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Overview & Management of Dengue  Kolitha Sellahewa MBBS.MD.FCCP.FRACP(Hon.) Consultant Physician Epidemiology Unit  SRI LA...
Dengue Viral Infection <ul><li>Asymptomatic - 75% </li></ul><ul><li>Symptomatic – 25% </li></ul><ul><li>Dengue fever – 99%...
Clinical Course DHF <ul><li>Febrile phase </li></ul><ul><ul><ul><li>2 – 7 days </li></ul></ul></ul><ul><li>Critical phase ...
Febrile Phase <ul><li>High continued fever </li></ul><ul><li>Skin erythema </li></ul><ul><li>Myalgia </li></ul><ul><li>Art...
Febrile Phase DF? Or DHF? <ul><li>DF </li></ul><ul><ul><li>Skin rash </li></ul></ul><ul><ul><li>Arthralgia </li></ul></ul>...
Critical Phase Plasma Leakage 24-48Hrs <ul><li>Tachycardia </li></ul><ul><li>Narrowing of pulse pressure  < 20 mm </li></u...
Dynamics of Plasma Leakage Dr. Kolitha Sellahewa
0 Hr 24 Hr 48 Hr 6 Hr 36 Hr Rapid Slow Moderate Dr. Kolitha Sellahewa R F C
0 Hr 24 Hr 48 Hr Time of Presentation and Management  Dr. Kolitha Sellahewa F C R
Early Recognition of Entry into Critical Phase <ul><li>WBC 5000 or less + TT +ve & PLT < 100,000 entering CP next 24 </li>...
Confirm Entry  into the Critical Phase <ul><li>Evidence of  plasma leakage  </li></ul><ul><ul><ul><li>Pleural  and/or peri...
How to time the  onset  of critical phase and predict  end  .... <ul><li>Have serial FBCs done during the illness , ideall...
How to time the onset of critical phase? Onset End 17 th   8 am D3 18 th 8 am D4 18 th   8 pm D4 19 th 8 am D5 19 th 8 pm ...
<ul><li>How to time the onset of critical phase? </li></ul>17 th   8 am 18 th 8 am 18 th   8 pm D4 19 th 8 am 19 th 8 pm 2...
Timing the onset of critical period 17 th   8 am 18 th 8 am 18 th   8 pm 19 th 8 am 19 th 8 pm 20 th   8 am 20 th   8  pm ...
Timing the onset of critical period platelets WBC 17 th   8 am 18 th 8 am 18 th   8 pm 19 th 8 am 19 th 8 pm 20 th   8 am ...
 
 
Convalescent Phase <ul><li>Good appetite </li></ul><ul><li>Convalescent rash </li></ul><ul><li>Pruritus </li></ul><ul><ul>...
Convalescent Rash
 
 
Management Out Patient <ul><li>Restricted Physical Activity </li></ul><ul><li>Diet & fluid </li></ul><ul><li>Antipyretics ...
Criteria for Admission Essential <ul><li>Warning signs </li></ul><ul><ul><ul><li>Abdominal pain or tenderness </li></ul></...
Criteria for Admission Essential <ul><li>Pregnancy </li></ul><ul><li>Elderly patients & infants </li></ul><ul><li>Obese </...
Criteria for Admission <ul><li>Looks ill </li></ul><ul><li>Social reasons </li></ul><ul><ul><ul><li>Poor home support </li...
Management Inward <ul><li>Diagnosis – Dengue infection </li></ul><ul><li>Recognize the clinical type – DF or DHF? </li></u...
Diagnosis <ul><li>Hyper-endemic setting </li></ul><ul><ul><ul><li>Think of dengue – all with fever with in 8 days </li></u...
Differential Diagnosis <ul><li>Leptospirosis </li></ul><ul><ul><ul><li>Occupational history </li></ul></ul></ul><ul><ul><u...
 
Diffuse blanching erythema
Rash in Dengue <ul><li>Diffuse erythematous macules </li></ul><ul><li>Maculo-papular  </li></ul><ul><li>Petechial </li></u...
Dengue fever
 
 
Identify the Clinical Type <ul><li>DF </li></ul><ul><ul><ul><li>No plasma leakage </li></ul></ul></ul><ul><li>DHF </li></u...
Risk Stratification <ul><li>Patient - stable but has predictors of developing severe disease </li></ul><ul><ul><ul><li>Abd...
Recognize the Stage of the Disease <ul><li>Febrile phase  </li></ul><ul><li>Critical phase  </li></ul><ul><li>Convalescent...
Fluid Therapy “ No Fixed Regime” <ul><li>Cornerstone of management </li></ul><ul><li>Dynamic approach </li></ul><ul><li>Be...
Fluid Shifts <ul><li>N.Saline – 1 hour </li></ul><ul><li>Colloids – 4 to 6 hours </li></ul>Dr. Kolitha Sellahewa
Febrile Phase <ul><li>Oral fluids only </li></ul><ul><ul><ul><li>Electrolyte solutions </li></ul></ul></ul><ul><li>IV flui...
Critical Phase of DHF Without Shock <ul><li>Objective: </li></ul><ul><ul><ul><li>Prevent progression to shock </li></ul></...
Dr. Kolitha Sellahewa
Calculation of Total Fluid Quota for the Critical Period <ul><li>M   = </li></ul><ul><li>5 %   =  </li></ul><ul><li>M + 5%...
Guide to rate of  fluid intake in Critical Phase Dr. Kolitha Sellahewa Pulse BP Pulse Pressure CRFT Warmth / Coldness UOP ...
DHF with Shock Aggressive Fluid Therapy <ul><li>Objective </li></ul><ul><ul><ul><li>Resuscitate </li></ul></ul></ul><ul><u...
Compensated Shock <ul><li>N.Saline 10ml/kg (approx 500 ml) IV – 1Hr </li></ul><ul><li>No improvement </li></ul><ul><ul><ul...
Hypotensive Shock  HCT  before & after  fluid bolus <ul><li>N.Saline 10ml/kg IV bolus over 15 mts </li></ul><ul><li>2 nd  ...
Choice of Colloid Boluses   NOT  infusions <ul><li>Dextran 40 </li></ul><ul><ul><ul><li>3 boluses over 24 hours </li></ul>...
Monitoring & Documentation <ul><li>Early detection of shock </li></ul><ul><ul><ul><li>Pulse pressure < 20 mm Hg </li></ul>...
0 Hr 24 Hr 48 Hr Time of Presentation and Management  F C R
DHF Date/Time Febrile Date/Time Critical Date/Time Convalescent Dr. Kolitha Sellahewa
 
Basic Monitoring All Patients <ul><li>Pulse rate </li></ul><ul><li>Pulse pressure </li></ul><ul><li>CRFT </li></ul><ul><li...
Monitoring  Platelet Count Drops Below 100,000 <ul><li>FBC-   twice daily </li></ul><ul><li>Vital parameters-  four hourly...
Monitoring Evidence of Plasma Leakage <ul><li>Escalate  </li></ul><ul><li>Vital signs -  hourly </li></ul><ul><li>HCT  - 8...
 
 
Monitoring IV Fluid Therapy <ul><li>Phase of the illness – be fully aware </li></ul><ul><li>Adequacy of fluid therapy </li...
Monitoring  Chart I - for Management of Dengue Patients – Febrile Phase  <ul><li>Purposes:  </li></ul><ul><li>Differentiat...
Monitoring  Chart I - for Management of Dengue Patients – Febrile Phase  Dengue Fever D4 without Fever D3 with Fever WBC <...
Monitoring  Chart I - for Management of Dengue Patients – Febrile Phase  D4 with Fever TT +  ve , WBC <5000/mm 3 N-40% L-5...
Monitoring Chart II for Management of DHF Patients during Critical Phase <ul><li>Purposes:  </li></ul><ul><li>Early detect...
0 Hr 24 Hr 48 Hr Date/Time Scale 2 Hrs Date/Time Scale 20 Hrs Date/Time Scale 36 Hrs Dr. Kolitha Sellahewa
Monitoring Chart II for Management of DHF Patients during Critical Phase Dr. Kolitha Sellahewa
Monitoring Chart II for Management of DHF Patients during Critical Phase Dr. Kolitha Sellahewa
Monitoring Chart II for Management of DHF Patients during Critical Phase Dr. Kolitha Sellahewa
Dr. Kolitha Sellahewa
 
Summary –  Febrile Patient <ul><li>Dengue or not? </li></ul><ul><ul><li>Clinical </li></ul></ul><ul><ul><li>FBC </li></ul>...
Summary <ul><li>In Critical phase </li></ul><ul><ul><li>Time of entry </li></ul></ul><ul><ul><li>Predicted time of end </l...
COMPLICATIONS – Non? <ul><li>V igilance – detect  </li></ul><ul><li>A lert – plasma leakage </li></ul><ul><li>A ctive – IV...
THANK YOU
Complications and Adjuvant Therapy Dr. Jayantha Weeraman Consultant Paediatrician Dr. Jayantha Weeraman
Pts with complications .... <ul><li>Usually due to </li></ul><ul><ul><li>PROLONG  SHOCK </li></ul></ul><ul><ul><li>FLUID  ...
Bleeding in Dengue Hemorrhagic Fever Phase   Early Pre-Shock Shock Prolong-sh  Death Severity of     Mild of Bleeding Mode...
<ul><li>Fluid overload </li></ul><ul><ul><li>Too much fluids in febrile phase </li></ul></ul><ul><ul><li>Calculation of fl...
Dr.  Jayantha Weeraman
Management of fluid overload Frusemide 1 mg/kg Critical Phase Dr.  Jayantha Weeraman
Indications for IV Frusemide <ul><li>Midway in the infusion of colloids when colloids are given to patients who are alread...
<ul><li>Prolonged shock </li></ul><ul><ul><li>Delayed diagnosis/ delayed resuscitation </li></ul></ul><ul><ul><li>Late pre...
Dr.  Jayantha Weeraman
Prolonged shock in dengue – a challenge to clinicians? <ul><li>> 4 hours untreated </li></ul><ul><ul><ul><li>Liver failure...
Complicated DHF <ul><li>When a pt is deteriorating with no response to fluid therapy…. </li></ul>A:  Acidosis B:  Bleeding...
A  : Acidosis <ul><li>Acidosis is common in profound shock </li></ul><ul><li>Prolonged acidosis makes patients more prone ...
B  : Bleeding <ul><li>Significant overt bleeding -  >6-8ml/kg BW </li></ul><ul><li>Concealed bleeding </li></ul>Dr.  Jayan...
When to suspect bleeding ? <ul><li>When PCV drop without clinical improvement </li></ul><ul><ul><li>Even with bleeding the...
<ul><li>Massive bleeding </li></ul><ul><ul><li>Not given blood transfusion </li></ul></ul><ul><ul><li>Delayed blood transf...
How to manage bleeding <ul><li>Use PRC or WB  </li></ul><ul><li>If there is fluid overload(most frequently) use PRC as 5ml...
..how to manage bleeding <ul><li>5ml/kg of PRC or 10ml/kg of WB will increase PCV by 5% </li></ul><ul><ul><li>Eg.10 year o...
C  : Hypocalcaemia <ul><li>Every patient with complicated DHF has hypocalcaemia. </li></ul><ul><li>Dengue patients who dev...
When to give calcium? <ul><li>If the patient is  complicated  , and deteriorating or not showing expected improvement to f...
Treat if blood sugar below 4 mmol/lt Give 10% dextose 3-5ml/kg bolus followed by an infusion <ul><li>S  : Hypoglycaemia </...
Platelet transfusion- <ul><li>when platelets are low may need but only in very exceptional circumstances  </li></ul><ul><u...
Why do you do platelet counts? <ul><li>To recognize the beginning of critical stage- YES </li></ul><ul><li>To decide on pl...
Recombinant factor VII <ul><li>1 dose = 1,500 USD in a 10-kgs patient </li></ul><ul><li>No use in cases with prolonged sho...
Place of dopamine and dobutamine... <ul><li>Very limited in DHF </li></ul><ul><li>May do harm than good by giving a false ...
NO PLACE FOR STEROIDS AND IV IMMUNOGLOBULINS IN DENGUE
Blood & blood component used in DHF/DSS patients Crystalloid 100% Colloid 20-25% Blood 10-15% Platelet  0.4% Dr.  Jayantha...
Myocardial involvement in Dengue <ul><li>Global dysfunction of myocardial contractility seen in prolonged shock </li></ul>...
Causes of death in DHF patients <ul><li>Prolonged shock </li></ul><ul><ul><li>Delayed diagnosis/ delayed resuscitation  </...
Dr.  Jayantha Weeraman
THANK YOU
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Pakistan Dengue Management 14.9.11

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Transcript of "Pakistan Dengue Management 14.9.11"

  1. 1. Overview & Management of Dengue Kolitha Sellahewa MBBS.MD.FCCP.FRACP(Hon.) Consultant Physician Epidemiology Unit SRI LANKA
  2. 2. Dengue Viral Infection <ul><li>Asymptomatic - 75% </li></ul><ul><li>Symptomatic – 25% </li></ul><ul><li>Dengue fever – 99% </li></ul><ul><li>DHF – 1% ( 10,000 infected only 25 DHF ) </li></ul><ul><li>Dengue with severe & often life threatening complications </li></ul><ul><ul><ul><li>Shock </li></ul></ul></ul><ul><ul><ul><li>Bleeding - DIC </li></ul></ul></ul>Dr. Kolitha Sellahewa
  3. 3. Clinical Course DHF <ul><li>Febrile phase </li></ul><ul><ul><ul><li>2 – 7 days </li></ul></ul></ul><ul><li>Critical phase </li></ul><ul><ul><ul><li>3-7 days </li></ul></ul></ul><ul><ul><ul><li>Lasts only for 24 – 48 hours </li></ul></ul></ul><ul><li>Convalescent phase </li></ul><ul><ul><ul><li>Begins after the critical phase & lasts for 5 - 7 days </li></ul></ul></ul>Dr. Kolitha Sellahewa
  4. 4. Febrile Phase <ul><li>High continued fever </li></ul><ul><li>Skin erythema </li></ul><ul><li>Myalgia </li></ul><ul><li>Arthralgia </li></ul><ul><li>Headache </li></ul><ul><li>Leucopenia < 5000 cells/c.mm </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>Tender hepatomegaly – DHF > DF </li></ul>Dr. Kolitha Sellahewa
  5. 5. Febrile Phase DF? Or DHF? <ul><li>DF </li></ul><ul><ul><li>Skin rash </li></ul></ul><ul><ul><li>Arthralgia </li></ul></ul><ul><ul><li>Bone pain </li></ul></ul><ul><li>DHF </li></ul><ul><ul><li>Tender hepatomegaly </li></ul></ul><ul><li>Common </li></ul><ul><ul><li>Leucopaenia < 5000 </li></ul></ul><ul><ul><li>Thrombocytopaenia </li></ul></ul><ul><ul><li>Bleeding manifestations </li></ul></ul>Dr. Kolitha Sellahewa
  6. 6. Critical Phase Plasma Leakage 24-48Hrs <ul><li>Tachycardia </li></ul><ul><li>Narrowing of pulse pressure < 20 mm </li></ul><ul><li>CRFT > 2 secs </li></ul><ul><li>HCT 20% increase from base line </li></ul><ul><li>Pleural effusions </li></ul><ul><li>Ascitis </li></ul><ul><li>Ser albumin < 3.5 g/dl </li></ul><ul><li>Non fasting ser cholesterol < 100 mg/dl </li></ul>Dr. Kolitha Sellahewa
  7. 7. Dynamics of Plasma Leakage Dr. Kolitha Sellahewa
  8. 8. 0 Hr 24 Hr 48 Hr 6 Hr 36 Hr Rapid Slow Moderate Dr. Kolitha Sellahewa R F C
  9. 9. 0 Hr 24 Hr 48 Hr Time of Presentation and Management Dr. Kolitha Sellahewa F C R
  10. 10. Early Recognition of Entry into Critical Phase <ul><li>WBC 5000 or less + TT +ve & PLT < 100,000 entering CP next 24 </li></ul><ul><li>Haemoconcentration </li></ul><ul><ul><ul><li>HCT progressive rise </li></ul></ul></ul><ul><ul><ul><li>HCT 20% rise from baseline </li></ul></ul></ul><ul><li>Radiology </li></ul><ul><ul><ul><li>CXR – right lateral decubitus </li></ul></ul></ul><ul><ul><ul><li>US scan </li></ul></ul></ul><ul><ul><ul><ul><li>Oedematous gall bladder wall </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ascitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pleural effusions </li></ul></ul></ul></ul>Dr. Kolitha Sellahewa
  11. 11. Confirm Entry into the Critical Phase <ul><li>Evidence of plasma leakage </li></ul><ul><ul><ul><li>Pleural and/or peritoneal cavities </li></ul></ul></ul><ul><li>Radiology </li></ul><ul><ul><ul><li>CXR – right lateral decubitus </li></ul></ul></ul><ul><ul><ul><li>US scan </li></ul></ul></ul><ul><ul><ul><ul><li>Oedematous gall bladder wall </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ascitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pleural effusions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Biochemistry </li></ul></ul></ul></ul><ul><ul><ul><li>Ser albumin < 3.5 g/dl </li></ul></ul></ul><ul><ul><ul><li>Non fasting ser cholesterol < 100 mg/dl </li></ul></ul></ul>Dr. Kolitha Sellahewa
  12. 12. How to time the onset of critical phase and predict end .... <ul><li>Have serial FBCs done during the illness , ideally from the same reliable lab </li></ul><ul><li>Beyond Day 3... when WBC is dropping below(or close to ) 5000 and platelets are <150,000 and dropping do more than once/day </li></ul><ul><li>DO FBC – Not PCV & Platelets!!! </li></ul>Dr. Kolitha Sellahewa
  13. 13. How to time the onset of critical phase? Onset End 17 th 8 am D3 18 th 8 am D4 18 th 8 pm D4 19 th 8 am D5 19 th 8 pm D5 20 th 8 am D6 <ul><li>20 th </li></ul><ul><li>Pm </li></ul><ul><li>D6 </li></ul>21 st 8 am D7 21 st 8 pm D7 WBC 3200 2800 1900 2900 3700 4500 6000 7000 7300 N % 53 41 31 26 25 31 33 43 58 L % 44 56 68 71 73 67 66 55 41 PCV % 39 36 39 42 43 39 44 43 38 Plt 252000 121000 110000 61000 22000 18000 12000 8000 19000
  14. 14. <ul><li>How to time the onset of critical phase? </li></ul>17 th 8 am 18 th 8 am 18 th 8 pm D4 19 th 8 am 19 th 8 pm 20 th 8 am 20 th 8 pm 21 st 8 am 21 st 8 pm WBC 3200 2800 1900 2900 3700 4500 6000 7000 7300 N % 53 41 31 26 25 31 33 43 58 L % 44 56 68 71 73 67 66 55 41 PCV % 39 36 39 42 43 39 44 43 38 Plt 121000 96000 94000 41000 22000 18000 12000 8000 19000
  15. 15. Timing the onset of critical period 17 th 8 am 18 th 8 am 18 th 8 pm 19 th 8 am 19 th 8 pm 20 th 8 am 20 th 8 pm 21 st 8 am 21 st 8 pm 7500 7000 6500 6000 5500 5000 4500 4000 3500 3000 2500 2000 1500 260,000 240,000 220,000 200,000 180,000 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0
  16. 16. Timing the onset of critical period platelets WBC 17 th 8 am 18 th 8 am 18 th 8 pm 19 th 8 am 19 th 8 pm 20 th 8 am 20 th 8 pm 21 st 8 am 21 st 8 pm 7500 7000 6500 6000 5500 5000 4500 4000 3500 3000 2500 2000 1500 260,000 240,000 220,000 200,000 180,000 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0
  17. 19. Convalescent Phase <ul><li>Good appetite </li></ul><ul><li>Convalescent rash </li></ul><ul><li>Pruritus </li></ul><ul><ul><ul><li>Palms & soles </li></ul></ul></ul><ul><li>Heamodynamic stability </li></ul><ul><li>Bradycardia </li></ul><ul><li>Diuresis </li></ul><ul><li>Stabilization of HCT </li></ul><ul><li>Rise in WBC rise in platelet count </li></ul>Dr. Kolitha Sellahewa
  18. 20. Convalescent Rash
  19. 23. Management Out Patient <ul><li>Restricted Physical Activity </li></ul><ul><li>Diet & fluid </li></ul><ul><li>Antipyretics </li></ul><ul><ul><li>Paracetamol </li></ul></ul><ul><li>Do NOT give NSAIDs NOT even suppositories </li></ul><ul><li>Advice on review & admission </li></ul>Dr. Kolitha Sellahewa
  20. 24. Criteria for Admission Essential <ul><li>Warning signs </li></ul><ul><ul><ul><li>Abdominal pain or tenderness </li></ul></ul></ul><ul><ul><ul><li>Persistent vomiting </li></ul></ul></ul><ul><ul><ul><li>Lethargy & restlessness </li></ul></ul></ul><ul><ul><ul><li>Hepatomegaly </li></ul></ul></ul><ul><ul><ul><li>Mucosal bleeding </li></ul></ul></ul><ul><ul><ul><li>Evidence of plasma leakage </li></ul></ul></ul><ul><li>Platelet count < 100,000 cells/c.mm </li></ul>Dr. Kolitha Sellahewa
  21. 25. Criteria for Admission Essential <ul><li>Pregnancy </li></ul><ul><li>Elderly patients & infants </li></ul><ul><li>Obese </li></ul><ul><li>Co morbidity </li></ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul><ul><ul><ul><li>IHD </li></ul></ul></ul><ul><ul><ul><li>Chronic renal failure </li></ul></ul></ul>Dr. Kolitha Sellahewa
  22. 26. Criteria for Admission <ul><li>Looks ill </li></ul><ul><li>Social reasons </li></ul><ul><ul><ul><li>Poor home support </li></ul></ul></ul><ul><ul><ul><li>Poor access to hospital facility </li></ul></ul></ul><ul><ul><ul><li>Living alone </li></ul></ul></ul><ul><li>Individual discretion </li></ul>Dr. Kolitha Sellahewa
  23. 27. Management Inward <ul><li>Diagnosis – Dengue infection </li></ul><ul><li>Recognize the clinical type – DF or DHF? </li></ul><ul><li>DHF – phase of the illness ? </li></ul><ul><li>Fluid therapy </li></ul><ul><li>Monitoring & documentation </li></ul><ul><li>Adjuvant therapy </li></ul>Dr. Kolitha Sellahewa
  24. 28. Diagnosis <ul><li>Hyper-endemic setting </li></ul><ul><ul><ul><li>Think of dengue – all with fever with in 8 days </li></ul></ul></ul><ul><li>Clinical </li></ul><ul><li>Laboratory data – not essential </li></ul><ul><li>Features of a viral infection </li></ul><ul><ul><ul><li>Acute onset of fever </li></ul></ul></ul><ul><ul><ul><li>Myalgia </li></ul></ul></ul><ul><ul><ul><li>Arthralgia </li></ul></ul></ul><ul><ul><ul><li>Retro-orbital pain </li></ul></ul></ul><ul><ul><ul><li>Usually corhyza is abscent </li></ul></ul></ul><ul><ul><ul><li>Rash - Diffuse blanching erythema </li></ul></ul></ul><ul><li>WBC < 5000 cells / c. mm </li></ul><ul><li>Positive tourniquet test (PPV >85%) </li></ul>Dr. Kolitha Sellahewa
  25. 29. Differential Diagnosis <ul><li>Leptospirosis </li></ul><ul><ul><ul><li>Occupational history </li></ul></ul></ul><ul><ul><ul><li>Muscle tenderness - calves </li></ul></ul></ul><ul><ul><ul><li>Icterus </li></ul></ul></ul><ul><ul><ul><li>Conjunctival injection </li></ul></ul></ul><ul><ul><ul><li>Polymorphonuclear leucocytosis </li></ul></ul></ul><ul><ul><ul><li>Thrombocytopenia </li></ul></ul></ul><ul><li>Other viral fevers </li></ul><ul><ul><ul><li>Leucopaenia </li></ul></ul></ul><ul><ul><ul><li>Normal platelet count </li></ul></ul></ul>Dr. Kolitha Sellahewa
  26. 31. Diffuse blanching erythema
  27. 32. Rash in Dengue <ul><li>Diffuse erythematous macules </li></ul><ul><li>Maculo-papular </li></ul><ul><li>Petechial </li></ul><ul><li>Diffuse blanching erythema </li></ul><ul><li>Blanching papular erythema </li></ul>Dr. Kolitha Sellahewa
  28. 33. Dengue fever
  29. 36. Identify the Clinical Type <ul><li>DF </li></ul><ul><ul><ul><li>No plasma leakage </li></ul></ul></ul><ul><li>DHF </li></ul><ul><ul><li>Plasma leakage </li></ul></ul><ul><ul><li>Platelet count < 100,000 </li></ul></ul><ul><ul><ul><li>With or without shock </li></ul></ul></ul><ul><ul><ul><li>With or without bleeding </li></ul></ul></ul><ul><li>Patient with unusual or uncommon complications – Exceedingly rare </li></ul>Dr. Kolitha Sellahewa
  30. 37. Risk Stratification <ul><li>Patient - stable but has predictors of developing severe disease </li></ul><ul><ul><ul><li>Abdominal pain </li></ul></ul></ul><ul><ul><ul><li>Persistent vomiting </li></ul></ul></ul><ul><ul><ul><li>Mucosal bleeding </li></ul></ul></ul><ul><ul><ul><li>Lethargy & restlessness </li></ul></ul></ul><ul><ul><ul><li>Tender hepatomegaly </li></ul></ul></ul><ul><ul><ul><li>Ascitis, pleural effusions </li></ul></ul></ul><ul><ul><ul><li>Increase HCT with rapid decrease in platelet count </li></ul></ul></ul><ul><ul><ul><li>WBC,5000 with relative lymphocytosis & an increase in atypical lymphocytes </li></ul></ul></ul><ul><ul><ul><li>Elderly, Pregnancy & co-morbid states </li></ul></ul></ul>Dr. Kolitha Sellahewa
  31. 38. Recognize the Stage of the Disease <ul><li>Febrile phase </li></ul><ul><li>Critical phase </li></ul><ul><li>Convalescent phase </li></ul><ul><li>Day of the illness ? </li></ul><ul><li>Evidence of plasma leakage ? </li></ul><ul><li>Convalescent rash ? </li></ul>HOW Dr. Kolitha Sellahewa
  32. 39. Fluid Therapy “ No Fixed Regime” <ul><li>Cornerstone of management </li></ul><ul><li>Dynamic approach </li></ul><ul><li>Be fully aware of the dynamics of the disease </li></ul><ul><li>Mode of intervention depends on: </li></ul><ul><ul><ul><li>Phase </li></ul></ul></ul><ul><ul><ul><li>Clinical type </li></ul></ul></ul><ul><li>Type of fluid </li></ul><ul><ul><ul><li>Oral fluids </li></ul></ul></ul><ul><ul><ul><li>Crystalloid </li></ul></ul></ul><ul><ul><ul><li>Colloid </li></ul></ul></ul>Dr. Kolitha Sellahewa
  33. 40. Fluid Shifts <ul><li>N.Saline – 1 hour </li></ul><ul><li>Colloids – 4 to 6 hours </li></ul>Dr. Kolitha Sellahewa
  34. 41. Febrile Phase <ul><li>Oral fluids only </li></ul><ul><ul><ul><li>Electrolyte solutions </li></ul></ul></ul><ul><li>IV fluids are not mandatory </li></ul><ul><ul><ul><li>Undue vomiting or diarrhea </li></ul></ul></ul><ul><ul><ul><li>Oral fluids not tolerated </li></ul></ul></ul><ul><li>Quantity: </li></ul><ul><ul><ul><li>1500ml – 2500ml/24Hrs </li></ul></ul></ul><ul><ul><ul><li>Both oral & IV </li></ul></ul></ul><ul><li>Type: </li></ul><ul><ul><ul><li>N.Saline </li></ul></ul></ul>Dr. Kolitha Sellahewa
  35. 42. Critical Phase of DHF Without Shock <ul><li>Objective: </li></ul><ul><ul><ul><li>Prevent progression to shock </li></ul></ul></ul><ul><ul><ul><li>Avoid fluid overloading </li></ul></ul></ul><ul><li>Judicious fluid therapy- Fluid restriction </li></ul><ul><li>Quantity – calculated </li></ul><ul><ul><ul><li>M+5% = 4600 ml / 48 hrs (50Kg) </li></ul></ul></ul><ul><ul><ul><li>Full quota for entire critical phase 48 hrs </li></ul></ul></ul><ul><ul><ul><li>Approximately 90 ml/hr </li></ul></ul></ul><ul><ul><ul><li>Adjust infusion rate to match the dynamics of plasma leakage </li></ul></ul></ul><ul><li>Type: </li></ul><ul><ul><ul><li>N.Saline </li></ul></ul></ul>Monitor HR PP > 20 mm Hg CRFT < 2 secs U.O.P. 0.5-1ml/kg/hr HCT RR <20/mt Dr. Kolitha Sellahewa
  36. 43. Dr. Kolitha Sellahewa
  37. 44. Calculation of Total Fluid Quota for the Critical Period <ul><li>M = </li></ul><ul><li>5 % = </li></ul><ul><li>M + 5% = </li></ul>Dr. Kolitha Sellahewa
  38. 45. Guide to rate of fluid intake in Critical Phase Dr. Kolitha Sellahewa Pulse BP Pulse Pressure CRFT Warmth / Coldness UOP – ml/kg/hr Evidence of Bleeding
  39. 46. DHF with Shock Aggressive Fluid Therapy <ul><li>Objective </li></ul><ul><ul><ul><li>Resuscitate </li></ul></ul></ul><ul><ul><ul><li>Prevent further shock </li></ul></ul></ul><ul><ul><ul><li>Anticipate & prevent complications of shock </li></ul></ul></ul><ul><ul><ul><ul><ul><li>GIT bleeding & DIC </li></ul></ul></ul></ul></ul><ul><li>Intervention depends on: </li></ul><ul><li>Compensated shock </li></ul><ul><ul><ul><li>Systolic pressure maintained but signs of reduced perfusion </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Narrow Pulse Pressure </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cold extremities </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Low volume pulse </li></ul></ul></ul></ul></ul><ul><li>Hypotensive shock </li></ul><ul><ul><ul><li>Unrecordable BP & Pulse </li></ul></ul></ul>Dr. Kolitha Sellahewa
  40. 47. Compensated Shock <ul><li>N.Saline 10ml/kg (approx 500 ml) IV – 1Hr </li></ul><ul><li>No improvement </li></ul><ul><ul><ul><li>Collect blood </li></ul></ul></ul><ul><ul><ul><ul><ul><li>venous BGA </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Calcium HCT before & after fluid bolus </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sugar </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sodium </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Grouping & DT </li></ul></ul></ul></ul></ul><ul><li>Colloid bolus 10ml/kg IV over 1 hr </li></ul><ul><li>Colloid boluses </li></ul><ul><ul><ul><li>Haemodynamically unstable </li></ul></ul></ul><ul><ul><ul><li>HCT drops </li></ul></ul></ul><ul><li>Blood transfusion </li></ul>Dr. Kolitha Sellahewa
  41. 48. Hypotensive Shock HCT before & after fluid bolus <ul><li>N.Saline 10ml/kg IV bolus over 15 mts </li></ul><ul><li>2 nd bolus 10 ml/kg over 60 mts </li></ul><ul><li>Collect blood </li></ul><ul><ul><ul><li>Blood gas analysis </li></ul></ul></ul><ul><ul><ul><li>Calcium </li></ul></ul></ul><ul><ul><ul><li>Electrolytes </li></ul></ul></ul><ul><ul><ul><li>Sugar </li></ul></ul></ul><ul><ul><ul><li>Grouping & cross matching </li></ul></ul></ul><ul><li>Colloid 10 ml/kg IV bolus over 1 hr </li></ul>Dr. Kolitha Sellahewa
  42. 49. Choice of Colloid Boluses NOT infusions <ul><li>Dextran 40 </li></ul><ul><ul><ul><li>3 boluses over 24 hours </li></ul></ul></ul><ul><ul><ul><li>6 boluses over 48 hours </li></ul></ul></ul><ul><li>6% starch-Heta starch(Voluven) </li></ul><ul><ul><ul><li>5 boluses over 24 hours </li></ul></ul></ul><ul><ul><ul><li>10 boluses over 48 hours </li></ul></ul></ul><ul><li>Fresh Frozen Plasma </li></ul><ul><ul><ul><li>1 bolus </li></ul></ul></ul><ul><ul><ul><li>3 units approximately 450 – 600 ml </li></ul></ul></ul>Dr. Kolitha Sellahewa
  43. 50. Monitoring & Documentation <ul><li>Early detection of shock </li></ul><ul><ul><ul><li>Pulse pressure < 20 mm Hg </li></ul></ul></ul><ul><ul><ul><li>CRFT > 2 secs </li></ul></ul></ul><ul><ul><ul><li>HCT increase of 20% or more from baseline </li></ul></ul></ul><ul><li>Judge the efficacy of IV fluid therapy </li></ul><ul><ul><ul><li>PP , CRFT, No postural hypotension </li></ul></ul></ul><ul><ul><ul><li>Hourly UOP 0.5 – 1.0 ml/kg/hr </li></ul></ul></ul><ul><li>Early detection of complications of fluid therapy </li></ul><ul><ul><ul><li>Respiratory rate > 20/mt </li></ul></ul></ul><ul><ul><ul><li>Lung bases </li></ul></ul></ul><ul><ul><ul><li>SaO2 < 92% </li></ul></ul></ul><ul><ul><ul><li>CXR </li></ul></ul></ul>Dr. Kolitha Sellahewa
  44. 51. 0 Hr 24 Hr 48 Hr Time of Presentation and Management F C R
  45. 52. DHF Date/Time Febrile Date/Time Critical Date/Time Convalescent Dr. Kolitha Sellahewa
  46. 54. Basic Monitoring All Patients <ul><li>Pulse rate </li></ul><ul><li>Pulse pressure </li></ul><ul><li>CRFT </li></ul><ul><li>Respiratory rate </li></ul><ul><li>FBC - HCT </li></ul><ul><li>Intensity of monitoring depends on </li></ul><ul><ul><ul><li>Phase of the illness </li></ul></ul></ul><ul><ul><ul><li>Severity </li></ul></ul></ul><ul><ul><ul><li>Aggressiveness of fluid therapy </li></ul></ul></ul><ul><li>Accurate fluid balance charts </li></ul>Dr. Kolitha Sellahewa
  47. 55. Monitoring Platelet Count Drops Below 100,000 <ul><li>FBC- twice daily </li></ul><ul><li>Vital parameters- four hourly </li></ul><ul><ul><li>Pulse rate </li></ul></ul><ul><ul><li>Blood pressure (both systolic and diastolic), </li></ul></ul><ul><ul><li>Respiratory rate, </li></ul></ul><ul><ul><li>Capillary refill time </li></ul></ul><ul><li>Detailed fluid balance chart- </li></ul><ul><ul><li>Type and route of fluid hourly, </li></ul></ul><ul><ul><li>Urine output four hourly </li></ul></ul>Dr. Kolitha Sellahewa
  48. 56. Monitoring Evidence of Plasma Leakage <ul><li>Escalate </li></ul><ul><li>Vital signs - hourly </li></ul><ul><li>HCT - 8 hourly </li></ul><ul><li>Fluid intake & the balance left from the calculated quota </li></ul><ul><ul><ul><li>Temporal relationship </li></ul></ul></ul><ul><ul><ul><li>Critical phase </li></ul></ul></ul><ul><ul><ul><li>In hours </li></ul></ul></ul><ul><li>Detailed fluid balance chart </li></ul>Dr. Kolitha Sellahewa
  49. 59. Monitoring IV Fluid Therapy <ul><li>Phase of the illness – be fully aware </li></ul><ul><li>Adequacy of fluid therapy </li></ul><ul><ul><ul><li>Pulse Pressure >20 mmHg </li></ul></ul></ul><ul><ul><ul><li>CRFT <2 sec </li></ul></ul></ul><ul><ul><ul><li>Pulse Rate <80/mt </li></ul></ul></ul><ul><ul><ul><li>UOP > 0.5 ml/Kg/hr </li></ul></ul></ul><ul><ul><ul><li>HCT </li></ul></ul></ul><ul><li>Early detection of fluid overloading </li></ul><ul><ul><ul><li>Respiratory rate > 20/mt </li></ul></ul></ul><ul><ul><ul><li>Lung bases </li></ul></ul></ul><ul><ul><ul><li>SaO2 < 92% </li></ul></ul></ul><ul><ul><ul><li>CXR </li></ul></ul></ul>Shift to ICU Dr. Kolitha Sellahewa
  50. 60. Monitoring Chart I - for Management of Dengue Patients – Febrile Phase <ul><li>Purposes: </li></ul><ul><li>Differentiate DF from DHF </li></ul><ul><li>To detect entry in to Critical Phase </li></ul>Dr. Kolitha Sellahewa Vital Signs
  51. 61. Monitoring Chart I - for Management of Dengue Patients – Febrile Phase Dengue Fever D4 without Fever D3 with Fever WBC <5000/mm 3 N-40% L-58% TT + ve Dr. Kolitha Sellahewa
  52. 62. Monitoring Chart I - for Management of Dengue Patients – Febrile Phase D4 with Fever TT + ve , WBC <5000/mm 3 N-40% L-58% Tender Liver Dr. Kolitha Sellahewa Entry in to Critical Phase
  53. 63. Monitoring Chart II for Management of DHF Patients during Critical Phase <ul><li>Purposes: </li></ul><ul><li>Early detection of Shock </li></ul><ul><li>Accurate Fluid management </li></ul>Dr. Kolitha Sellahewa
  54. 64. 0 Hr 24 Hr 48 Hr Date/Time Scale 2 Hrs Date/Time Scale 20 Hrs Date/Time Scale 36 Hrs Dr. Kolitha Sellahewa
  55. 65. Monitoring Chart II for Management of DHF Patients during Critical Phase Dr. Kolitha Sellahewa
  56. 66. Monitoring Chart II for Management of DHF Patients during Critical Phase Dr. Kolitha Sellahewa
  57. 67. Monitoring Chart II for Management of DHF Patients during Critical Phase Dr. Kolitha Sellahewa
  58. 68. Dr. Kolitha Sellahewa
  59. 70. Summary – Febrile Patient <ul><li>Dengue or not? </li></ul><ul><ul><li>Clinical </li></ul></ul><ul><ul><li>FBC </li></ul></ul><ul><ul><ul><li>Leucopaenia + thrombocytopaenia </li></ul></ul></ul><ul><li>DF or DHF ? </li></ul><ul><ul><li>Plasma leakage + or – </li></ul></ul><ul><li>If DHF – what is the phase ? </li></ul>Dr. Kolitha Sellahewa
  60. 71. Summary <ul><li>In Critical phase </li></ul><ul><ul><li>Time of entry </li></ul></ul><ul><ul><li>Predicted time of end </li></ul></ul><ul><li>Aggressive monitoring </li></ul><ul><li>Calculate the fluid quota </li></ul><ul><li>Dynamic approach to fluid therapy </li></ul><ul><li>Final diagnosis – precise (DF or DHF & grade) </li></ul>Dr. Kolitha Sellahewa
  61. 72. COMPLICATIONS – Non? <ul><li>V igilance – detect </li></ul><ul><li>A lert – plasma leakage </li></ul><ul><li>A ctive – IV fluid </li></ul><ul><li>A ggressive - manipulate </li></ul>Dr. Kolitha Sellahewa
  62. 73. THANK YOU
  63. 74. Complications and Adjuvant Therapy Dr. Jayantha Weeraman Consultant Paediatrician Dr. Jayantha Weeraman
  64. 75. Pts with complications .... <ul><li>Usually due to </li></ul><ul><ul><li>PROLONG SHOCK </li></ul></ul><ul><ul><li>FLUID OVERLOAD </li></ul></ul>Dr. Jayantha Weeraman
  65. 76. Bleeding in Dengue Hemorrhagic Fever Phase Early Pre-Shock Shock Prolong-sh Death Severity of Mild of Bleeding Moderate SEVERE Mechanism Drug Vascular injury Platelet Dysfunction Thrombocytopenia Coagulopathy-DIC Fibrinolysis Dr. Kolitha Sellahewa
  66. 77. <ul><li>Fluid overload </li></ul><ul><ul><li>Too much fluids in febrile phase </li></ul></ul><ul><ul><li>Calculation of fluids in obese pt-ABW vs IBW </li></ul></ul><ul><ul><li>Use of hypotonic saline </li></ul></ul><ul><ul><li>Given excess fluids </li></ul></ul><ul><ul><li>Given more than time of leakage </li></ul></ul><ul><ul><li>Not using colloidal solution when indicates </li></ul></ul><ul><ul><li>Not giving blood when there is concealed bleeding </li></ul></ul><ul><ul><li>Inappropriate IV Fluids for “severe bleeding” </li></ul></ul><ul><ul><ul><li>Eg: FFP, platelets & cryo </li></ul></ul></ul>Dr. Jayantha Weeraman
  67. 78. Dr. Jayantha Weeraman
  68. 79. Management of fluid overload Frusemide 1 mg/kg Critical Phase Dr. Jayantha Weeraman
  69. 80. Indications for IV Frusemide <ul><li>Midway in the infusion of colloids when colloids are given to patients who are already fluid overloaded or who are likely to be overloaded depending on the fluids already given. </li></ul><ul><li>Midway between blood transfusions.  </li></ul><ul><li>In patients passing less than 0.5ml/kg/hr of urine despite receiving adequate fluids and having stable BP, pulse, Hct to improve the UOP.  </li></ul><ul><li>During recovery phase when there is suggestion of pulmonary oedema or fluid overload.   </li></ul>Dr. Jayantha Weeraman
  70. 81. <ul><li>Prolonged shock </li></ul><ul><ul><li>Delayed diagnosis/ delayed resuscitation </li></ul></ul><ul><ul><li>Late presentation </li></ul></ul><ul><ul><li>Fluid restriction without monitoring </li></ul></ul>Dr. Jayantha Weeraman
  71. 82. Dr. Jayantha Weeraman
  72. 83. Prolonged shock in dengue – a challenge to clinicians? <ul><li>> 4 hours untreated </li></ul><ul><ul><ul><li>Liver failure- prognosis 50% </li></ul></ul></ul><ul><ul><ul><li>Liver + Renal failure - prognosis10% </li></ul></ul></ul><ul><ul><ul><li>3 organs failure (+respiratory failure) – Prognosis is a miracle!!! </li></ul></ul></ul><ul><li>> 10 hours untreated - Death!!! </li></ul>Dr. Jayantha Weeraman
  73. 84. Complicated DHF <ul><li>When a pt is deteriorating with no response to fluid therapy…. </li></ul>A: Acidosis B: Bleeding C: Calcium S: Sugar Dr. Jayantha Weeraman
  74. 85. A : Acidosis <ul><li>Acidosis is common in profound shock </li></ul><ul><li>Prolonged acidosis makes patients more prone to DIC </li></ul><ul><li>Correct acidosis if pH is <7.35 together with HCO 3- level <15 mmol/l </li></ul><ul><li>One may use empirical NaHCO3 1ml/kgs slow bolus (max 10ml) diluted in equal volume </li></ul>Dr. Jayantha Weeraman
  75. 86. B : Bleeding <ul><li>Significant overt bleeding - >6-8ml/kg BW </li></ul><ul><li>Concealed bleeding </li></ul>Dr. Jayantha Weeraman
  76. 87. When to suspect bleeding ? <ul><li>When PCV drop without clinical improvement </li></ul><ul><ul><li>Even with bleeding the PCV drop may take time(4-5hrs). When the pt does not show improvement important to do repeat PCVs frequently! </li></ul></ul><ul><li>Haematocrit not as high as expected for the degree of shock to be explained by plasma leakage alone. (Hypotensive shock with low or normal HCT) </li></ul><ul><li>Severe metabolic acidosis and end-organ dysfunction despite adequate fluid replacement </li></ul>Dr. Jayantha Weeraman
  77. 88. <ul><li>Massive bleeding </li></ul><ul><ul><li>Not given blood transfusion </li></ul></ul><ul><ul><li>Delayed blood transfusion </li></ul></ul>Remember!!! In DHF Bleeding could be concealed Dr. Jayantha Weeraman
  78. 89. How to manage bleeding <ul><li>Use PRC or WB </li></ul><ul><li>If there is fluid overload(most frequently) use PRC as 5ml/kg at once and repeat only if needed depending on the response </li></ul><ul><li>If there is no fluid overload use 10ml/kg of WB </li></ul><ul><li>Even if bleeding is likely and if PCV is >45% do not give blood without bringing down the PCV first by giving a colloid. </li></ul>Dr. Jayantha Weeraman
  79. 90. ..how to manage bleeding <ul><li>5ml/kg of PRC or 10ml/kg of WB will increase PCV by 5% </li></ul><ul><ul><li>Eg.10 year old girl with PCV of 26% in shock.. </li></ul></ul><ul><ul><li>Base line PCV in a 10 yr old 36% but if in shock it will be up by 20%  43%. There is 17% deficit which need 3 PRC transfusuions </li></ul></ul>Dr. Jayantha Weeraman
  80. 91. C : Hypocalcaemia <ul><li>Every patient with complicated DHF has hypocalcaemia. </li></ul><ul><li>Dengue patients who develop convulsions are likely to have hypocalcaemia.( may give them empirical calcium) </li></ul><ul><li>Detection of hypocalcaemia: </li></ul><ul><ul><li>Measure serum Ca 2+ level </li></ul></ul><ul><ul><li>Corrected QT interval in ECG </li></ul></ul>Dr. Jayantha Weeraman
  81. 92. When to give calcium? <ul><li>If the patient is complicated , and deteriorating or not showing expected improvement to fluid Rx think of hypocalcaemia. </li></ul><ul><li>Give empirical calcium to such pts </li></ul><ul><ul><li>Dose 1ml/kg of 10% Ca Gluconate slow bolus diluted in N saline over 10-15 min(look for bradycaria while pushing slowly) Max: 10ml . Can even give every 6Hrs if pt is not improving </li></ul></ul>Dr. Jayantha Weeraman
  82. 93. Treat if blood sugar below 4 mmol/lt Give 10% dextose 3-5ml/kg bolus followed by an infusion <ul><li>S : Hypoglycaemia </li></ul>Dr. Jayantha Weeraman
  83. 94. Platelet transfusion- <ul><li>when platelets are low may need but only in very exceptional circumstances </li></ul><ul><ul><li>(Thailand only in <0.4% of pts with DHF) </li></ul></ul><ul><ul><li>Each platelet pack is 50-150ml  contribute to fluid overload </li></ul></ul><ul><ul><li>No prophylaxis platelet transfusion </li></ul></ul>Dr. Jayantha Weeraman
  84. 95. Why do you do platelet counts? <ul><li>To recognize the beginning of critical stage- YES </li></ul><ul><li>To decide on platelet transfusion- NO </li></ul><ul><li>As a prognostic indicator- YES </li></ul>Dr. Jayantha Weeraman
  85. 96. Recombinant factor VII <ul><li>1 dose = 1,500 USD in a 10-kgs patient </li></ul><ul><li>No use in cases with prolonged shock and multiple organs failure </li></ul><ul><li>Consider in cases with bleeding where the cause is not prolonged shock BUT other reason: peptic ulcer, trauma etc </li></ul>Dr. Jayantha Weeraman
  86. 97. Place of dopamine and dobutamine... <ul><li>Very limited in DHF </li></ul><ul><li>May do harm than good by giving a false impression about BP </li></ul><ul><li>When using1 st make sure that there is enough intravascular volume shown by increased CVP </li></ul>Dr. Jayantha Weeraman
  87. 98. NO PLACE FOR STEROIDS AND IV IMMUNOGLOBULINS IN DENGUE
  88. 99. Blood & blood component used in DHF/DSS patients Crystalloid 100% Colloid 20-25% Blood 10-15% Platelet 0.4% Dr. Jayantha Weeraman
  89. 100. Myocardial involvement in Dengue <ul><li>Global dysfunction of myocardial contractility seen in prolonged shock </li></ul><ul><li>Due to, metabolic acidosis, Hypocalcaemia </li></ul><ul><li>Unlikely to cause death </li></ul><ul><li>If myocarditis is suspected fluid should be given very carefully </li></ul><ul><li>Rx- Symptomatic </li></ul>Dr. Jayantha Weeraman
  90. 101. Causes of death in DHF patients <ul><li>Prolonged shock </li></ul><ul><ul><li>Delayed diagnosis/ delayed resuscitation </li></ul></ul><ul><ul><li>Late presentation </li></ul></ul><ul><li>Fluid overload </li></ul><ul><ul><li>Use of hypotonic saline </li></ul></ul><ul><ul><li>Given excess fluids </li></ul></ul><ul><ul><li>Given more than time of leakage </li></ul></ul><ul><li>Massive bleeding </li></ul><ul><ul><li>Not given blood transfusion </li></ul></ul><ul><ul><li>Delayed blood transfusion </li></ul></ul><ul><li>Unusual manifestations </li></ul><ul><ul><li>Encephalopathy </li></ul></ul><ul><ul><li>Underlying co-morbidity </li></ul></ul><ul><ul><li>Dual infection </li></ul></ul>Dr. Jayantha Weeraman
  91. 102. Dr. Jayantha Weeraman
  92. 103. THANK YOU
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