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Dengue with who guidelines
 

Dengue with who guidelines

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  • Dear Mr Paed. Your slide really useful for my study. Would you mind to send me the literature please? thx in advance

    febriansyah.darus@gmail.com
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  • - Grade I     มีไข้และมีอาการร่วมอื่นๆแต่ไม่จำเพาะ แต่เมื่อทำ tourniquet test จะให้ผล positive - Grade II     อาการเหมือน grade I แต่ที่เพิ่มเติมคือ พบเลือดออกเป็นจุดเลือดใต้ผิวหนัง - Grade III     ระบบไหลเวียนโลหิตเริ่มล้มเหลวเกิดอาการช็อค ชีพจรเร็ว เบา pulse pressure แคบ ความดันโลหิตต่ำ ริมฝีปากเขียว ตัวเย็น กระสับกระส่าย - Grade IV     แสดงอาการช็อครุนแรง ความดันโลหิตและชีพจรวัดไม่ได้  
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  • - Grade I     มีไข้และมีอาการร่วมอื่นๆแต่ไม่จำเพาะ แต่เมื่อทำ tourniquet test จะให้ผล positive - Grade II     อาการเหมือน grade I แต่ที่เพิ่มเติมคือ พบเลือดออกเป็นจุดเลือดใต้ผิวหนัง - Grade III     ระบบไหลเวียนโลหิตเริ่มล้มเหลวเกิดอาการช็อค ชีพจรเร็ว เบา pulse pressure แคบ ความดันโลหิตต่ำ ริมฝีปากเขียว ตัวเย็น กระสับกระส่าย - Grade IV     แสดงอาการช็อครุนแรง ความดันโลหิตและชีพจรวัดไม่ได้
  • dengue infection is defined as primary if IgM/IgG OD ratio > 1.2 (using pt’s sera at 1/100 dilution) or 1.4 (using pt’s sera at 1/20 dilutions) secondary if ratio <1.2 or 1.4 Ratios : vary between lab

Dengue with who guidelines Dengue with who guidelines Presentation Transcript

  • Dengue infection ReviseD Who guiDelines 2009
  • Dengue viral infection● The most rapidly spreading mosquito-borne viral disease in the world● Dengue virus : 4 serotypes : DEN1, DEN2,DEN3, and DEN4 Family Flaviviridae Genus Flavivirus Single stranded RNA virus● “Asian” genotypes of DEN-2 and DEN-3 : frequently associated with severe disease accompanying secondary dengue infections
  • Average annual number of DF and DHF cases reported to WHO, and of countries reporting dengue,1955–2007
  • Dengue Virus Infection● Immunity : long lasting in same serotype, partial and transient to other serotypes● Primary infection, secondary infection● Greater risk of serious symptoms in secondary infection• Plasma leakage distinguishes dengue fever from dengue hemorrhagic fever• Plasma leakage,hemoconcentration and abnormalities in homeostasis characterize severe dengue
  • Dengue Virus Infection: Clinical Syndromes● Undifferentiated fever● Dengue fever: fever, headache, muscle pain, nausea/vomiting, rash● DHF● DSS Gr I, II Plasma leakage Gr III, IV
  • Definition of Dengue Hemorrhagic Fever 4 necessary criteria:• Fever, or recent history of acute fever• Hemorrhagic manifestations● Low platelet count (100,000/mm3 or less)● Objective evidence of “leaky capillaries”  elevated hematocrit (20% or more over baseline)  pleural or other effusions  Fall in hematocrit >20% after I.V Fluids
  • Definition of Dengue Shock Syndrone4 criteria for DHF● Evidence of circulatory failure manifested indirectly by all of the following:  Rapid and weak pulse  Narrow pulse pressure (< 20 mm Hg) OR hypotension for age  Cold, clammy skin and altered mental status● Frank shock is direct evidence of circulatory failure
  • WHO classification● Undifferentiated fever● Dengue fever (DF)● Dengue haemorrhagic fever (DHF) 4 severity grades grades III and IV : dengue shock syndrome (DSS)● Currently the classification into DF/DHF/DSS continues to be widely used
  • WHO classification
  • ● patients with non-severe dengue patients with warning signs patients without warning signs● “dengue is one disease entity with different clinical presentations and often with unpredictable clinical evolution and outcome”
  • Vectors● Aedes aegypti Stegomyia aegypti (formerly Aedes aegypti)
  • Dengue● incubation period of 4-10 days● wide spectrum of illness (most, asymptomatic or subclinical)● Primary infection : induce lifelong protective immunity to the infecting serotype● Individuals suffering an infection are protected from clinical illness with a different serotype within 2-3 months of the primary infection● no long-term cross-protective immunity
  • Risk factors (determine the severity of disease and secondary infection)● Age● Ethnicity● Possibly chronic diseases (bronchial asthma, sickle cell anemia and DM)● Young children (less able to compensate for capillary leakage and are consequently at greater risk of dengue shock)● Secondary heterotypic infection as risk factor for severe dengue
  • The course of dengue illness
  • Febrile phase● High-grade fever, 2–7 days● facial flushing, skin erythema, body ache, myalgia, arthralgia, headache and N/V● Indistinguishable between severe and non-severe dengue cases● Monitoring for warning signs● Mild hemorrhagic manifestations : petechiae and mucosal membrane bleeding (e.g. nose and gums)● Liver often enlarged and tender after a few days of fever● The earliest abnormality in CBC : progressive decrease in WBC
  • The course of dengue illness Dengue: Guidelines for diagnosis, treatment, prevention and control. WHO 2009
  • Critical phase● Day 3–7 of illness● Progressive leukopenia  rapid ↓platelet count plasma leakage● Patients without ↑capillary permeability will improve● Patients with ↑capillary permeability : worse, lose plasma volume● The degree of increase above the baseline HCT reflects severity of plasma leakage• Shock-WBC may increase in patients with severe bleeding
  • The course of dengue illness Dengue: Guidelines for diagnosis, treatment, prevention and control. WHO 2009
  • Recovery phase● Gradual reabsorption of extravascular compartment fluid takes place in the following 48–72 hours● Well-being improves, appetite returns, GI symptoms abate, hemodynamic status stabilizes and diuresis ensues● Rash : “isles of white in the sea of red” Some may experience generalized pruritus● Hct stabilizes or lower due to the dilutional effect of reabsorbed fluid● WBC usually rise soon after defervescence but the recovery of platelet count is typically later than that of WBC
  • Febrile, critical and recovery phases in dengueFebrile phase Dehydration; high fever may cause neurological disturbances and febrile seizures in young childrenCritical phase Shock from plasma leakage; severe hemorrhage; organ impairmentRecovery phase Hypervolemia (only if iv fluid therapy has been excessive and/or has extended into this period)
  • Severe dengue● Fever of 2–7 days plus any of the following  Evidence of plasma leakage :  high or progressively rising Hct  pleural effusions or ascites  circulatory compromise or shock (tachycardia, cold and clammy extremities, capillary refill time > 3 seconds, weak or undetectable pulse, narrow PP or, in late shock, unrecordable BP)  Significant bleeding  Altered level of consciousness (lethargy or restlessness, coma, convulsions)  Severe GI involvement (persistent vomiting, increasing or intense abdominal pain, jaundice)  Severe organ impairment (acute liver failure, ARF, encephalopathy or encephalitis, or other unusual manifestations, cardiomyopathy)
  • Diagnosis of Dengue Infection● Antibody detection  Hemagglutination Inhibition (HAI)  ELISA (IgG/IgM)  Rapid test (IgG/IgM)● Antigen detection  NS1 & E/M antigen● RNA detection  PCR● Viral isolation
  • Diagnosis • Approximate time-line of primary and secondary dengue virus infections and the diagnostic methods that can be used to detect infection
  • Interpretation of dengue diagnostic tests
  • Primary Infection● NS1 antigen : Day 1 after onset of fever and up to day 9● IgM antibody : Day 5 of infection, sometimes as early as Day 3 IgM levels : peak in 2 weeks, followed by a 2 week rapid decay Undetectable 2 to 3 months after infection● Low levels of IgG are detected in the early convalescent phase, not during the acute phase
  • Secondary Infection● NS1 antigen : day 1 after onset of fever and up to day 9● IgM response is more varied● Usually preceded by IgG and appears quite late during the febrile phase● Minority of patients will show no detectable levels of IgM● May not be produced until 20 days after onset of infection● High levels of IgG are detectable during the acute phase● Persist for 30-40 days then decline to levels found in primary or past infection
  • Atypical neurological manifestations of dengue● Neurologic abnormalities : uncommon during dengue fever● DHF, encephalopathy is well recognized, from several factors cerebral anoxia cerebral edema cerebral hemorrhage hyponatremia toxicity secondary to liver failure● Studies in southeast Asia, encephalopathy associated with classic DF can occur in up to half of the cases
  • Atypical gastrointestinal manifestations of dengue• Hepatitis  Hepatomegaly, jaundice and raised aminotransferase levels (AST>ALT)  caused by the dengue virus and ⁄or Hypoxia and tissue ischemia in cases of shock• Fulminant hepatic failure  Severe hepatic dysfunction (ALT and AST >10x normal) was seen with DHF associated with spontaneous bleeding tendencies  tends to occur more often in DHF or DSS compared to classic dengue infections• Acalculous cholecystitis• Acute pancreatitis
  • Atypical cardiovascular manifestations of dengue fever● uncommon● Cardiac rhythm disorders : atrioventricular blocks atrial fibrillation sinus node dysfunction ectopic ventricular beats● Most are asymptomatic, benign self limiting course with resolution of infection● Attributed to viral myocarditis
  • Atypical respiratory manifestations of dengue● ARDS● Pulmonary hemorrhage : thrombocytopenia, changes in vascular permeability, platelet dysfunction
  • Dengue myositis● Dengue fever : break bone fever, severe muscle, joint and bone pain● Acute benign myositis : elevated SGOT, SGPT, and CPK● Dengue virus infection may also cause persisting, severe, myositis for weeks
  • Lymphoreticular complications of dengue● Dengue virus antigen is found predominantly in cells of the spleen, thymus and lymph nodes● DHF, lymphadenopathy is observed in half of the cases● Splenomegaly is rarely observed● Splenic rupture and lymph node infarction in DHF are rare
  • Management of dengue infection
  • A stepwise approach to the management of dengueStep I. Overall assessment History : symptoms, past medical and family history Physical examination : full physical and mental assessment Investigation : routine laboratory and dengue-specificlaboratoryStep II. Diagnosis, assessment of disease phase and severityStep III. Management Disease notification Management decisions. Depending on the clinicalmanifestations and other circumstances, patients may:– be sent home (Group A);– be referred for in-hospital management (Group B);– require emergency treatment and urgent referral (Group C).
  • Groups A-Patients who are sent home• Encourage plenty of oral fluids• Inform about the warning signs• Paracetamol for high fever. Never aspirin,ibuprofen or other NSAIDS
  • Admission criteria
  • Group B-In Patient Hospital Management
  • Algorithm for fluid management in compensated shock Compensated shock (SBP maintained but has signs of reduced perfusion) Fluid resuscitation with isotonic crystalloid 5–10 ml/kg/hr over 1 hour Improvement NO YES Check HCTIV crystalloid 5–7 ml/kg/hr for 1–2 HCT↑ or high HCT↓hours, then: reduce to 3–5 ml/kg/hr for 2–4 hours; Administer 2nd bolus of fluid Consider significant reduce to 2–3 ml/kg/hr for 2–4 hours. 10–20 ml/kg/hr for 1 hour occult/overt bleed Initiate transfusionIf patient continues to improve, fluid can be Improvement with fresh wholefurther reduced. bloodMonitor HCT 6–8 hourly. YES NOIf the patient is not stable, act accordingto HCT levels: If patient improves, if HCT ↑, consider bolus fluid administration reduce to 7–10 ml/kg/hror increase fluid administration; for 1–2 hours if HCT ↓, consider transfusion with fresh Then reduce furtherwhole transfusion.Stop at 48 hours.
  • Algorithm for fluid management in hypotensive shock Hypotensive shock Fluid resuscitation with 20 ml/kg isotonic crystalloid or colloid over 15 minutes. Try to obtain a HCT level before fluid resuscitation Improvement YES NO Review 1st HCTCrystalloid/colloid 10 ml/kg/hr for 1 hour, HCT↓then continue with: HCT↑ or high IV crystalloid 5–7 ml/kg/hr for 1– 2 hours; Administer 2nd bolus fluid (colloid) Consider significant reduce to 3–5 ml/kg/hr for 2–4 hours; 10–20 ml/kg over ½-1 hour occult/overt bleed reduce to 2–3 ml/kg/hr for 2–4 hours. Initiate transfusion with Improvement fresh whole bloodIf patient continues to improve, fluid can befurther reduced. YES NOMonitor HCT 6-hourly. Repeat 2nd HCTIf the patient is not stable, act according HCT↑ or high HCT↓to HCT levels: if HCT ↑, consider bolus fluid administration Administer 3rd bolus fluid (colloid)or increase fluid administration; 10–20 ml/kg over 1 hour if HCT ↓, consider transfusion with freshwhole transfusion. ImprovementStop at 48 hours. YES NO Repeat 3rd HCT
  • Treatment of hemorrhagic complications● Mucosal bleeding :  if patient remains stable with fluid resuscitation/replacement, considered as minor● Bleeding improves rapidly during recovery phase● Patients with profound thrombocytopenia :  strict bed rest and protect from trauma  not give i.m injections (avoid hematoma)  prophylactic platelet transfusions for severe thrombocytopaenia in hemodynamically stable patients not shown to be effective and not necessary
  • Management of Dengue Infection● No hemorrhagic manifestations and patient is well- hydrated:  home treatment● Hemorrhagic manifestations or hydration borderline:  outpatient observation center or hospitalization● Warning signs (even without profound shock) or DSS:  hospitalize
  • Treatment of Dengue Fever● Fluids● Rest● Antipyretics (avoid aspirin and NSAIDs)● Monitor blood pressure, hematocrit, platelet count, level of consciousness