Pearls and pitfalls in DHF management

Dr. Aung Kyi Wynn

Senior consultant pediatrician

DENGUE

Definition
Acute illness caused by four serotypes of

dengue virus and characterized by a

hemorrhagic diathesis and a tendency to
develop a shock syndrome (dengue shock
syndrome DSS) that may be fatal.
Thrombocytopenia with concurrent

haemoconcentration is a constant findings.

Causal Agent

Dengue virus = Serotype 1- 4

Infection with one type gives lifelong

immunity for this type, but partial
immunity for other types

Vector
Transmitted by Aedes aegypti.
Bite during daytime
Grow in clear water

Countries/areas at risk of dengue transmission, 2008

Virus multiplies in midgut, brain,

body fat, salivary glands

Man-Mosquitoe-Man cycle

(3-14days
(8-12days
avr 4-6 days
virus
replicates)
(about 5 days)
(about 5 days)
virus replicates)

Principal
reservoir host

Awareness of DHF
Pearls - Aware and Recognize DHF

Pitfall Failure to get diagnosis of

DHF

CRITERIA FOR DENGUE

Probable dengue
-live in /travel to dengue endemic area.
-Fever and 2 of the following criteria:
Nausea, vomiting
Rash
Aches and pains
Tourniquet test positive
Leukopenia
Any warning sign

Laboratory-confirmed dengue
(important when no sign of plasma leakage)
10

Use of NS 1 Antigen

NS 1 rapid tests (eg. SD BIOLINE) had

similar diagnostic sensitivities ( 61.6% )
compared to RT PCR ( 62.4%) in
confirmed cases
Both tests have 100% specific
Sensitivity become significantly
improved (83.7%)when NS 1 and/or Ig
G and/or IgM was positive.

Use of NS 1 Antigen

significantly more sensitive for Primary

than secondary Dengue.
Associated with underlying viraemia

(Vianney Tricou et,al at Oxford University Clinical Research

Unit)

13

14

USG findings

Hepatomegaly
87.5 %
Pericholecystic oedema 83%
Gallbladder wall thickening 80%
Ascites
74%
Pleural effusion (Rt)
44%
Splenomegaly
3.4%
Pleural effusion (Bilateral) 2%
(on third and fourth day of fever)
15

CRITERIA FOR SEVERE DENGUE

Severe plasma leakage

leading to:
Shock (DSS)
Fluid accumulation with respiratory distress

Severe bleeding
as evaluated by clinician

Severe organ involvement

Liver: AST or ALT 1000
CNS: Impaired consciousness
Heart and other organs
16

Bleeding in
mesentry and
intestinal wall

17

Many faces of DHF

DHF with GE
DHF with Asthmatic Bronchitis
DHF with Appendicitis
DHF with extreme drowsiness
DHF with Hepatitis
DHF with acute intravascular hemolysis

18

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19

HESS TEST
Pearls Proper doing and interpretation

Pitfall Wrong methods and interpretation

20

HESS TEST

Appropriate cuff
Exact 5 minutes
Proper method
Wait till the bluish discoloration gone
1 square inch square at maximum area

21

HESS TEST - Interpretation

Not any spot is positive

> 20 positive
10-20 Equivocal
< 10 Negative
Be aware of false (+)

22

Positive tourniquet test

23

Febrile, critical and recovery phases in dengue

24

25

engue case classification and level of

everity

27

A stepwise approach to the management of dengue

28

DETECTION OF SHOCK
Pearls Predict or Detect in Time
Pitfall Failure to recognize shock

29

DETECTION OF SHOCK

Warn parents that fall in temperature is more

important than fever

Afebrile with improvement or deterioration

Proper written instruction

30

DETECTION OF SHOCK
At the time when the temperature drops i.e.,

from day 3 onwards with worsening of

general condition
In other diseases, with the drop in

temperature,
the child feels better, eats better, is alert, up and

go about and can play

wherelse in DSS, it is reversed
31

WHY DETECTION OF SHOCK IS IMPORTANT

Stagnant acidemia promote

occurrence and enhanced

severity of DIC

32

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WHEN TO ADMIT
Pearls Proper admission
Pitfall Too early or late admission

34

WHEN TO ADMIT

Dangerous mistake DHF patients

need admission only when develop
shock

Admission Criteria
Patients with warning signs
Those with co-exisitng
conditions that may make
dengue or its management
more complicated
(infancy, obesity, diabetes
mellitus, renal failure,
chronic haemolytic
diseases)

Admission criteria

Signs and symptoms related to hypotension

(possible plasma leakage)
Dehydrated patient, unable to tolerate oral fluids
Giddiness or postural hypotension
Profuse perspiration, fainting, prostration during

defervescence
Hypotension or cold extremities

37

Admission criteria

Bleeding
spontaneous bleeding
independent of the platelet count

Organ impairment
Renal, hepatic, neurological or cardiac

enlarged, tender liver, although not yet in

shock
chest pain or respiratory distress, cyanosis

38

Admission criteria

Findings through further investigations

Rising haematocrit
Pleural effusion, ascites or asymptomatic

gall-bladder thickening

39

Admission criteria

Co-existing conditions
Pregnancy
Co-morbid conditions, such as diabetes

mellitus, hypertension, peptic ulcer,

haemolytic anemias and others
Overweight or obese (rapid venous access
difficult in emergency)
Infancy or old age

40

Admission criteria

Social circumstances
Living alone
Living far from health facility
Without reliable means of transport

41

WHERE TO ADMIT
Pearls Close monitoring and
Titration
Pitfall Inadequate monitoring
& Inadequate experience

42

Management according to groups AC

Group A
patients who may be sent home

Group B
patients who should be referred for in-hospital

management

Group C
patients who require emergency treatment and urgent

referral when they have severe dengue

43

Group A
(who may be sent home)

Patients who do not have warning signs

OR

who are able to tolerate adequate volumes of

oral fluids and
pass urine at least once every six hours
do not have any of the warning signs
particularly when fever subsides

44

Group B
(Referred for in-hospital care)

Patients with any of the following features:

co-existing conditions
such as pregnancy, infancy, old age, diabetes
mellitus, renal failure
social circumstances
such as living alone, living far from hospital

OR

Existing warning signs

45

Group C
(Require emergency treatment)

Patients with any of the following features:

severe plasma leakage with shock and/or fluid

accumulation with respiratory distress

severe bleeding
severe organ impairment

46

Group A patient
Treatment

Advice for:
adequate bed rest
adequate fluid intake
Paracetamol, 3gram maximum per day in adults

and accordingly in children.(10mg/dose)

Patients with stable HCT can be sent home

47

Group A patient
Monitoring

Daily review for disease progression:

decreasing white blood cell count
defervescence
warning signs (until out of critical period).

Advice for immediate return to hospital if

development of any warning signs, and

written advice for management (e.g. home care card

for dengue)

48

Use of Drugs

Pearls Use of appropriate Drugs and

avoidance of unnecessary and
dangerous drugs

Pitfalls Use of unnecessary and

dangerous drugs

49

Use of Drugs

Use Paracetamol only as antipyretic

Not need to have food

Avoid all others NSAID No Nimuslide, No

Ibuprofen

50

OTHER DRUGS

ORS or Any fluid and Salt

Avoid unusual large amount especially in

older children

? Antacids & Ranitidine

51

Group B
(with co-existing conditions or social circumstances)

Treatment
Encouragement for oral fluids
If not tolerated, start intravenous fluid therapy 0.9%

saline or Ringers Lactate at maintenance rate

52

Group B
(with co-existing conditions or social circumstances)

Monitor:
temperature pattern
volume of fluid intake and losses
urine output (volume and frequency)
warning signs
HCT, white blood cell and platelet counts

53

Group B
(with existing warning signs)

Treatment

Obtain reference HCT before fluid

therapy
Give isotonic solutions
such as 0.9 % saline, Ringers Lactate
Start with 57 ml/kg/hr for 12 hours,
then reduce to 35 ml/kg/hr for 24 hr, and
then reduce to 23 ml/kg/hr or less according

to clinical response

54

Group B
(with existing warning signs)

Reassess clinical status and repeat HCT:

if HCT remains the same or rises only minimally ->
continue with 23 ml/kg/ hr for another 24 hours;

if worsening of vital signs and rapidly rising HCT ->

increase rate to 510 ml/kg/hr for 12 hours

55

49 & 50

56

Group B
(with existing warning signs)

Reassess clinical status, repeat HCT and

review fluid infusion rates accordingly:

reduce intravenous fluids gradually

when the rate of plasma leakage decreases

towards the end of the critical phase

This is indicated by:

adequate urine output and/or fluid intake
HCT decreases below the baseline value in a stable

patient

57

Group B
(with existing warning signs)

Monitor

vital signs and peripheral perfusion (14 hourly) until

patient is out of critical phase
urine output (46 hourly)
HCT (before and after fluid replacement, then 612
hourly)
blood glucose
other organ functions (renal profile, liver profile,
coagulation profile, as indicated)
58

Pearls and Pitfalls In the

Management of Shock
DSS is hypovolemic shock due to plasma

leakage:
Volume replacement with isotonic salt

solutions, plasma, plasma substitute, for the

period of plasma leakage(24 - 48hrs)is lifesaving

59

Pearls and Pitfalls in the

Management of Shock

Volume replacement should be monitored according

to the rate of plasma leakage (PCV, vital signs, urine
output) to avoid fluid over load

The rate of leakage is more rapid in 1 st 6 12 hrs

60

Group C
(Require emergency treatment)

Treatment of compensated shock

Start IV fluid resuscitation with isotonic

crystalloid solutions at 510 ml/kg/hr
over 1 hour
Reassess patients condition

61

Group C
(Require emergency treatment)

Treatment of compensated shock

If patient improves:
IV fluids should be reduced gradually to 57 ml/kg/hr for

12 hours,
then to 35 ml/kg/hr for 24 hours,
then to 2-3 ml/kg/hr for 24 hours and
then reduced further depending on haemodynamic
status;
IV fluids can be maintained for up to 2448 hours
62

Group C
(Require emergency treatment)
Treatment of compensated shock
If patient is still unstable:
check HCT after 1st bolus;
if HCT increases/still high (>50%), repeat a 2nd bolus of
crystalloid solution at 1020 ml/kg/hr for 1hr
if there is improvement after 2nd bolus, reduce rate to 710
ml/kg/hr for 12 hrs and continue to reduce as above
if HCT decreases, this indicates bleeding and need to
cross-match and transfuse blood as soon as possible

63

Group C
(Require emergency treatment)
Treatment of hypotensive shock

Initiate IV fluid resuscitation with crystalloid or colloid

solution at 20 ml/kg as a bolus for 15 minutes

-If patient improves:

give a crystalloid/colloid solution of 10 ml/kg/hr for 1 hr, then

reduce gradually as above

64

Group C
Treatment of hypotensive shock
-If patient is still unstable:
review the HCT taken before the 1st bolus;
if HCT was low (<40% in children), this indicates
bleeding, the need to cross-match and transfuse
if HCT was high compared to baseline value, change to
IV colloids at 1020 ml/kg as a 2nd bolus over 30 minutes
to 1 hr; reassess after second bolus
If patient is improving reduce the rate to 710ml/kg/hr for
12 hr, then back to IV crystalloids and reduce rates as
above

65

Group C
Treatment of hypotensive shock
-If patient is still unstable:
repeat HCT after second bolus.
If HCT decreases, this indicates bleeding
if HCT increases/remains high (>50%), continue colloid
infusion at 1020 ml/kg as a 3rd bolus over 1 hr,
then reduce to 710 ml/kg/h 12 hr, then change back
to crystalloid solution and reduce rate as above
66

Group C
(Require emergency treatment)

Treatment of haemorrhagic complications

Give 510 ml/kg of fresh packed red cells or

1020 ml/kg of fresh whole blood

67

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Pearls and Pitfalls In the

Management of Shock ( contd)
Stagnant acidemia promote occurrence and

enchanced severity of DIC

PRP transfusion as prophylaxis for bleeding in

all shock cases is not recommended

69

Pearls and Pitfalls In the

Management of Shock ( contd)
There are abnormal haemostatic changes that

potentiate bleeding in DHF/DSS

Severe bleeding ( may be concealed ) often

occurs in cases with prolonged shock and

further perpetuates shock

70

Pearls and Pitfalls In the

Management of Shock ( contd)
Refractory shock despite adequate volume

replacement and a drop in PCV ( at any rate

e.g. from 50 % to 40 % ) indicates significant
bleeding and a need for FWB transfusion
( 10 ml/kg/dose )

71

Pearls and Pitfalls In the

Management of Shock ( contd)
Major contributory factor to the high mortality rate
failure to recognize internal bleeding
over transfusion with crystalloid and/or plasma fluid

instead of blood

72

Pearls and Pitfalls In the

Management of Shock ( contd)
Pitfall------------ Too much rely on platelet count and
PCV
Pearl------------ In conjunction with hemodynamic
Status

73

Key decisions
When
When

to give blood?

to stop IV fluid or
give diuretics?

IV fluid therapy

Narrow therapeutic index

Timely
Appropriate volume
Rate
Appropriate type
Appropriate duration

(Fluid replacement- 40-60ml/kg)

75

PREVENTION
Pearls - Correct prioritization

Pitfall Just for show

76

PREVENTION

Larva control more important than killing adult mosquitoes

School, Tuition, Nursery, Day care centre

Whole wards or villages

Health more important than Education

DHF more important than lung diseases

77

Prevention (contd)
Key Container should not be in the vicinity

where 3 -8 yrs old children are aggregated

e.g. primary school, private tuition, day- care centre

Control measures should be emphasized in

these areas

78

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79

CONCLUSIONS

It is a preventable and treatable disease

Awareness of clinical features, early and

effective treatment of shock, appropriate
management with close monitoring can save
the lives of patients

Effective preventative measures will reduce

the burden of DHF
80

FAQS

Secondary dengue infection Vs

virulence theory
Role of corticosteroid
Two attacks of dengue in the same
season?
Importance of D/C diagnosis

81

FAQS cont.

Role of OPD MO
Role of ward MO
Role of abate
Dengue vaccine

82

Thank you

83