2. Biodata
âą My patient Mohammad Gulzar, 20 Years,old
resident of Jhelum, and manual worker by
profession, unmarried, presented in
emergency department on 9th September,
2014.
3. Presenting complaints
âą High grade Fever for 8 days
âą Bodyaches for 8 days
âą Vomiting for 6 days
4. âą Patient was in his usual state of health when
he started fever.
âą It was sudden in onset initially high grade,
associated with rigors and chills and slightly
relieved by medications from the local doctor.
5. âą It was associated with body aches of severe
degree and patient felt very weak and he was
not able to continue his daily job activities.
âą Fever has daily variation of less than 10C and
whenever recorded with thermometer it was
around 102 to 103 OF.
âą Was no associated rash on the body
âą He went to local doctor who gave him some
open medications but those medications gave
no relief to the patient.
6. âą During his illness he has marked nausea and
he was not able to take food in fact his
appetite was markedly suppressed and his
nausea worsens whenever he looked at or ate
food.
7. âą 6 days back he started having vomiting as
well. He had 2 episodes of vomiting on first
day, which were non foul smelling containing
food particles which he recently took and it
was non-projectile.
âą On 6th day both vomiting episodes were clear
and not containing the slightest of blood.
8. âą On 7th day he again had 3 episodes of
vomiting non projectile and non foul smelling
and occurred after in take of food.
âą But this time around all 3 vomitus contained
blood (coffee ground).
âą After that patientâs attendants took him to the
hospital and he was admitted in emergency
ward of Mayo Hospital.
9. Systemic review
âą General: decrease sleep, decrease appetite,
decrease energy.
âą Git : no history of diarrhea, no history of black
tarry stools, no history of yellow discoloration
of eyes or sclera.
âą Respiratory: no history of shortness of breath,
no history of seasonal variation, no history of
nose or ear discharge, no history of cough
with sputum.
10. âą CVS: no history of shortness of breath on lying
flat, no history of chest pain on exertion, no
history of palpitation.
âą CNS: no history of focal weakness, no history
of fits, no history of diplopia, no history of
headache.
11. Past history
âą No history of previous hospital admission.
âą No history of hypertension, diabetes, TB, CVA,
MI or meningitis.
12. Socio-economic history
âą Patient is laborer by profession and his
earning is only 6000 per month.
âą He belongs to a lower socio-economic class.
13. Drug history
âą No history of any drug allergies.
âą He was not using any medications for any
reason previously.
âą During this illness, he used medications from
local doctor but those were open medications
without any labels.
15. âą At presentation he was afebrile and lethargic
and ill looking.
âą Patient was not maintaining bp. His bp was
only 70 systolic.
âą He was shifted to HDU west medical ward
where he was given NS 50-80ml/hr.
âą His platelet count was 7000 only
âą He was transfused one pint of mega platelet
concentrate.
16. On 11th September
âą After that he went into overload with fine
crepts up to middle zone of both lungs.
âą His JVP was raised as well. Initially dextran 40
was not available but later on it was arranged
from emergency and he was given bolus of
dextran 40.
âą After that his BP was built up to 125/80mm of
hg.
17. âą At that point his breathing was gasping and he
was not maintaining oxygen saturation even with
3l/min oxygen inhalation.
âą Inj lasix 40mg was given iv stat to relieve his
overload and to took him out of pulmonary
edema.
âą Meanwhile ventilator was arranged and ETT
passed and patient was put onto ventilator on
SIMV with pressure support and PEEP was kept at
5 but later on increased to 7 which helped to
achieve saturation of 98%.
18. On 12th September
âą Patient was given one more shot of inj lasix
40mg iv stat. and 1 pint of pcv of blood was
transfused.
âą Patient developed high grade fever and inj
tazocin 4.5g iv tds was started to cover
pseudomonas of ICU setting.
19. âą One more PCV was arranged as HB level was
falling and we were suspecting occult bleed.
âą Ventilator was kept on SIMV with pressure
support mode.
âą Tepid water sponging were continued and
only fluid to be given was dextran 40.
âą Patient had three instances of fall in BP which
were managed by giving dextran 40 bolus.
20. On 13th September
âą Antibiotic was continued but fever didnât
settle so blood culture and sensitivity and
urine culture and sensitivity were planned and
sent.
âą On examination power was 5/5 in all 4 limbs
with +2 reflexes at ankle, knee, bicep and
tricep.
21. âą Patient was started NG feed and atralax was
stopped and later patient was shifted to CPAP
mode of ventilator.
âą He was able to maintain Oxygen saturation on
CPAP and bp was also stable.
22. On 14th September
âą Patient had episode of bradycardia and
neubulization with ventolin and tab theograde
350mg œ po bd was started. Soon heart rate
was normalized but fever continued.
âą Tepid water sponging were continued and inj
flagyll was added.
23. âą CK MB report was sent which was found to be
raised 57.
âą Call to cardiology was attended and they said
its sinus arrhythmia and advised to repeat call
on Monday for consultant opinion.
âą Patient was still kept on CPAP mode of
ventilator and he was maintaining oxygen
saturation and bp.
24. On 15th September
âą Patient was weaned off from ventilator and
kept under observation for 2hrs he was
maintaining oxygen saturation and he was
then extubated as well.
âą Echocardiography and repeat cardiac enzymes
were planned.
âą Patient is fully conscious and oriented and he
was able to take his food as well without NG
tube
25.
26.
27. A young male ill looking lying on
bed with ETT passed and on
ventilator
29. RESPIRATORY SYSTEM
INSPECTION
âą Respiratory rate 34/min
âą Abdomino-thoracic type
âą Pattern of respiration is shallow rapid breathing
âą No scar mark
âą Chest seems to be moving equally on inspection
âą Trachea is central
30. PALPATION
âą Chest movements are equal bilaterally
âą Chest expansion is 5cm
âą Vocal fremitus is normal and bilaterally equal.
PERCUSSION
âą Liver upper border is in fifth intercostal space
âą Percussion note is resonant all over and bilaterally equal
AUSCULTATION
âą NVB
âą Fine end inspiratory crepts at bases bilaterally and
extending upto middle zone.
âą No rhonchi, no coarse crepts, no pleural rub
31. GASTRO-INTESTINAL SYSTEM
INSPECTION
âą Flat abdomen moving with respiration, no fullness in
flanks, umbilicus central and inverted, no scar mark.
PALPATION
âą On superficial palpation , slight tenderness in
epigastric and right hypochondrial area. No palpable
mass
âą On deep palpation liver is not enlarged and span is
13 cm. spleen is 1 finger breath enlarged
âą Kidneys are not palpable.
32. PERCUSSION
âą Shifting dullness is negative.
âą Fluid thrill is negative.
AUSCULTATION
Bowel sounds are audible.
33. CARDIO VASCULAR SYSTEM
INSPECTION
âą NO VISIBLE PULSATIONS
âą NO SCAR MARK
PALPATION
âą TRACHEA IS CENTRAL
âą APEX BEAT IS IN 5TH INTERCOSTAL SPACE JUST MEDIAL TO
MID-CLAVICULAR LINE OF NORMAL CHARACTER
âą NO PALPABLE THRILL
âą NO PARASTERNAL HEAVE.
AUSCULTATION
S1+S2 and no added sounds
34. CENTRAL NERVOUS SYSTEM
âą GCS is 14/15
âą Patient was on ventilator hence speech and
higher mental functions can not be assessed.
âą Bulk and tone both are normal in all 4 limbs.
âą Power and reflexes in all 4 limbs are 5/5 and
+2 respectively.
âą Planters bilaterally down going
49. Diagnosis for Dengue
âą Travel history and symptom profile
âą Detection of antibodies against the virus
âą Complete blood count
âą Chemistry panel
âą Liver function test
âą Occult blood in stool
âą DIC panel
50. Recognize the Stage of the
Disease
âșFebrile phase
âșCritical phase
âșConvalescent phase
HOW
âșDay of the illness ?
âșEvidence of plasma leakage ?
âșConvalescent rash ?
51. Fluid Therapy
âNo Fixed Regimeâ
âșCornerstone of management
âșDynamic approach
âșBe fully aware of the dynamics of the
disease
âșMode of intervention depends on:
âș Phase
âș Clinical type
âșType of fluid
âșOral fluids
âșCrystalloid
âșColloid
53. Febrile Phase
âșOral fluids only
âșElectrolyte solutions
âșIV fluids are not mandatory
âșUndue vomiting or diarrhea
âșOral fluids not tolerated
âșQuantity:
âș1500ml â 2500ml/24Hrs
âșBoth oral & IV
âșType:
âșN.Saline
54. Critical Phase of DHF Without Shock
âș Objective:
âș Prevent progression to shock
âș Avoid fluid overloading
âș Judicious fluid therapy- Fluid restriction
âș Quantity â calculated
âș M+5% = 4600 ml / 48 hrs (50Kg)
âș Full quota for entire critical phase 48 hrs
âș Approximately 90 ml/hr
âș Adjust infusion rate to match the dynamics of plasma leakage
âș Type:
âș N.Saline
Monitor
HR
PP > 20 mm Hg
CRFT < 2 secs
U.O.P. 0.5-1ml/kg/hr
HCT
RR <20/mt
55.
56. Calculation of Total Fluid Quota for the
Critical Period
âșM =
âș 5 % =
âș M + 5% =
57. Guide to rate of fluid intake in Critical Phase
Pulse
BP
Pulse Pressure
CRFT
Warmth / Coldness
UOP â ml/kg/hr
Evidence of
Bleeding
58. DHF with Shock
Aggressive Fluid Therapy
âș Objective
âșResuscitate
âșPrevent further shock
âșAnticipate & prevent complications of shock
âșGIT bleeding & DIC
âș Intervention depends on:
âș Compensated shock
âșSystolic pressure maintained but signs of reduced
perfusion
âșNarrow Pulse Pressure
âș Cold extremities
âș Low volume pulse
âș Hypotensive shock
âșUnrecordable BP & Pulse
59. Compensated Shock
âș N.Saline 10ml/kg (approx 500 ml) IV â 1Hr
âș No improvement
âș Collect blood
âș venous BGA
âș Calcium HCT before & after fluid bolus
âș Sugar
Sodium
âș Grouping & DT
âș Colloid bolus 10ml/kg IV over 1 hr
âș Colloid boluses
âș Haemodynamically unstable
âș HCT drops
âș Blood transfusion
60. Hypotensive Shock
HCT before & after fluid bolus
âș N.Saline 10ml/kg IV bolus over 15 mts
âș2nd bolus 10 ml/kg over 60 mts
âș Collect blood
âșBlood gas analysis
âșCalcium
âșElectrolytes
âșSugar
âșGrouping & cross matching
âș Colloid 10 ml/kg IV bolus over 1 hr
61. Choice of Colloid
Boluses NOT infusions
âșDextran 40
âș3 boluses over 24 hours
âș6 boluses over 48 hours
âș6% starch-Heta starch(Voluven)
âș5 boluses over 24 hours
âș10 boluses over 48 hours
âșFresh Frozen Plasma
âș1 bolus
âș3 units approximately 450 â 600 ml
62. Monitoring & Documentation
âș Early detection of shock
âșPulse pressure < 20 mm Hg
âșCRFT > 2 secs
âșHCT increase of 20% or more from baseline
âș Judge the efficacy of IV fluid therapy
âșPP , CRFT, No postural hypotension
âșHourly UOP 0.5 â 1.0 ml/kg/hr
âș Early detection of complications of fluid therapy
âșRespiratory rate > 20/mt
âșLung bases
âșSaO2 < 92%
âșCXR
64. DH
F
Date/Time
Febrile
Date/Time
Critical
Date/Time
Convalesce
nt
65. Basic Monitoring
All Patients
âșPulse rate
âșPulse pressure
âșCRFT
âșRespiratory rate
âșFBC - HCT
âșIntensity of monitoring depends on
âșPhase of the illness
âșSeverity
âșAggressiveness of fluid therapy
âșAccurate fluid balance charts
66. Monitoring
Platelet Count Drops Below 100,000
âșFBC- twice daily
âșVital parameters- four hourly
ï§ Pulse rate
ï§ Blood pressure (both systolic and diastolic),
ï§ Respiratory rate,
ï§ Capillary refill time
âș Detailed fluid balance chart-
ï§ Type and route of fluid hourly,
ï§ Urine output four hourly
67. Monitoring
Evidence of Plasma Leakage
Escalate
âșVital signs - hourly
âșHCT - 8 hourly
âșFluid intake & the balance left from the
calculated quota
âșTemporal relationship
âșCritical phase
âșIn hours
âșDetailed fluid balance chart
68. Monitoring
IV Fluid Therapy
Phase of the illness â be fully aware
âșAdequacy of fluid therapy
âșPulse Pressure >20 mmHg
âșCRFT <2 sec
âșPulse Rate <80/mt
âșUOP > 0.5 ml/Kg/hr
âșHCT
âșEarly detection of fluid overloading
Respiratory rate > 20/mt
âșLung bases
âșSaO2 < 92%
âșCXR
Shift to
ICU
69. Monitoring Chart I - for Management of Dengue
Patients â Febrile Phase
70. Monitoring Chart I - for Management of Dengue
Patients â Febrile Phase
D3 with Fever
WBC
<5000/mm3
N-40% L-
58%
TT + ve
D4 without
Fever
71. Monitoring Chart I - for Management of Dengue
Patients â Febrile Phase
D4 with Fever
TT + ve, WBC
<5000/mm3
N-40% L-58%
Tender Liver
72. Monitoring Chart II for Management of DHF Patients
Monitoring Chart II for Management of DHF Patients during Critical Phase
Patient to be monitored hourly
Annexure II
Name of the patient âŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠBHTâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠ.Date and time of admission âŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠward -âŠâŠâŠâŠâŠâŠâŠ
Critical Phase Commencing date and time -âŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠ.. End date and time âŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠ
10
9
8
7
6
5
4
3
2
1.5
1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
PCV
Fluids
HR
BP
Pulse
Pressure
RR
CRFT
extremities
UOP
UOP
ml/Kg/hr
Platelet
count
Weight -
âŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠ
Height -
âŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠ
Ideal body weight - âŠâŠâŠâŠâŠ M- âŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠâŠ M+ 5% = âŠâŠâŠâŠâŠâŠâŠâŠâŠâŠml
Used
Remaining
during Critical Phase
76. Summary â Febrile Patient
âșDengue or not?
ï§ Clinical
ï§ FBC
âșLeucopaenia + thrombocytopaenia
âșDF or DHF ?
ï§ Plasma leakage + or â
âșIf DHF â what is the phase ?
77. Summary
âșIn Critical phase
ï§ Time of entry
ï§ Predicted time of end
âșAggressive monitoring
âșCalculate the fluid quota
âșDynamic approach to fluid therapy
âșFinal diagnosis â precise (DF or DHF &
grade)
78. 78
Pts with complications ....
Usually due to
âą PROLONG SHOCK
âą FLUID OVERLOAD
79. Fluid overload
â Too much fluids in febrile phase
â Calculation of fluids in obese pt-ABW vs
IBW
â Use of hypotonic saline
â Given excess fluids
â Given more than time of leakage
â Not using colloidal solution when indicates
â Not giving blood when there is concealed
bleeding
â Inappropriate IV Fluids for âsevere
bleedingâ
Eg: FFP, platelets & cryo 79
82. Indications for IV Frusemide
âș 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.
âș Midway between blood transfusions.
âș 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.
âș During recovery phase when there is suggestion of
pulmonary oedema or fluid overload.
82
83. Prolonged shock
â Delayed diagnosis/ delayed
resuscitation
â Late presentation
â Fluid restriction without monitoring
83
86. Complicated DHF
âșWhen a pt is deteriorating with no
response to fluid therapyâŠ.
A: Acidosis
B: Bleeding
C: Calcium
S: Sugar
86
87. A : Acidosis
âșAcidosis is common in profound shock
âșProlonged acidosis makes patients more
prone to DIC
âșCorrect acidosis if pH is <7.35 together with
HCO3- level <15 mmol/l
âșOne may use empirical NaHCO3 1ml/kgs
slow bolus (max 10ml) diluted in equal
volume
87
89. When to suspect bleeding ?
âą 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!
âą 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)
âą Severe metabolic acidosis and end-organ
dysfunction despite adequate fluid replacement
89
90. Massive bleeding
ï§ Not given blood
transfusion
ï§ Delayed blood transfusion
90
Remember!!!
In DHF Bleeding could be concealed
91. How to manage bleeding
âșUse PRC or WB
âșIf there is fluid overload(most frequently)
use PRC as 5ml/kg at once and repeat only
if needed depending on the response
âșIf there is no fluid overload use 10ml/kg of
WB
âșEven if bleeding is likely and if PCV is >45%
do not give blood without bringing down the
PCV first by giving a colloid.
91
92. âą 5ml/kg of PRC or 10ml/kg of WB will
increase PCV by 5%
â Eg.10 year old girl with PCV of 26% in shock..
â Base line PCV in a 10 yr old 36% but if in shock
it will be up by 20%ï 43%. There is 17%
deficit which need 3 PRC transfusuions
92
93. C : Hypocalcaemia
âșEvery patient with complicated DHF has
hypocalcaemia.
âșDengue patients who develop convulsions
are likely to have hypocalcaemia.(may give
them empirical calcium)
âșDetection of hypocalcaemia:
ï§ Measure serum Ca2+ level
ï§ Corrected QT interval in ECG
93
95. S : Hypoglycaemia
Treat if blood sugar below 4 mmol/lt
Give 10% dextose 3-5ml/kg bolus followed by
an infusion
95
96. Platelet transfusion-
âșwhen platelets are low may need but only
in very exceptional circumstances
ï§ (Thailand only in <0.4% of pts with DHF)
ï§ Each platelet pack is 50-150ml ï contribute
to fluid overload
ï§ No prophylaxis platelet transfusion
96
97. Why do you do platelet
counts?
ï§ To recognize the beginning of critical stage-
YES
ï§ To decide on platelet transfusion- NO
ï§ As a prognostic indicator- YES
97
98. Recombinant factor VII
âș1 dose = 1,500 USD in a 10-kgs patient
âșNo use in cases with prolonged shock and
multiple organs failure
âșConsider in cases with bleeding where the
cause is not prolonged shock BUT other
reason: peptic ulcer, trauma etc
98
99. Place of dopamine and
dobutamine...
âșVery limited in DHF
âșMay do harm than good by giving a false
impression about BP
âșWhen using1st make sure that there is
enough intravascular volume shown by
increased CVP
99
100. No Place For Steroids And Iv
Immunoglobulins In Dengue
100
101. 101
Blood & blood component used
in DHF/DSS patients
Crystalloid
100%
Colloid
Platelet 0.4%
Blood 20-25%
10-15%
102. Myocardial involvement in
Dengue
âșGlobal dysfunction of myocardial
contractility seen in prolonged shock
âșDue to, metabolic acidosis, Hypocalcaemia
âșUnlikely to cause death
âșIf myocarditis is suspected fluid should be
given very carefully
âșRx- Symptomatic
102
103. Causes of death in DHF
patients
âą Prolonged shock
â Delayed diagnosis/ delayed resuscitation
â Late presentation
âą Fluid overload
â Use of hypotonic saline
â Given excess fluids
â Given more than time of leakage
âą Massive bleeding
â Not given blood transfusion
â Delayed blood transfusion
âą Unusual manifestations
â Encephalopathy
â Underlying co-morbidity
â Dual infection
103
Editor's Notes
The diagnosis for dengue includes the following: travel history and symptom profile, detection of antibodies against the virus, a complete blood count, a chemistry panel, liver function test, occult blood in stool and DIC panel