakage

• Look for defervescence

• Hours since onset of leakage

Identify phase of

illness

Symptoms & signs

Assess peripheral circulation

Lab parameters

Suresh

A good

Dengue

team

Suresh

Thank you

Hospital Sungai Buloh