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Pakistan Dengue Management 14.9.11

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