Severe Dengue in Intensive Care

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The ICU Rule

Obstetric patients
MUST ADMIT

Asthmatic patients Dengue patients DKA Because they shouldnt DIE !!! 3/24/12
Dr Tai Li Ling

Intensive Care Management

The management of DHF/ DSS in the intensive care unit (ICU) follows the general principles of management of any critically ill patient in the ICU.

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Severe Dengue

Severe plasma leakage that may lead to shock and/ or fluid accumulation with or without respiratory distress Severe bleeding Severe organ involvement
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Indications for Referral to Intensive Care:

1. Recurrent or persistent shock 2. Requirement for respiratory support (non-invasive and invasive ventilation) 3. Significant bleeding 4. Encephalopathy or encephalitis

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RECOGNIZE AND TREAT

The key to success is frequent monitoring and changing strategies depending on clinical and laboratory evaluations.
Experts from India

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Indications for Referral to Intensive Care:

1. Recurrent or persistent shock 2. Requirement for respiratory support (non-invasive and invasive ventilation) 3. Significant bleeding 4. Encephalopathy or encephalitis

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1st Indication :Dengue Shock Syndrome and treatment of shock is essential Early recognition

Early referral ALL Grade 3 and Grade 4 DHF should be referred to ICU Management of DSS is a medical emergency and requires prompt and adequate fluid replacement Early and effective replacement of plasma losses results in a favorable outcome

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Indications for Referral to Intensive Care:

1. Recurrent or persistent shock

2. Requirement for respiratory support (non-invasive and invasive ventilation) bleeding 3. Significant 4. Encephalopathy or encephalitis

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Oxygen therapy should be given to ALL patients in shock

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Indications for respiratory support ( invasive and non-invasive)

Main objectives of respiratory support support pulmonary gas exchange reduce the metabolic cost of breathing
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Reduces work of breathing & O2 consumption Improves oxygen delivery to tissues and allows redistribution of blood flow to vital organs.

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Indications for respiratory support ( invasive and non-invasive)

In general, respiratory support should be considered EARLY in a patients course of illness. The decision to initiate respiratory support should be based on clinical judgement that considers the entire clinical situation.

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Indications for respiratory support ( invasive and non-invasive)

1.

Respiratory Failure poor gas exchange

Time frame of plasma leakage In late phase of plasma leakage, respiratory distress may be compounded by pleural effusion, ascites acute pulmonary oedema in late phase of leakage or resorption phase

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Indications for respiratory support ( invasive and non-invasive)

2. Metabolic acidosis work of breathing In early phase of plasma leakage, metabolic acidosis is secondary to tissue hypoperfusion. Appropriate management is fluid resuscitation and mechanical ventilation In patients with metabolic acidosis, respiratory support should be 3/24/12 considered despite the preservation of

When to Intubate?
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When to Intubate

General principles of management applies 3 main indications in dengue-

-Respiratory distress and fatigue due to excessive lung or pleural fluid accumulation/overload, -Moderate to severe metabolic acidosis (decompensated shock).
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Indications for respiratory support

Respiratory Distress and Fatigue Recognize the decompensated patients :
When PaCO2 is higher than expected to compensate for the acidosis, the patient should be promptly intubated. Formula to calculate the expected PaCO2 = 1.5 x [HCO3-] + 82 mmHg

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RECOGNIZE AND TREAT

Indications for respiratory support

Severe shock is the result of inadequately treated plasma leakage bleeding. Prolonged shock leads to metabolic acidosis and multi-organ dysfunction. Severe metabolic acidosis is a late sign !
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Lactic acidosis in DSS

Lactate ( Normal < 2 mmol/l) : end product of anaerobic glycolysis 1. An increase in blood lactate levels in patients who are haemodynamically unstable is taken as evidence of impaired oxygen utilization by cells / circulatory shock (Tissue hypoxia) 2. Liver failure

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Indications for respiratory support

3. Encephalopathy In patients with encephalopathy and GCS of < 9 , intubation is often required to protect the airway.

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Neurological impairment: possible causes

n n n n n n n

Hypoxic encephalopathy Shock Hyponatraemia Metabolic acidosis Hepatic encephalopathy Dengue encephalitis Intracerebral bleed

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Other Considerations in ICU

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The Question of Vasopresors

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Indications for haemodynamic support In dengue, hypotension is usually due to plasma leakage or
internal bleeding. Fluid resuscitation is crucial and should be initiated first. However, vasopressor (e.g. dopamine, noradrenaline) may be considered when a mean arterial pressure is persistently < 60 mmHg despite ADEQUATE fluid resuscitation. During induction for intubation if hypotensive whilst still undergoing vigorous fluid resus

Inotropic and vasopressor support NOT the first line.

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The Question of Invasive Tubings

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Guide on safety and risk of invasive procedures

1. Central venous catheter (CVC) insertion No studies on dengue patients with regards to invasive procedures and bleeding risks. Volume resuscitation does not require a CVC if sufficient peripheral intravenous access can be obtained (e.g. 14- or 16gauge intravenous catheters). Peripheral intravenous catheterisation may be preferable because a greater flow rate can be achieved.

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Guide on safety and risk of invasive procedures Central venous catheter (CVC) insertion
In general, thrombocytopaenia and other bleeding diathesis are relative contraindications to CVC placement. High femoral, low internal jugular, and subclavian venous punctures are difficult to compress and confer an increased risk of uncontrolled bleeding. Incidence of bleeding in patients with coagulopathy varies (0-15.5%).

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Guide on safety and risk of invasive procedures Central venous catheter (CVC) insertion

When CVC is indicated it should be inserted by a skilled operator, preferably under ultrasound guidance if available.

Subclavian vein cannulation should be avoided as far as possible.

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2. Arterial catheter insertion

Intra-arterial cannulation is useful as it enables continuous arterial pressure monitoring and repeated arterial blood gas sampling. It has a very low incidence of bleeding (1.8 2.6%) An arterial catheter should be inserted in DSS patients who require intensive monitoring and frequent blood taking for investigations.

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3. Gastric tube If a gastric tube is required, the nasogastric route should be avoided. Consider orogastric tube as this is less traumatic.

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4. Pleural tap and chest drain

Intercostal drainage of pleural effusions should be avoided as it can lead to severe haemorrhage and sudden circulatory collapse. Intercostal drainage for pleural effusion is not indicated to relieve respiratory distress. Mechanical ventilation should be considered.

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Watch out for confounders

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Co morbid conditions

Congestive cardiac failure, valvular heart disease Thyrotoxicosis ESRF

Pregnancy Medications beta blockers, anticoagulants 3/24/12

1. The management of severe dengue is a medical emergency and the key to success is frequent monitoring and changing strategies 2. Recognize the severe cases. 3. Early referral and PROMPT TRANSFER to intensive care. 4. Attend to patient on arrival 5. In ICU BE VIGILANT. Early recognition and treatment of shock improves outcome.

Take Home Messages

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6.

Take Home Messages Consider early respiratory support.

7. Metabolic acidosis is a late sign, dont wait till patient collapses. 8. Inotropic and vasopressor support is not the answer to shock, prompt and adequate fluid replacement is.
9.

CVP monitoring is not indicated

10. Avoid invasive procedures e.g. chest drain, ascitic drainage as they are hazardous.

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