1. A.M is a 30/F who came at the OPD with a chief
complaint of on and off fever, for five days
accompanied by body malaise and chills.
2. Review of systems:
No vomiting, no abdominal pain, no rashes, no
hematemesis, no melena, no cough, no colds, no
change in the color of the urine.
Past Medical History: unremarkable
Personal/Social: Patient is a smoker consumimg 12 sticks per day and an occasional alcoholic
beverage drinker.
3. Physical Examination: VS
BP:100/70, CR:78, RR:22, T:38 C
General Survey: Patient is conscious, coherent not in
cardiorespiratory distress.
HEENT: pink palpebral conjunctivae, anicteric
sclerae, (+) subconjunctival suffusion, no
tonsillopharyngeal congestion, no cervical
lymphadenopathies.
Chest/Lungs:Symmetrical chest expansion, (-)
retractions, clear breath sounds.
Heart: Adynamic precordium, normal rate regular
rhythm, (-) murmur.
Abdomen: Flabby, normoactive bowel sounds, soft, non
tender
Extremities: Grossly normal, no rashes, no edema
4. Pertinent
1.A.M 30 y/o, female
2.Fever (37.9) on and off
3.Body malaise
4.Chills
Impression: To consider Dengue Fever Syndrome
without Warning signs
5.
6. Case Definition for Dengue without Warning
Signs
Probable dengue
Lives in or travels to dengue-endemic area, with
fever, plus any two of the ff:
- Headache
- Body malaise
- Myalgia
- Arthralgia
- Retro-orbital pain
- Anorexia
New Case Classification and Levels
of Severity
8. Case definition for Dengue with warning signs:
Lives in or travels to dengue-endemic area,
with fever lasting for 2-7 days, plus any one of the
ff:
- Abdominal pain or tenderness
- Persistent vomiting
- Clinical signs of fluid accumulation
- Mucosal bleeding
- Lethargy, restlessness
- Liver enlargement
- Laboratory: increase in Hct and/or decreasing
platelet count
Confirmed dengue:
-Viral culture isolation
-PCR
9. Case Definition for Severe Dengue
Lives in or travels to a dengue-endemic area with
fever of 2-7 days, and any of the above clinical
manifestations for dengue with or without
warning signs, plus any of the ff:
Severe plasma leakage leading to:
Shock
Fluid accumulation with respiratory distress
Severe bleeding
Severe organ impairment
Liver: AST or ALT >/= 1000
CNS: e.g., myocarditis
Kidneys e.g., renal failure
10. Dengue infection is a systemic and dynamic
disease. It has a wide clinical spectrum that
includes severe and non-severe forms of clinical
manifestations. After the incubation period, the
illness begins abruptly and be followed by 3
phases: febrile, critical and recovery phase.
COURSE OF DENGUE ILLNESS
FEBRILE PHASE
1.The acute febrile phase usually lats 2-7 days.
Monitoring for warning signs is crucial to
recognize its progression to the phase.
2.Clinical Signs/Symptoms
- fever
General guidelines
11. Headcahe
- Body malaise
- Myalgia
- Arthralgia
- Retro-orbital pain
- Anorexia
- Nausea
- Vomiting
- Diarrhea
- Flushed skin
- Rash
3.Laboratory test, at least CBC (leukopenia with or
without thrombocytopenia) and /or dengue NS1
antigen test or dengue IgM test (optional)
-
12. Critical Phase
1.Defervescence occurs on day 3-7 of illness, when the
temperature drops to 37.5- 38 C or less and remain
below this level. Around the time of
defervescence, patients can either improve or
deteriorate. Those who improve after defervescence
have DENGUE WITHOUT WARNING SIGNS. Those who
deteriorate will manifest warning signs have DENGUE
WITH WARNING SIGNS.
2.Warning Signs
- Abdominal pain or tenderness
- Persistent vomiting
- Clinical signs of fluid accumulation
- Mucosal bleeding
- Lethargy, restlessness
- Liver enlargement
13. 3.Laboratory: inc. in hematocrit and/or decreasing
platelet count some may deteriorate—SEVERE
DENGUE defined by one or more of the following:
a. Plasma leakage that may lead to shock (dengue
shock) and/or fluid accumulation with or without
respiratory distress, and/or
b. Severe bleeding, and/or
c. Severe organ impairment
14. Recovery Phase
1.takes place in the next 48-72 hours
2.well being improves
3.hemodynamic status stabilizes
4.Diuresis ensues
5.Hermann’s rash (―isles of white in the sea of
red‖)
6.Normalizaton of the platelet count is typically
later than that of the WBC count.
15.
Febrile Phase- dehydration; high fever may
cause febrile seizure in young children;
neurological disturbances
Critical phase- shock from plasma leakage;
severe hemorrhage; organ impairment
Recovery phase- hypervolemia (only if
intravenous fluid therapy has been excessive
and/or extended into this period).
Clinical Problems encountered during
the different phases of dengue are:
16. Assessment
Step 1– Overall Assessment
1.1 History
1.2 Physical Examination
1.3 Investigaton
Step 2– Diagnosis, Assessment of Disease
Phase and Severity
Step 3– Management
Treatment Guidelines: A Stepwise
Approach To Management Of Dengue
17. Treatment (by type of patient)
I Group A- patients who may be sent home
Action Plan: Oral rehydration solution
Calculation of oral Rehydration fluid Using
weight
(Ludan Method)
Body weight (kg)
ORS to be Given
> 3-10
100ml/kg/day
>10-20
75ml/kg/day
>20-30
50-60/kg/day
>30-60
4050ml/kg/day
18. II Group B- Patients who should be referred
for in-hospital management.
Action Plan:
Dengue without warning signs
1.Encourage oral fluids.
2.If not tolerated, start the patient with
intravenous fluid using isotonic
solution(D5LRS, D5NSS,D5 0.9 NACL)
Calculation of maintenance IVF
Body Weight
Total Fluid Requirement (ml/day)
0-10
100ml/kg
>10-20
1000ml + 50ml/kg for each kg >10kg
>20
1500ml + 20 ml/kg for each kg > 20kg
19. TFR = Maintenance IVF + Fluids as for Mild
Dehydration
Where the volume of fluids for mild dehydration is
computed as follows:
infants
Older child or adult
50ml/kg
30ml/kg
One–half of the computed TFR is given in 8 hours
and the remaining one-half is given in the next
16 hours
The IVF rate may be decreased anytime as
necessary based on clinical assessment
20. Dengue With Warning Signs
1.Obtain a reference hematocrit before fluid
therapy
2.Give only isotonic solutions such as 0.9%
NaCl, Ringer’s lactate, Hartmann’s solution.
Start with 5-7 ml/kg/hr for 1-2hours
then, reduce to 3-5ml/kg/hr for 2-4 hours,then
reduce to 2-3 ml/kg/hr or less according to
clinical response
3.Reassess the clinical status and repeat the
hematocrit
4.If the hematocrit remains the same or rises only
minimally, continue with the same rate (2-3
ml/kg/hr) for another 2-4 hrs.
21. 5. If there are worsening of vital signs and rapidly
rising hematocrit, increase the rate to 510ml/kg/hr for 1-2 hours.
6. Reassess the clinical status, repeat hematocrit
and review fluid infusion rates accordingly.
7. Give the minimum intravenous fluid volume
required to maintain good perfusion and urine
output of about 0.5ml/kg/hr. Intravenous fluid
are usually neede only 24 to 48 hours.
22. III Group C- Patients with Severe Dengue requiring
emergency Treatment and Urgent Referral
COMPENSATED SHOCK
1.Start IVF resuscitation with isotonic crystalloid at 510 ml/kg/hr over 1 hour, then reassess the patient’s
condition
2.If the patient’s condition improves, IVF should be
gradually reduced to:
5-7ml/kg/hr for 1-2 hrs,then
3-5ml/kg/hr for 2-4 hours, then
2-3ml/kg/hr and then
to reduce further depending on hemodynamic
status, which can be maintained for up to 24 to 48
hours.
23. 3.If vital signs are still unstable (shock
persists), check the hematocrit after the first
bolus:
*If hematocrit increases or still high
(>50%), repeat a second bolus of crystalloid
solution at 10-20ml/kg/hr for 1 hour. After this
second bolus, if there is improvement, then
reduce the rate to 7-10 ml/kg/hr for 1-2 hrs, and
then continue to reduce as above
* If hematocrit decreases compared to the initial
reference hematocrit (<40% in children and adult
females, <45% in adult males) this indicates
bleeding and the need to crossmatch and
transfuse blood as soon as possible. reduce to 35ml/kg/hr
24. HYPOTENSIVE SHOCK
1.Initiate intravenous fluid resuscitation with
crystalloid or colloid solution (if available) at 20
ml/kg as bolus given over 15min to bring the
patient out of shock as quickly as possible
2.If the patient’s condition improves, give a
crystalloid/colloid infusion of 10ml/kg/hr for 1
hour, then continue with cryatalloid infusion and
gradually reduce
to 5-7ml/kg/hr for 1-2hours,then
to 3-5 ml/kg/hr for 2-4 hours and then
to 2-3 ml/kg/hr or less, which can be
maintained for up to 24-48 hours
25. 3. If vital signs are still unstable, check hematocrit
after the first bolus:
*If hematocrit increases compared to the
previous value or remaining very high (>50%)
change IVF to colloid solutions at 10-20 ml/kg as
a second bolus over ½ hours, then change back
to crysalloid solution and reduce rate of infusion
as mentioned above when the patient’s condition
improves
*If hematocrit decreases compared to the
previous value (40% in children and adult
females, <45% in adult males), this indicates
bleeding and the need to cross-match and
transfuse blood as soon as possible
26. 4. Further boluses of fluids may need to be given
during the next 24hrs. The rate and volume of
each bolus infusion should be titrated to the
clinical response. Patients with dengue should be
admitted to the high dependency or intensive
areas.
28. Discharge criteria:
All of the following must be present
1.No fever for more than 48 hours
2.Improvement in clinical status
3.Increasing trend of platelet count
4.Stable hematocrit without IVF
