Dengue Fever

Agent Arthopode borne virus,Arbovirus

belongs to Flavi virus family.
Vector Mosquito Ades Aegypti

Epidemological Aspects

For each person 150 200 subclinical

cases in community therefore isolation of
diseased is useless
Mosquito once infected remain infected for
life I.e. for 2 4 weeks
Mosquito is difficult to iradicate b/c its
eggs can withstand dessiccation for 1
year.

Classification
Dengue Virus Infection

Asymptomatic

Undifferentiated
Fever
Without
Haemorrhage

Symptomatic

Dengue Fever
Syndrome
Unusual
Haemorrhage

Dengue Haemorrhagic Fever

(Plasma Leakage)
No Shock

Dengue Shock
Syndrome

Diagnosis

High continuous fever of 3 days or more

Abdominal pain

Petechial hemorrhage and/or other spontaneous bleeding

Rash generalized flushing/maculopapular

Hepatomegaly

Fall in platelet count that precedes or occurs simultaneously

with a rise in haematocrit

Normal WBC or leucopaenia with relative lymphocytosis

Normal ESR (< 20mm per hour)

Shock

Atypical featuresAcute abdominal pain, diarrhea, severe gastrointestinal

haemorrhage.
Severe headache, convulsions, altered sensorium.
Encephalitic signs associated with or without intracranial
hemorrhage.
Irregular pulse and heart rate .

Atypical features continueRespiratory distress .

Fulminant hepatic failure, obstructive jaundice,
raised liver enzymes , Reye syndrome.
Acute renal failure, hemolytic uraemic syndrome .
Disseminated intravascular coagulation (DIC).
Vertical transmission in newborns

Chronology of symptomsDay
1
Classical DF
Prostration
Epigastric
pain
Irritability
Hypotension
Hemorrage
Hepatomegal
Shock
Temp (F) 105
104
103
102
101
100
99
98
97
Hematocrit

S. Protiens
Platelets

Tourniquet Test

Recommended >
4years

Appropriate sized blood

pressure cuff should be
used

Increase
pressure 20mm
< systolic
Positive reading is
taken as > 20
petechiae per 2.5cm2
area
Positive predictive value
of 90% for dengue

Lab diagnosis

Platelet counts < 1 lac

Hemoconsentration>20%
Hemodilution >20 % after fluid therapy
LFT - increased SGOT >SGPT
Hypoabuminemia,Hyponatremia,Acidosis
Strip test - not reliable
Viral Culture - Not available

Lab diagnosisThe IgM capture enzyme-linkedimmunosorbent assay (ELISA) detects IgM antibody,which usually

appear by day 5 after onset and persists for 2 to3 months

-suggest recent infection/Specific

Diagosis

IgG antibodies

Appears simultaneously or shortly after IgM but persists for life

Diagnosis using IgG requires paired acute and convalescent

blood samples to demonstrate a four fold or greater rise in
specific antibody - recent infection due to Flavi virus

Criteria for admission

--

Restlessness or lethargy

Cold extremities or circumoral cyanosis

Bleeding in any form

Oliguria or reluctance to drink fluids

Rapid and weak pulse

Criteria for admission

Capillary refill time > 2 seconds

Narrowing of pulse pressure (< 20mmHg) or

hypotension

Haematocrit of 40, or rising haematocrit

Platelet count of less than 100,000/mm 3

Acute abdominal pain

Evidence of plasma leakage, e.g. pleural effusion, as

WHO Grading for Dengue

Grade I
In the presence of haemoconcentration, fever and non-specific
constitutional symptoms, a positive tourniquet test is the only
haemorrhagic manifestation
Grade II
Spontaneous bleeding in addition to the manifestation of Grade I
Grade III * (DHSS)
Circulatory failure, pulse pressure less than 20 mmHg but systolic
pressure is still normal
Grade IV * (DHSS)
Profound shock, hypotension or unrecordable blood pressure

Management of grade I & II DHF

All cases are to be admitted

Encourage patient to drink fluids, ORS, fruit-juices

Start intravenous fluid (N/2 dextrose saline initially) for those with
poor oral intake

Paracetamol for high fever

Daily capillary haematocrit determination (haematocrit will rise

before pulse or blood pressure changes)

Rise in haematocrit of 20% or more reflects a significant plasma

loss and also indicates need for intravenous fluid therapy

Monitor urine output, vital signs

Fluid Therapy

Maintenance fluid requirements in DHF

(calculated according to the Halliday and
Segar Formula)

- <10 kg body weight: 100 ml/kg.

- 1020 kg body weight: 1000 ml + 50 ml for
each kg
in excess of 10 kg.
- .20 kg body weight: 1500 ml + 20 ml for each
kg in
excess of 20 kg.

PROTOCOL 1 (Modified from WHO Protocol)

initial IV fluid
@ 6 ml/kg/hr
5% D/NS (5%D/0.45%saline in younger children)

Follow up Hematocrit at least 6 hourly / hourly vital signs / urine output

IMPROVEMENT
Hct.
Stable pulse & BP
Urine output

Reduceivrateto5
ml/kg/hr

IMPROVEMENT

NO IMPROVEMENT
Hct. Pulse
Pulse pressure < 20
mmHg
Urine output

VITAL SIGNS WORSEN

OR HAEMATOCRIT

IMPROVEMENT

*Increaseivrateto10
ml/kg/hr

NO IMPROVEMENT

ml/kg/hr

IMPROVEMENT

VITAL SIGNS WORSEN

OR HAEMATOCRIT

IMPROVEMENT

*Increaseivrateto10
ml/kg/hr

NO IMPROVEMENT

Reduceivrateto3
ml/kg/hr

FURTHER
SHIFT
TO PICU
IMPROVEMENT
MANAGE AS DENGUE
SHOCK SYNDROME

Stopivinfusionafter
24-48hr

VITAL SIGNS & Hct.

STABLE
Adequate diuresis

Indication for shifting in PICU

The child is shifted to PICU if

Pulse pressure at admission <10 mmHg,

has altered consciousness,

uncontrolled bleeding or

the pulse pressure is not being maintained > 20

mm Hg,

poor urine output inspite of adequate fluids

significant respiratory distress requiring oxygen

Grade III and Grade IV DHF

Management of Grade III&IV

Shift in PICU -maintain ABC-Bolus of

0.9%saline 20 ml/kg Repeat if vitals dont
improvechange to 0.45 % saline in D 5% and
adjust rate to 5 10 ml/kg/hour Guided by
Hct,UOP,Vital sign monitoring.
If not improves clinically after 2 boluses- Do a
work up CBC/Albumin/coagulation
profile/Xray/ECHO/CVP/Clinical Reassesment

After shifting in PICU-

Mostly need ventilation now

Put central line also(preferably)
Arrange for blood products/Correct
acidosis and shock-Colloid preffered as 3 rd
bolus while arranging for blood products
Monitor CVif CVP is
<6 Fluid 5 15 ml/kg/hr to continue & look
for HCT %

Shock management

If Hct % Low Think of internal bleeding

If CVP > 6 still shock present
Dopamine and Epinephrine are used for
decompansated shock
Dobutamin is used for decompansated
shock
Look for ECHO report

Role of ECHO

Underfilling of left Atrium Give more

fluids
Systolic Dysfunction give ionotrops&
vasodialator.
Diastolic dysfunction Milrinone is
warranted.
Continue fluids for 1-2 days for ongoing
losses in third space.

Criteria for discharging

Absence of fever for patients 24 hours without the use of

antipyretics, and a return of appetite

Visible improvement inhospitalized

clinical picture
with dengue/DHF

Stable haematocrit

Three days after recovery from shock

Platelet count greater than 50,000/mm 3 and rising

No respiratory distress