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Dengue fever – practice parameters
 

Dengue fever – practice parameters

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    Dengue fever – practice parameters Dengue fever – practice parameters Presentation Transcript

    • Dengue fever – practice parameters
    • Dengue fever management The first principle….. Dengue virus infection has no specific therapy
    • Dengue fever management Why should I know about dengue management  Case fatality rate of dengue hemorrhagic fever in most countries is 5 %  Most fatal cases are among children and young adults
    • Dengue fever management Why should I know about dengue management  Most important mosquito-borne viral disease of humans  Global distribution comparable to malaria  2.5 billion people live in areas at risk for epidemic transmission  Annually tens of millions of dengue fever and hundreds of thousands of dengue hemorrhagic fever occur
    • Dengue fever management Illustrative case scenario  Master Rahul is a three-year-old boy who presented with fever since 3 days  His intake was poor and he had vomited twice on the day he presented  He was febrile when seen  He was given amoxycillin (Mox kid DT), mefenemic acid (Ponstan) and B-complex syrup
    • Dengue fever management Case vignette  No diagnosis was attempted  Blanket therapy in blinded manner  He was ‘listless’ next day  Seen by another pediatrician and admitted
    • Dengue fever management Course…  Treated with antimalarial therapy and ceftrioxone (presumably for enteric fever)  Leukopenia warranted consideration of typhoid  Elevated transaminases considered as ‘malarial versus enteric hepatitis’
    • Dengue fever management Case vignette – tests  Blood culture negative, tests for malaria and leptospira negative  Serology for dengue - positive
    • Dengue fever management First principle  Fever and constitutional symptoms in any patient-consider dengue in the differential  Exclude other treatable diseases that mimic dengue like malaria, leptospira and enteric fever
    • Dengue fever management Therapeutic strategies  Symptomatic therapy  Supportive therapy  Specific therapy  Preventive therapy
    • Dengue fever management Management options  No specific therapy  Treatment is essentially supportive
    • Dengue fever management Symptomatic management  Avoid dehydration  Adequate oral hydration and intake  Paracetamol for fever and myalgia  Avoid aspirin and NSAIDs – to avoid gastric bleed and Reye’s syndrome  Evaluate for impending complications, such as early evidence of dengue hemorrhagic fever
    • Dengue fever management Management hierarchy  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
    • Dengue fever management Out patient management  Paracetamol  Hydration  Rest  Instruction regarding danger signs  Repeated clinical evaluation  Bare minimum tests: HCt, Platelet count, AST
    • Dengue fever management Danger Signs  Abdominal pain - intense and sustained  Persistent vomiting  Abrupt change from fever to hypothermia, with sweating and prostration  Restlessness or somnolence
    • Dengue fever management Follow up for outpatients  For patients with bleeding manifestations Serial HCt and platelets at least daily until temperature is normal for 1 to 2 days
    • Dengue fever management When to admit  BP < 90/60 mm Hg  HCt > 50 %  Platelets < 50,000/cu.mm  Bleeding other than petechiae  When danger signs develop
    • Dengue fever management Case vignette - course  Master Rahul was severely dehydrated warranting admission  Fortunately dehydration detected early
    • Dengue fever management  Management of dehydration in dengue
    • Dengue fever management I.V Fluids for Moderate Dehydration  <7 kg 220 ml/kg/d  7 – 11 kg 165 ml/kg/d  12 – 18 kg 132 ml/kg/d  19 – 40 kg 88 ml/kg/d
    • Dengue fever management Case vignette management  Master Rahul was 18 kg  Treated with 18 x 132 = 2356 ml, ie. 100 ml/hour RL solution
    • Dengue fever management Rehydrating Patients > 40 kg  Volume required for rehydration is twice the recommended maintenance requirement  Formula for calculating maintenance volume: 1500 + 20 x (weight in kg - 20)  For example, maintenance volume for 55 kg patient is: 1500 + 20 x (55-20) = 2200 ml  For this patient, the rehydration volume would be 2 x 2200, or 4400 ml
    • Dengue fever management  Avoid invasive procedures when possible  Shock requires ICU treatment
    • Dengue fever management Treatment of shock – WHO guidelines  Initial bolus of 5 % DNS or RL(10 to 20 mL per kg) infused rapidly  Followed by continuous infusion (10 to 20 mL/kg per hour)  Continue until vital signs and urine output normalize  Infusion rate then gradually reduced until it matches plasma fluid losses
    • Dengue fever management Management pearls  Adequacy of fluid repletion: Serial HCt, BP, pulse, and urine output  Shock on presentation: Vital signs every 30 minutes and HCt every 2–4 hours  Narrowing of pulse pressure an indication of hypovolemia in children even with a normal systolic BP  Normalization of HCt is an important goal of early fluid repletion; however, a normal or low HCt may be misleading in patients with overt bleeding and severe hypovolemia
    • Dengue fever management Keep vigil….  Close clinical observation even after normal blood volume is restored, because patients can develop shock for one to two days after initial fluid resuscitation which represents the period of increased vascular permeability in DHF  Most who present for medical attention before profound shock develops and who receive appropriate fluid therapy will recover quickly
    • Dengue fever management Do not overdo things … !  Fluids lost into tissue spaces during the period of plasma leakage rapidly reabsorbed  So i.v fluid supplementation to be discontinued once patients take oral fluids and have normal HCt, vital signs, and urine output  Usually < 48 hours of i.v fluids needed  Excessive fluid administration after this point can precipitate hypervolemia and pulmonary edema
    • Dengue fever management  Master Rahul was followed up with serial HCt and platelets  Developed melena  Had coffee ground vomitus once
    • Dengue fever management  Management of bleeding complications
    • Dengue fever management Significant bleeding  Gastrointestinal bleeding or menorrhagia can be severe enough to require blood transfusion.  Factors that contribute to bleeding: thrombocytopenia due to decreased platelet survival, DIC  Platelet transfusions rarely given, warranted with severe thrombocytopenia (<10,000/mm3) and active bleeding
    • Dengue fever management  Continue monitoring after defervescence  If any doubt, provide i.v fluids, guided by serial HCt, BP and urine output
    • Dengue fever management Unproven therapies  Unknown if the use of steroids, intravenous immune globulin, or platelet transfusions to shorten the duration or decrease the severity of thrombocytopenia is effective
    • Dengue fever management Immunomodulatory therapy  Corticosteroids have no role  They do not alter mortality, bleeding severity, duration of shock, need for fluid replacement, or complications
    • Dengue fever management When to plan discharge  Clinical criteria  Visible improvement in clinical picture  No fever for 24 hours without anti-fever therapy  Return of appetite with normal oral intake  Normal urine output  3 days after recovery from shock  No respiratory distress from pleural effusions/ascites  Lab criteria  Stable hematocrit  Platelets ≥ 50,000/mm3
    • Dengue fever management  Master Rahul improved and was discharged on day 7
    • Dengue fever management  Prevention is better than cure….
    • Dengue fever management Dengue Vaccine?  No licensed vaccine at present  Effective vaccine must be tetravalent  Field testing of an attenuated tetravalent vaccine currently underway  Effective, safe and affordable vaccine will not be available in the immediate future
    • Dengue fever management Mosquito Barriers  Only needed until fever subsides, to prevent Aedes aegypti mosquitoes from biting patients and acquiring virus  Keep patient in screened sickroom or under a mosquito net
    • Dengue fever management Closing balance…  Dengue virus infection has no ‘specific’ therapy  But so much can be done to the patient
    • Dengue fever management Message…  Mortality reduction is five-fold  Case fatality rate of dengue hemorrhagic fever in most countries is 5 %  This can be reduced 5-fold ie to < 1 % with proper treatment
    • Dengue fever management Apollo Experience  Retrospective collection of 21 cases  Year of study: 2005 – 2006  Positive dengue by serology  Data subject to collection bias
    • Dengue fever management Demography  21 hospitalized patients  Male: Female :: 12: 9  Age range: 5 months to 65 years
    • Dengue fever management Age (in years) 0 1 2 3 4 5 6 7 8 0 - 5 years 6 - 20 years 20 - 50 years > 50 years 3-D Column 1
    • Dengue fever management Clinical features (n=21)  Fever – 20  Vomiting – 8  Seizures – 2  Myalgias – 8  Sore throat – 1  Breathlessness – 2  Hemetemesis – 1  Melena – 1  Epistaxis – 1
    • Dengue fever management Lab tests  Platelets: Normal – 4; Low – 17  Hematocrit rise in 11  Leukopenia in 15  Azotemia in 5; 1 needed peritoneal dialysis  USG abdomen: hepatomegaly – 3; splenomegaaly – 6  Pleural effusion – 5  Ascitis – 1  CT scan – 2 - Normal
    • Dengue fever management  Blood transfusion – 3  Platelet transfusion – 3  All were on antibacterial therapy –  ? justification
    • Dengue fever management  Duration of hospitalization: 3 – 25 days  Oldest person – 65 years, stayed for 25 days  Usual duration of stay 7 – 10 days
    • Dengue fever management Morbidity  One needed peritoneal dialysis  Four needed ventilatory assistance  One 35-year-old man expired  Others were asymptomatic at discharge
    • Dengue fever management Dengue misconceptions Dengue + bleeding = DHF Need 4 WHO criteria, capillary permeability DHF kills only by hemorrhage Patient dies as a result of shock Poor management turns dengue into DHF Poorly managed dengue can be more severe, but DHF is a distinct condition, which even well-treated patients may develop Positive tourniquet test = DHF Tourniquet test is a nonspecific indicator of capillary fragility
    • Dengue fever management Dengue - more misconceptions DHF is a pediatric disease All age groups are involved DHF is a problem of low income families All socioeconomic groups are affected Tourists will certainly get DHF with a second infection Tourists are at low risk to acquire DHF
    • Dengue fever management