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DENGUE

FEVER

Amila Weerasinghe
MBBS Undergraduate
2010/2011 Batch (21st )
Faculty of Medical Sciences
University of Sri
Jayewardenepura
Sri Lanka
19/01/2015

Contents
What is Dengue ?
2. Epidemiology
3. Vector
4. Virus
5. Pathogenesis of the disease
6. Classification
7. The natural course of the illness
8. Diagnosis and Management at OPD
level and by primary care physician.
9. In-ward Management of DF/DHF
10. Management of complicated
1.

1. What is Dengue ?

A vector borne disease.

The most rapidly spreading


mosquito-borne viral disease in
the world.

A notificable disease in Sri Lanka

2. Epidemiology

World situation

last 50 years, 30 fold rise

2.5 billion or 40% of the world, live


in dengue endemic countries.
WHO (2009).Dengue: guidelines for diagnosis, treatment,
prevention and control -- New edition

Yearly 50 to 100 million infections


500,000 DHF cases
22,000 deaths, mostly among
children.

Sri

Lankan situation

First serologically confirmed case


- 1962

First documented dengue


outbreak -1965- 1966

First epidemic of DHF/ Dengue


Shock Syndrome - 1989 1990.

2014

46584

Cases
50000
45000
40000
35000
30000
25000
20000
15000
10000
5000
0

Year 2014, 46584 suspected


dengue cases

55.26% of dengue cases from the


Western province.

http://www.epid.gov.lk
http://www.dengue.health.gov.l
k

Vector

Dengue is an interplay of
3 factors

3. Vector

A biological vector Mosquitoes


In Sri Lanka
Aedes albopictus and Aedes
aegypti

4. Virus

Genus Flavi virus

Family Flaviviridae

Virus Dengue virus (DEN)

Serotypes 4 serotypes
DEN 1 to 4

5. Pathogenesis of the disease

Primary dengue infection


First time viral infection,

Any of the 4 virus types


.

Secondary dengue infection

# Viral infection, except


which resulted the primary
infection.
# NOT necessarily the second
dengue

infection.

6. Classification

Old WHO classification

WHO new classification

WHO new classification

Old WHO classification

Dengue fever [DF]

2 7 days of illness + high grade


fever
Headache
Retro orbital pain
Myalgia
Arthralgia
Rash & haemorrhagic
manifestations
positive tourniquet test

Dengue Haemorrhagic
Fever

Signs & symptoms + PLASMA


leakage.

Criteria

High fever/ recent history of acute fever

A (+)ve tourniquet test

Thrombocytopaenia <100,000 cells/mm 3

Objective evidence of leaky capilaries

20% Elevated haematocrit


Pleural or other effusion - eg,
ascites.

7. The natural course of the illness


Dengue haemorrhagic fever is a
dynamic disease
1.

Febrile phase

2.

Critical phase

3.

Convalescent phase

8. Diagnosis and Management


at OPD level and
by primary care physician.

When

to suspect
DF/DHF

Management as out patients


Oral

fluid (maintainance)

Eg:-oral rehydration fluid,


king coconut juice, fruit juices.etc

Except plain water and red and brown


drinks

Rest

& tepid sponging

Paracetamol

10-15mg/kg/dose
(max 60mg/kg/day)

Anti-emetics
NO

and H2 RB.

NSAIDs or any STEROID

Review

with FBC , 1st after 3 days

of onset
Advice

to return immediately for

review if

When to admit the patient ?

Clinical judgment

All patients with plt 100,000/mm3

All patients with warning signs

Following patients with probable


dx of DF should admit.
Infants
Obese
Major co-morbidities
Adverse social
circumstances

9.In-ward Management of DF/DHF

Febrile Phase

Febrile Phase
In DF & DHF ; lasts for 2-7 days

Total WBC count


initially high or normal
5000/mm3

drops <

Platelet count
Initially normal

drops < 100,000/mm


in 50% DF & 100%

DHF
Tender hepatomegaly

DHF > DF

Erythematous/ maculo-papular rash


DHF < DF

Adequate fluid intake

Total fluid requirement degree of


dehydration
(oral + IV)
Maintenance volume
Infants <6 months 5% dextrose in N/2
Others normal saline

Adequate physical rest

Paracetamol 10-15mg/kg/dose
(max 60mg/kg/day)

NO all NAIDSs & STEROIDS

Monitoring - ( Annexure iii) in the


dengue guideline

Critical Phase
Seen

only in DHF
late febrile phase;
3rd day to 7th day of illness up.
Rapid
Lasts
DHF

drop in temperature
for 24 48 hours

is a very dynamic disease.

Identifying

the beginning & the end of the critical


phase
is a KEY FACTOR
in guiding fluid therapy in DHF.

Leak starts slowly, increases


gradually, peak around 24 hours,
slows down and ceases around
.

48 hours
.
30
25
20
15
10
5
0

10

20

30

40

50

60

Shock can be fatal

Until the very last stage of shock; patient


can appear conscious & very alert
If Pulse Rate & Blood pressure NOT
measured,
early shock could be missed.

Early detection of the critical


phase (plasma leakage)

Platelets <100,000/mm3
Be Alert

Patient may be in either of the,


DF(50%

of patients)

DHF

febrile phase

DHF

critical phase (early or late)

Patient in critical phase if


<100,000/mm3 platelet count & any
one of the below
1. 20% rise in the haematocrit

2. Objective evidence detected

radiologically
Pleural

effusion

Chest X-ray Right


Lateral decubitus

Ascites : USS abdomen

USS chest

3. Biochemical parameters
Serum albumin < 3.5g/dl or
dropped by
0.5g/dl
Serum cholesterol <100mg/dl or
dropped by
20mg/dl

Monitoring during the critical phase


( Annexure iv) in the dengue guideline

( Annexure iv) in the dengue guideline - during peak of leakage & shock

Fluid management in the


critical phase

Calculation of the fluid quota


(oral+IV)
Max fluid intake during ENTIRE
critical phase
[Irrespective of its length]
Maintenance + 5% deficit

Maintenance = 100ml/kg for 1 st 10kg


+ 50ml/kg for next 10kg
+ 20ml/kg for the
balance weight
5% deficit
(kg)

= 50ml/kg x body weight

Ideal body weight


Weight for height [ BEST
]
Growth
chart
th
50
centile
Weight for age
BUT
Actual body weight is taken for
the calculations,
if the actual weight < ideal
weight

Maximum weight = 50kg


Maximum fluid intake =
4600ml

IV fluids
N/2 +5% dextrose

< 6 months infants

N saline + 5% dextrose > 6 months;


who is not taking orally for prolonged
[ 50ml of 50% dextrose + 450ml N
saline ]

Rate of administration of fluids

A patient without shock

IV normal saline/ Hartmanns


solution largest possible size for
the age. + oral fluids

Initially; oral +IV = 1.5ml/kg/hr

Who can drink well = 0.5ml/kg/hr

Pulse, BP, Pulse pressure, CRFT,HCT &


UOP

UOP calculation

Hourly UOP ; Best guide for the rate


of infusion
0.5-1.0ml/kg/hr sufficient

IF
UOP

>1.0 too high infusion rates

UOP

<0.5 inadequate fluids

A patient with shock


Symptoms

Sweating

Abdominal pain

Restlessness

Altered conscious level

Signs

Cold extremities

CRFT > 2 sec

Unexplained tachycardia

Increased DBP

Narrowing pulse pressure


20mm/Hg

Indications for colloids


(Dextran 40 and 6% Starch)

Mx of shock (if pulse & BP not


picked up.)

After

2 crystalloid boluses;

Already
The

having a fluid overload

full fluid quota given.

ONLY during the critical phase

ONLY used as a bolus; Maximum


over 1 hour.
(10ml/kg/hr)

Dextran 40 up to 3 doses within


24 hrs
(10ml/kg/hr)

6% Starch up to 5 doses within 24


hrs
(10ml/kg/hr)

End of the critical


phase

Stable vital signs

HCT becomes normal

Clinically improvement

Diuresis

Convalescent Phase

Lasts for 2-5 days

Reabsorption of the extravasated


fluid.

Complications
Fluid overload
Hypocalaemia
Nosocomial infections

Criteria to be fulfilled before


the discharge

No fever 24hrs, without


antipyretics

At least 2 days after recovery from


shock

Generally good & Increasing


apetite

No distress from pleural effusion or


ascitis

Rising platelet count & >50,000/mm3

No other complication

High risk patients for complications

Infants

Obese

Bleeding

Encephalopathy

Underline diseases

Pregnancy

Primary causes of death in DHF


Prolonged shock
>4 hrs

organ failure

Liver failure 50% prognosis


Liver + Renal 10% prognosis
3 organs(+ respiratory) very bad

Fluid overload
Features :Early- puffy eye lids, distended
abdomen (ascites), tachypnoea,
mild dyspnoea
Late Respiratory distress, SOB, &
wheezing

ABCS
A acidosis
B Bleeding
C Calcium (hypocalcaemia)
S Sugar (hypoglycaemia)

Acidosis

More prone to DIC & massive bleeding.

pH < 7.35 (Arterial normal 7.35-7.45)

HCO3- < 15 mmol/l (Arterial normal 2224)

Emperically
NaHCO3 1ml/kg slow bolus (max 50ml)

Bleeding

Ix for blood transfusion


Overt bleeding
Concealed bleeding
( HCT drop/metabolic acidosis)

Use Packed Red Cells

5ml/kg once

5ml/kg of PRC

HCT by 5 points

(eg:- 30 to 35)

If HCT > 45%, blood given only


after reducing HCT by a colloid.

Hypocalcaemia

Mostly with convulsions


Measure serum Ca2+ levels

Give calcium if complicated

1ml/kg of 10% Ca Gluconate,(max


10ml)
Slow IV bolus over 15-20 mins
Diluted in equal volume of NS
Repeat 6 hourly

Hypoglycaemia

Prevented by NS with 5% Dextrose


Dextrose saline (0.9% NaCl with

5% Dextrose)
Add 50ml 50% Dextrose to 450ml

of 0.9% NaCl

Immediate goal
plasma glucose at least
70mg/dl

10% dextrose, 2ml/kg by IV push


Continue IV dextrose rate at
8mg/kg/min

Hyponatraemia

Mainly due to Hyponatraemic fluids


N/2 NaCl, N/5 NaCl, Water

3% NaCl is 3-5ml/kg
Slow IV
Through a larger vein; mostly a
central vein

Encephalopathy

Mainly - Hepatic encephalopathy

Maintain cerebral perfusion pressure(CPP)


Maintain - Mean arterial pressure
(MAP)
Reduce Intra Cranial pressure (ICP)
CPP = MAP - ICP

Airway oxygenation with O2 therapy

Fluid management

Maintain MAP

Reduce ICP

Maintain blood sugar level >70 mg/dl

Maintain K+ & Na+ levels normal


3% NaCl if Na+ < 120meq/l

Vit K IV
3mg
<1yr
5mg
1-5yrs,
10mg
>5yrs

IV Phenobarbitone - cerebral
metabolism
Controls seizures

Gut cleaning
NG tube
Antibiotics Metranidazole
Lactulose

Adjunct therapy

Platelet transfusion
Recombinant factor vii
Inotrops
Steroids & IV immunoglobulins
Fresh frozen plasma (FFP)
Frusemide

Summary

Consider each patient as a dengue


patient, as its presentation is
changed.

Avoid all NSAIDs & steroids.

Correct diagnosis during early


febrile phase improves the

Identifying the beginning & the end


of the critical phase is a key factor in
guiding fluid therapy in DHF.

Correct fluid management during the


critical phase is the most important.

Pulse pressure, HR, HCT & UOP

Be concern about the possible


complications.

THANK YOU

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