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...
Dengue fever management
Why should I know about
dengue management
 Most important mosquito-borne viral disease
of humans
...
Dengue fever management
Illustrative case scenario
 Master Rahul is a three-year-old boy who
presented with fever since 3...
Dengue fever management
Case vignette
 No diagnosis was attempted
 Blanket therapy in blinded manner
 He was ‘listless’...
Dengue fever management
Course…
 Treated with antimalarial therapy and
ceftrioxone (presumably for enteric fever)
 Leuko...
Dengue fever management
Case vignette – tests
 Blood culture negative, tests for malaria and
leptospira negative
 Serolo...
Dengue fever management
First principle
 Fever and constitutional symptoms in any
patient-consider dengue in the differen...
Dengue fever management
Therapeutic strategies
 Symptomatic therapy
 Supportive therapy
 Specific therapy
 Preventive ...
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 ...
Dengue fever management
Management hierarchy
 No hemorrhagic manifestations and patient is
well-hydrated: home treatment
...
Dengue fever management
Out patient management
 Paracetamol
 Hydration
 Rest
 Instruction regarding danger signs
 Rep...
Dengue fever management
Danger Signs
 Abdominal pain - intense and sustained
 Persistent vomiting
 Abrupt change from f...
Dengue fever management
Follow up for outpatients
 For patients with bleeding manifestations
Serial HCt and platelets at ...
Dengue fever management
When to admit
 BP < 90/60 mm Hg
 HCt > 50 %
 Platelets < 50,000/cu.mm
 Bleeding other than pet...
Dengue fever management
Case vignette - course
 Master Rahul was severely dehydrated
warranting admission
 Fortunately d...
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 m...
Dengue fever management
Case vignette management
 Master Rahul was 18 kg
 Treated with 18 x 132 = 2356 ml, ie. 100
ml/ho...
Dengue fever management
Rehydrating Patients > 40 kg
 Volume required for rehydration is twice the
recommended maintenanc...
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 r...
Dengue fever management
Management pearls
 Adequacy of fluid repletion: Serial HCt, BP, pulse,
and urine output
 Shock o...
Dengue fever management
Keep vigil….
 Close clinical observation even after normal blood
volume is restored, because pati...
Dengue fever management
Do not overdo things … !
 Fluids lost into tissue spaces during the period of
plasma leakage rapi...
Dengue fever management
 Master Rahul was followed up with serial HCt
and platelets
 Developed melena
 Had coffee groun...
Dengue fever management
 Management of bleeding complications
Dengue fever management
Significant bleeding
 Gastrointestinal bleeding or menorrhagia can
be severe enough to require bl...
Dengue fever management
 Continue monitoring after defervescence
 If any doubt, provide i.v fluids, guided by
serial HCt...
Dengue fever management
Unproven therapies
 Unknown if the use of steroids, intravenous
immune globulin, or platelet tran...
Dengue fever management
Immunomodulatory therapy
 Corticosteroids have no role
 They do not alter mortality, bleeding se...
Dengue fever management
When to plan discharge
 Clinical criteria
 Visible improvement in clinical picture
 No fever fo...
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 t...
Dengue fever management
Mosquito Barriers
 Only needed until fever subsides, to prevent
Aedes aegypti mosquitoes from bit...
Dengue fever management
Closing balance…
 Dengue virus infection has no ‘specific’
therapy
 But so much can be done to t...
Dengue fever management
Message…
 Mortality reduction is five-fold
 Case fatality rate of dengue hemorrhagic
fever in mo...
Dengue fever management
Apollo Experience
 Retrospective collection of 21 cases
 Year of study: 2005 – 2006
 Positive d...
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 –...
Dengue fever management
Lab tests
 Platelets: Normal – 4; Low – 17
 Hematocrit rise in 11
 Leukopenia in 15
 Azotemia ...
Dengue fever management
 Blood transfusion – 3
 Platelet transfusion – 3
 All were on antibacterial therapy –
 ? justi...
Dengue fever management
 Duration of hospitalization: 3 – 25 days
 Oldest person – 65 years, stayed for 25 days
 Usual ...
Dengue fever management
Morbidity
 One needed peritoneal dialysis
 Four needed ventilatory assistance
 One 35-year-old ...
Dengue fever management
Dengue misconceptions
Dengue + bleeding = DHF
Need 4 WHO criteria, capillary permeability
DHF kill...
Dengue fever management
Dengue - more
misconceptions
DHF is a pediatric disease
All age groups are involved
DHF is a probl...
Dengue fever management
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Dengue fever – practice parameters

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Dengue fever – practice parameters

  1. 1. Dengue fever – practice parameters
  2. 2. Dengue fever management The first principle….. Dengue virus infection has no specific therapy
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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’
  8. 8. Dengue fever management Case vignette – tests  Blood culture negative, tests for malaria and leptospira negative  Serology for dengue - positive
  9. 9. 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
  10. 10. Dengue fever management Therapeutic strategies  Symptomatic therapy  Supportive therapy  Specific therapy  Preventive therapy
  11. 11. Dengue fever management Management options  No specific therapy  Treatment is essentially supportive
  12. 12. 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
  13. 13. 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
  14. 14. Dengue fever management Out patient management  Paracetamol  Hydration  Rest  Instruction regarding danger signs  Repeated clinical evaluation  Bare minimum tests: HCt, Platelet count, AST
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Dengue fever management Case vignette - course  Master Rahul was severely dehydrated warranting admission  Fortunately dehydration detected early
  19. 19. Dengue fever management  Management of dehydration in dengue
  20. 20. 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
  21. 21. Dengue fever management Case vignette management  Master Rahul was 18 kg  Treated with 18 x 132 = 2356 ml, ie. 100 ml/hour RL solution
  22. 22. 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
  23. 23. Dengue fever management  Avoid invasive procedures when possible  Shock requires ICU treatment
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. Dengue fever management  Master Rahul was followed up with serial HCt and platelets  Developed melena  Had coffee ground vomitus once
  29. 29. Dengue fever management  Management of bleeding complications
  30. 30. 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
  31. 31. Dengue fever management  Continue monitoring after defervescence  If any doubt, provide i.v fluids, guided by serial HCt, BP and urine output
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. Dengue fever management  Master Rahul improved and was discharged on day 7
  36. 36. Dengue fever management  Prevention is better than cure….
  37. 37. 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
  38. 38. 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
  39. 39. Dengue fever management Closing balance…  Dengue virus infection has no ‘specific’ therapy  But so much can be done to the patient
  40. 40. 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
  41. 41. Dengue fever management Apollo Experience  Retrospective collection of 21 cases  Year of study: 2005 – 2006  Positive dengue by serology  Data subject to collection bias
  42. 42. Dengue fever management Demography  21 hospitalized patients  Male: Female :: 12: 9  Age range: 5 months to 65 years
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. Dengue fever management  Blood transfusion – 3  Platelet transfusion – 3  All were on antibacterial therapy –  ? justification
  47. 47. Dengue fever management  Duration of hospitalization: 3 – 25 days  Oldest person – 65 years, stayed for 25 days  Usual duration of stay 7 – 10 days
  48. 48. Dengue fever management Morbidity  One needed peritoneal dialysis  Four needed ventilatory assistance  One 35-year-old man expired  Others were asymptomatic at discharge
  49. 49. 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
  50. 50. 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
  51. 51. Dengue fever management
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