DENGUE

1. By

2. Biodata
• My patient Mohammad Gulzar, 20 Years,old
resident of Jhelum, and manual worker by
profession, unmarried, presented in
emergency department on 9th September,
2014.

3. Presenting complaints
• High grade Fever for 8 days
• Bodyaches for 8 days
• Vomiting for 6 days

4. • Patient was in his usual state of health when
he started fever.
• It was sudden in onset initially high grade,
associated with rigors and chills and slightly
relieved by medications from the local doctor.

5. • It was associated with body aches of severe
degree and patient felt very weak and he was
not able to continue his daily job activities.
• Fever has daily variation of less than 10C and
whenever recorded with thermometer it was
around 102 to 103 OF.
• Was no associated rash on the body
• He went to local doctor who gave him some
open medications but those medications gave
no relief to the patient.

6. • During his illness he has marked nausea and
he was not able to take food in fact his
appetite was markedly suppressed and his
nausea worsens whenever he looked at or ate
food.

7. • 6 days back he started having vomiting as
well. He had 2 episodes of vomiting on first
day, which were non foul smelling containing
food particles which he recently took and it
was non-projectile.
• On 6th day both vomiting episodes were clear
and not containing the slightest of blood.

8. • On 7th day he again had 3 episodes of
vomiting non projectile and non foul smelling
and occurred after in take of food.
• But this time around all 3 vomitus contained
blood (coffee ground).
• After that patient’s attendants took him to the
hospital and he was admitted in emergency
ward of Mayo Hospital.

9. Systemic review
• General: decrease sleep, decrease appetite,
decrease energy.
• Git : no history of diarrhea, no history of black
tarry stools, no history of yellow discoloration
of eyes or sclera.
• Respiratory: no history of shortness of breath,
no history of seasonal variation, no history of
nose or ear discharge, no history of cough
with sputum.

10. • CVS: no history of shortness of breath on lying
flat, no history of chest pain on exertion, no
history of palpitation.
• CNS: no history of focal weakness, no history
of fits, no history of diplopia, no history of
headache.

11. Past history
• No history of previous hospital admission.
• No history of hypertension, diabetes, TB, CVA,
MI or meningitis.

12. Socio-economic history
• Patient is laborer by profession and his
earning is only 6000 per month.
• He belongs to a lower socio-economic class.

13. Drug history
• No history of any drug allergies.
• He was not using any medications for any
reason previously.
• During this illness, he used medications from
local doctor but those were open medications
without any labels.

14. Differential diagnosis
• Dengue hemorrhagic fever
• Enteric fever
• Aplastic anemia
• Lympho-proliferative disorder
• Malaria
• Yellow fever
• Secondary syphillis
• Ebola hemorrhagic fever
• Congo fever

15. • At presentation he was afebrile and lethargic
and ill looking.
• Patient was not maintaining bp. His bp was
only 70 systolic.
• He was shifted to HDU west medical ward
where he was given NS 50-80ml/hr.
• His platelet count was 7000 only
• He was transfused one pint of mega platelet
concentrate.

16. On 11th September
• After that he went into overload with fine
crepts up to middle zone of both lungs.
• His JVP was raised as well. Initially dextran 40
was not available but later on it was arranged
from emergency and he was given bolus of
dextran 40.
• After that his BP was built up to 125/80mm of
hg.

17. • At that point his breathing was gasping and he
was not maintaining oxygen saturation even with
3l/min oxygen inhalation.
• Inj lasix 40mg was given iv stat to relieve his
overload and to took him out of pulmonary
edema.
• Meanwhile ventilator was arranged and ETT
passed and patient was put onto ventilator on
SIMV with pressure support and PEEP was kept at
5 but later on increased to 7 which helped to
achieve saturation of 98%.

18. On 12th September
• Patient was given one more shot of inj lasix
40mg iv stat. and 1 pint of pcv of blood was
transfused.
• Patient developed high grade fever and inj
tazocin 4.5g iv tds was started to cover
pseudomonas of ICU setting.

19. • One more PCV was arranged as HB level was
falling and we were suspecting occult bleed.
• Ventilator was kept on SIMV with pressure
support mode.
• Tepid water sponging were continued and
only fluid to be given was dextran 40.
• Patient had three instances of fall in BP which
were managed by giving dextran 40 bolus.

20. On 13th September
• Antibiotic was continued but fever didn’t
settle so blood culture and sensitivity and
urine culture and sensitivity were planned and
sent.
• On examination power was 5/5 in all 4 limbs
with +2 reflexes at ankle, knee, bicep and
tricep.

21. • Patient was started NG feed and atralax was
stopped and later patient was shifted to CPAP
mode of ventilator.
• He was able to maintain Oxygen saturation on
CPAP and bp was also stable.

22. On 14th September
• Patient had episode of bradycardia and
neubulization with ventolin and tab theograde
350mg ½ po bd was started. Soon heart rate
was normalized but fever continued.
• Tepid water sponging were continued and inj
flagyll was added.

23. • CK MB report was sent which was found to be
raised 57.
• Call to cardiology was attended and they said
its sinus arrhythmia and advised to repeat call
on Monday for consultant opinion.
• Patient was still kept on CPAP mode of
ventilator and he was maintaining oxygen
saturation and bp.

24. On 15th September
• Patient was weaned off from ventilator and
kept under observation for 2hrs he was
maintaining oxygen saturation and he was
then extubated as well.
• Echocardiography and repeat cardiac enzymes
were planned.
• Patient is fully conscious and oriented and he
was able to take his food as well without NG
tube

27. A young male ill looking lying on
bed with ETT passed and on
ventilator

28. General physical examination
PALLOR +VE
• CYANOSIS -VE
• CLUBBING -VE
• JAUNDICE -VE
• PALMAR ERYTHEMA -VE
• PEDAL EDEMA +VE
• LYMPH NODES -VE
• THYROID -VE
• JANEWAY LESIONS -VE
• KOILONYCHIA -VE
• LEUKONYCHIA -VE

29. RESPIRATORY SYSTEM
INSPECTION
• Respiratory rate 34/min
• Abdomino-thoracic type
• Pattern of respiration is shallow rapid breathing
• No scar mark
• Chest seems to be moving equally on inspection
• Trachea is central

30. PALPATION
• Chest movements are equal bilaterally
• Chest expansion is 5cm
• Vocal fremitus is normal and bilaterally equal.
PERCUSSION
• Liver upper border is in fifth intercostal space
• Percussion note is resonant all over and bilaterally equal
AUSCULTATION
• NVB
• Fine end inspiratory crepts at bases bilaterally and
extending upto middle zone.
• No rhonchi, no coarse crepts, no pleural rub

31. GASTRO-INTESTINAL SYSTEM
INSPECTION
• Flat abdomen moving with respiration, no fullness in
flanks, umbilicus central and inverted, no scar mark.
PALPATION
• On superficial palpation , slight tenderness in
epigastric and right hypochondrial area. No palpable
mass
• On deep palpation liver is not enlarged and span is
13 cm. spleen is 1 finger breath enlarged
• Kidneys are not palpable.

32. PERCUSSION
• Shifting dullness is negative.
• Fluid thrill is negative.
AUSCULTATION
Bowel sounds are audible.

33. CARDIO VASCULAR SYSTEM
INSPECTION
• NO VISIBLE PULSATIONS
• NO SCAR MARK
PALPATION
• TRACHEA IS CENTRAL
• APEX BEAT IS IN 5TH INTERCOSTAL SPACE JUST MEDIAL TO
MID-CLAVICULAR LINE OF NORMAL CHARACTER
• NO PALPABLE THRILL
• NO PARASTERNAL HEAVE.
AUSCULTATION
S1+S2 and no added sounds

34. CENTRAL NERVOUS SYSTEM
• GCS is 14/15
• Patient was on ventilator hence speech and
higher mental functions can not be assessed.
• Bulk and tone both are normal in all 4 limbs.
• Power and reflexes in all 4 limbs are 5/5 and
+2 respectively.
• Planters bilaterally down going

36. 9/9/2014 10/9/201
4
11/9/201
4
12/9/201
4
13/9/201
4
14/9/201
4
15+16/9/
2014
HB
HCT
11.6
32
11
29
8.7
23
8.5,9.3
22 ,27
8.5,8.8
23.1 ,25
8.8,9.7
26.3,29.8
10.8,,10.3
31,,,,32.4
TLC 1,000 1.1,000 1.6 2.8,3.1 2.7,2.1 1.9,3.1 3.2,,,,,2.8
NEUTROPH
ILS
47% 65% 37% 68% 73% 52 75,,,,65
LYMPHOS 44% 30% 51% 30% 26% 46 22,,,,,34
PLATELET
S
7000 6000 4000 29000,32
000
31000,,,7
1000
21000,,
19000
29000,,
34000
ABGS PH
HCO3
O2 SAT
PCO2
7.26
14
61
32
7.46
23
99
32
7.50
24
99
31
7.51
24
99
30
7.5,7.51
26,,28
98,,95
33,,36
LFTS
RFTS
ALT-AST-ALBUM
75
187
2.7
25
17
3.4
87
250
2.7
60
158
2.7
57,,,
86
3.1

39. CT scan

40. X-RAY CHEST PA VIEW

41. Why patient went into fluid overload?

42. • Why patient was put on ventilator?

43. • Why higher PEEP was used?

44. • Why CK MB was raised?

45. • Why patient developed bradycardia?

46. • Why dextran 40 and inj lasix were used?

49. Diagnosis for Dengue
• Travel history and symptom profile
• Detection of antibodies against the virus
• Complete blood count
• Chemistry panel
• Liver function test
• Occult blood in stool
• DIC panel

50. Recognize the Stage of the
Disease
►Febrile phase
►Critical phase
►Convalescent phase
HOW
►Day of the illness ?
►Evidence of plasma leakage ?
►Convalescent rash ?

51. Fluid Therapy
“No Fixed Regime”
►Cornerstone of management
►Dynamic approach
►Be fully aware of the dynamics of the
disease
►Mode of intervention depends on:
► Phase
► Clinical type
►Type of fluid
►Oral fluids
►Crystalloid
►Colloid

52. Fluid Shifts
►N.Saline – 1 hour
►Colloids – 4 to 6 hours

53. Febrile Phase
►Oral fluids only
►Electrolyte solutions
►IV fluids are not mandatory
►Undue vomiting or diarrhea
►Oral fluids not tolerated
►Quantity:
►1500ml – 2500ml/24Hrs
►Both oral & IV
►Type:
►N.Saline

54. Critical Phase of DHF Without Shock
► Objective:
► Prevent progression to shock
► Avoid fluid overloading
► Judicious fluid therapy- Fluid restriction
► Quantity – calculated
► M+5% = 4600 ml / 48 hrs (50Kg)
► Full quota for entire critical phase 48 hrs
► Approximately 90 ml/hr
► Adjust infusion rate to match the dynamics of plasma leakage
► Type:
► N.Saline
Monitor
HR
PP > 20 mm Hg
CRFT < 2 secs
U.O.P. 0.5-1ml/kg/hr
HCT
RR <20/mt

56. Calculation of Total Fluid Quota for the
Critical Period
►M =
► 5 % =
► M + 5% =

57. Guide to rate of fluid intake in Critical Phase
Pulse
BP
Pulse Pressure
CRFT
Warmth / Coldness
UOP – ml/kg/hr
Evidence of
Bleeding

58. DHF with Shock
Aggressive Fluid Therapy
► Objective
►Resuscitate
►Prevent further shock
►Anticipate & prevent complications of shock
►GIT bleeding & DIC
► Intervention depends on:
► Compensated shock
►Systolic pressure maintained but signs of reduced
perfusion
►Narrow Pulse Pressure
► Cold extremities
► Low volume pulse
► Hypotensive shock
►Unrecordable BP & Pulse

59. Compensated Shock
► N.Saline 10ml/kg (approx 500 ml) IV – 1Hr
► No improvement
► Collect blood
► venous BGA
► Calcium HCT before & after fluid bolus
► Sugar
Sodium
► Grouping & DT
► Colloid bolus 10ml/kg IV over 1 hr
► Colloid boluses
► Haemodynamically unstable
► HCT drops
► Blood transfusion

60. Hypotensive Shock
HCT before & after fluid bolus
► N.Saline 10ml/kg IV bolus over 15 mts
►2nd bolus 10 ml/kg over 60 mts
► Collect blood
►Blood gas analysis
►Calcium
►Electrolytes
►Sugar
►Grouping & cross matching
► Colloid 10 ml/kg IV bolus over 1 hr

61. Choice of Colloid
Boluses NOT infusions
►Dextran 40
►3 boluses over 24 hours
►6 boluses over 48 hours
►6% starch-Heta starch(Voluven)
►5 boluses over 24 hours
►10 boluses over 48 hours
►Fresh Frozen Plasma
►1 bolus
►3 units approximately 450 – 600 ml

62. Monitoring & Documentation
► Early detection of shock
►Pulse pressure < 20 mm Hg
►CRFT > 2 secs
►HCT increase of 20% or more from baseline
► Judge the efficacy of IV fluid therapy
►PP , CRFT, No postural hypotension
►Hourly UOP 0.5 – 1.0 ml/kg/hr
► Early detection of complications of fluid therapy
►Respiratory rate > 20/mt
►Lung bases
►SaO2 < 92%
►CXR

63. Time of Presentation and Management
0 Hr 24
Hr
48
Hr
F C R

64. DH
F
Date/Time
Febrile
Date/Time
Critical
Date/Time
Convalesce
nt

65. 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

66. Monitoring
Platelet Count Drops Below 100,000
►FBC- twice daily
►Vital parameters- four hourly
 Pulse rate
 Blood pressure (both systolic and diastolic),
 Respiratory rate,
 Capillary refill time
► Detailed fluid balance chart-
 Type and route of fluid hourly,
 Urine output four hourly

67. Monitoring
Evidence of Plasma Leakage
Escalate
►Vital signs - hourly
►HCT - 8 hourly
►Fluid intake & the balance left from the
calculated quota
►Temporal relationship
►Critical phase
►In hours
►Detailed fluid balance chart

68. 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 to
ICU

69. Monitoring Chart I - for Management of Dengue
Patients – Febrile Phase

70. Monitoring Chart I - for Management of Dengue
Patients – Febrile Phase
D3 with Fever
WBC
<5000/mm3
N-40% L-
58%
TT + ve
D4 without
Fever

71. Monitoring Chart I - for Management of Dengue
Patients – Febrile Phase
D4 with Fever
TT + ve, WBC
<5000/mm3
N-40% L-58%
Tender Liver

72. Monitoring Chart II for Management of DHF Patients
Monitoring Chart II for Management of DHF Patients during Critical Phase
Patient to be monitored hourly
Annexure II
Name of the patient ………………………………………………………BHT……………………………….Date and time of admission ………………………………ward -…………………
Critical Phase Commencing date and time -…………………………………………………….. End date and time …………………………………
10
9
8
7
6
5
4
3
2
1.5
1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
PCV
Fluids
HR
BP
Pulse
Pressure
RR
CRFT
extremities
UOP
UOP
ml/Kg/hr
Platelet
count
Weight -
…………………………………
Height -
……………………………
Ideal body weight - …………… M- ………………………………… M+ 5% = …………………………ml
Used
Remaining
during Critical Phase

73. Date/Time Scale 20
Hrs
0 Hr 24
Hr
48
Hr
Date/Time Scale 2
Hrs
Date/Time Scale 36
Hrs

74. Monitoring Chart II for Management of DHF Patients
during Critical Phase

75. Monitoring Chart II for Management of DHF Patients
during Critical Phase

76. Summary – Febrile Patient
►Dengue or not?
 Clinical
 FBC
►Leucopaenia + thrombocytopaenia
►DF or DHF ?
 Plasma leakage + or –
►If DHF – what is the phase ?

77. Summary
►In 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)

78. 78
Pts with complications ....
Usually due to
• PROLONG SHOCK
• FLUID OVERLOAD

79. Fluid overload
– Too much fluids in febrile phase
– Calculation of fluids in obese pt-ABW vs
IBW
– Use of hypotonic saline
– Given excess fluids
– Given more than time of leakage
– Not using colloidal solution when indicates
– Not giving blood when there is concealed
bleeding
– Inappropriate IV Fluids for “severe
bleeding”
Eg: FFP, platelets & cryo 79

80. Clinical
Puffy eyelids
Distended abdomen
Tachypnea
Cough
Dyspnea and orthopnea
Respiratory distress
Vital Signs
Bounding Pulse
Wide pulse pressure
Hct UOP
> 1 ml/kg/hour

81. Management of fluid
overload
Critical Phase
Frusemide 1 mg/kg

82. Indications for IV Frusemide
► Midway in the infusion of colloids when colloids are given
to patients who are already fluid overloaded or who are
likely to be overloaded depending on the fluids already
given.
► Midway between blood transfusions.
► In patients passing less than 0.5ml/kg/hr of urine despite
receiving adequate fluids and having stable BP, pulse, Hct
to improve the UOP.
► During recovery phase when there is suggestion of
pulmonary oedema or fluid overload.
82

83. Prolonged shock
– Delayed diagnosis/ delayed
resuscitation
– Late presentation
– Fluid restriction without monitoring
83

84. Clinical
Restless
Irritable
Behaviour changes e.g. –
Confusion, speak fowl language
Vital Signs
Tachycardia
Pulse Pressure - < 20
CRFT - > 2 sec
Cold Extremities
Hct UOP
< 0.5 ml/kg/hour

85.  > 4 hours untreated
 Liver failure- prognosis 50%
 Liver + Renal failure - prognosis10%
 3 organs failure (+respiratory failure) – Prognosis is
a miracle!!!
 > 10 hours untreated - Death!!!
85

86. Complicated DHF
►When a pt is deteriorating with no
response to fluid therapy….
A: Acidosis
B: Bleeding
C: Calcium
S: Sugar
86

87. A : Acidosis
►Acidosis is common in profound shock
►Prolonged acidosis makes patients more
prone to DIC
►Correct acidosis if pH is <7.35 together with
HCO3- level <15 mmol/l
►One may use empirical NaHCO3 1ml/kgs
slow bolus (max 10ml) diluted in equal
volume
87

88. B : Bleeding
►Significant overt bleeding - >6-8ml/kg BW
►Concealed bleeding
88

89. When to suspect bleeding ?
• When PCV drop without clinical improvement
Even with bleeding the PCV drop may take time(4-5hrs).
When the pt does not show improvement important to
do repeat PCVs frequently!
• Haematocrit not as high as expected for the
degree of shock to be explained by plasma
leakage alone. (Hypotensive shock with low or
normal HCT)
• Severe metabolic acidosis and end-organ
dysfunction despite adequate fluid replacement
89

90. Massive bleeding
 Not given blood
transfusion
 Delayed blood transfusion
90
Remember!!!
In DHF Bleeding could be concealed

91. How to manage bleeding
►Use PRC or WB
►If there is fluid overload(most frequently)
use PRC as 5ml/kg at once and repeat only
if needed depending on the response
►If there is no fluid overload use 10ml/kg of
WB
►Even if bleeding is likely and if PCV is >45%
do not give blood without bringing down the
PCV first by giving a colloid.
91

92. • 5ml/kg of PRC or 10ml/kg of WB will
increase PCV by 5%
– Eg.10 year old girl with PCV of 26% in shock..
– Base line PCV in a 10 yr old 36% but if in shock
it will be up by 20% 43%. There is 17%
deficit which need 3 PRC transfusuions
92

93. C : Hypocalcaemia
►Every patient with complicated DHF has
hypocalcaemia.
►Dengue patients who develop convulsions
are likely to have hypocalcaemia.(may give
them empirical calcium)
►Detection of hypocalcaemia:
 Measure serum Ca2+ level
 Corrected QT interval in ECG
93

94. When to give calcium?
94

95. S : Hypoglycaemia
Treat if blood sugar below 4 mmol/lt
Give 10% dextose 3-5ml/kg bolus followed by
an infusion
95

96. Platelet transfusion-
►when platelets are low may need but only
in very exceptional circumstances
 (Thailand only in <0.4% of pts with DHF)
 Each platelet pack is 50-150ml  contribute
to fluid overload
 No prophylaxis platelet transfusion
96

97. Why do you do platelet
counts?
 To recognize the beginning of critical stage-
YES
 To decide on platelet transfusion- NO
 As a prognostic indicator- YES
97

98. Recombinant factor VII
►1 dose = 1,500 USD in a 10-kgs patient
►No use in cases with prolonged shock and
multiple organs failure
►Consider in cases with bleeding where the
cause is not prolonged shock BUT other
reason: peptic ulcer, trauma etc
98

99. Place of dopamine and
dobutamine...
►Very limited in DHF
►May do harm than good by giving a false
impression about BP
►When using1st make sure that there is
enough intravascular volume shown by
increased CVP
99

100. No Place For Steroids And Iv
Immunoglobulins In Dengue
100

101. 101
Blood & blood component used
in DHF/DSS patients
Crystalloid
100%
Colloid
Platelet 0.4%
Blood 20-25%
10-15%

102. Myocardial involvement in
Dengue
►Global dysfunction of myocardial
contractility seen in prolonged shock
►Due to, metabolic acidosis, Hypocalcaemia
►Unlikely to cause death
►If myocarditis is suspected fluid should be
given very carefully
►Rx- Symptomatic
102

103. Causes of death in DHF
patients
• Prolonged shock
– Delayed diagnosis/ delayed resuscitation
– Late presentation
• Fluid overload
– Use of hypotonic saline
– Given excess fluids
– Given more than time of leakage
• Massive bleeding
– Not given blood transfusion
– Delayed blood transfusion
• Unusual manifestations
– Encephalopathy
– Underlying co-morbidity
– Dual infection
103