dengue fever protocol

1. Dr Nibin
Chair: Dr. Anu

2.  Mosquito borne viral infection
 Major public health concern
 No specific treatment
 Supportive care at the right time – life saving

3.  Globally – 50 million infections
anually
 SEAR and Western pacific –
75% of global burden
 India – endemic for dengue
fever
 July – November – upsurge in
cases
 Perennial transmission in
south india

4.  ss RNA virus belonging to Flaviviridae family
 3 structural protein genes encoding core
protein (C), envelope protein (E), membrane
associated protein (M)
 7 non structural proteins ( Envelope
glycoprotein NS1)
 four virus serotypes --DENV-1, DENV-2, DENV-3
and DENV-4
 Infection with one serotype – lifelong immunity
to that serotype
 Secondary infection with another serotype –
severe dengue infection

5. Aedes aegypti
 Highly domesticated
 Breeds in man made water
receptacles
 Strongly anthrophilic
 Nervous feeder
 Discordant species
Aedes albopitcus
 Feeds on both humans and
animals
 Aggressive feeder
 Concordant species

7. Female Aedes takes blood meal from an infected person ( viremic stage)
Extrinsic incubation period (8-10 days)
bites a person and injects saliva
Intrinsic incubation period of 4-7 days ( range 3 – 14 days)
Patient develops symptoms

8. 4 mechanisms:
- Antibody dependent enhancement
- Cytokine storm
- Vasculopathy
- Coagulopathy

9. Dengue virus taken up by dendritic cells; antigen processing
Antibodies against E, M and NS1 protein
 Neutralizng and non-neutralizing antibodies produced
 Non neutralizing Ab bind to virus, but doesn’t destroy virus
 Virus entry into host cell enhanced
 Antibody Dependent Enhancement of infection (ADE)
 Cytokine Storm

10. Add flowchart and explain
Capillary leak
Coagulopathy

11.  Destruction of platelet (antiplatelet antibodies )
 DIC
 Bone marrow suppression in early stage
 Peripheral sequestration of platelets

13. Spectrum of disease varies from asymptomatic to severe life
threatening illness
 10 % symptomatic
0f the 10%,
- 50 % Undifferentiated viral fever
- 40 % Dengue fever
- 10% DHF
- 1-2 % DSS

14. DENGUE INFECTION
Symptomatic Asymptomatic
Mild
Moderate Severe

16.  mild to moderate fever
 similar to other viral illness
 may have maculopapular rash during fever or defervescence
 no capillary leak or coagulopathy

17. Acute febrile illness of 2-7 days duration with 2 or more of the
following:
headache
Retro orbital pain
 myalgia and/or arthralgia
Rash
 haemorrhagic manifestation

18. 1) Mild dengue- fever without complications like bleeding,
hypotension, organ involvement or without evidence of
capillary leak.
2) Moderate dengue
a) mild dengue fever in those with comorbid conditions
like infancy, elderly, obese, pregnancy, asthma, dm, htn,
peptic ulcer, CAD, on steroids/ immunosuppressive drugs,
hiv, antiplatelet/anticoagulants.
b) Dengue fever with warning signs

19.  recurrent vomiting( 3 in 1 hr /4 in 6 hrs)
 intense and persistent abdominal pain/tenderness
 general weakness/lethargy/restlessness
 minor mucous membrane bleeding(epistaxis, gum bleeding,
oral bleeding)
 hepatomegaly/mild hepatic dysfunction
 mild pleural effusion/ascites
 increasing haematocrit/decreasing platelet count.
progressive rise in haematocrit in atleast 2 consecutive
measurements.

20.  Inflate the BP cuff midway between systolic and diastolic BP
for 5 min and count the no of petechiae in 1 square inch area
in the elbow
 More than 10 is taken as positive
 False negative- obese and profound shock

21. 1) DF with significant haemorrhage
2)DHF with shock
3) Severe organ involvement(expanded organ syndrome- CNS, hepatic, renal,
cardiac, pulmonary, eye]
4) Severe metabolic derangements (metabolic acidosis, hyponatremia,
hypocalcemia, hypokalemia, hyperkalemia, hypoalbuminemia)

23.  DF- fever 2-7 days with 2 or more of the following –headache,
retroorbital pain, myalgia, arthralgia with or without leukopenia,
thrombocytopenia and no evidence of plasma leakage.
 DHF I : Above criteria + positive tourniquet test + evidence of
plasma leakage
 Thrombocytopenia with platelet count less than 1 lakh and PCV
rise more than 20% over baseline
 DHF II - Above plus some evidence of spontaneous bleeding in skin
or other organs

24.  DHF III(DSS)-
Above plus
circulatory failure(weak rapid pulse, narrow pulse pressure <
20mm Hg, hypotension,cold clammy skin, restlessness)
 DHF IV(DSS)- Profound shock with undetectable BP or pulse

25.  Vertical transmission reported
 Capillary leakage and bleeding tendency
Clinical manifestations
 Mild-- fever with petechial rash, thrombocytopenia, and
hepatomegaly.
 Severe – pleural effusion , gastric bleeding, circulatory
failure, massive ich
 Timing of maternal infection may be important – peripartum
maternal infection leads to symptoms in baby
 Transplacental transfer of antibodies

26.  Asymptomatic / mild / severe (4 – 9 months )
 High fever 2-7 days
 URTI and gastrointestinal symptoms more common
 Febrile convulsions maybe seen
 During defervescence, increased permeability and hemoconcentration
 Petechiae, mucosal and GI bleeding
 Hepatomegaly and splenomegaly
 Capillary leak  shock
 Rise in Hct maybe missed – as normal Hct low in this age; also superadded
Fe def anemia maybe there

27.  Malaria
 Enteric Fever
 Pharyngitis
 Tonsillitis
 Influenza
 Leptospirosis
 Meningococcal Infection
• Chikungunya Fever
• Scrub Typhus
• Ebola

30.  Pulse pressure less than 20mm hg or
 Rapid, low volume pulse with any 2 of the following- CFT >2 sec,cold
clammy skin, mottling
 SBP < 60mm hg in newborn
< 70mm hg in 1 – 12 months
< 70 + age x 2 in 1- 10yrs
< 90 in more than 10yr old.
 MAP < 40 + age x 1.5 in 1- 10yr
< 70mm hg in adults

31. NS1 ANTIGEN TEST
 Detection of NS1 antigen in blood
 During viremia
 ELISA based test
 Positive from day 1 , upto day 4-5
DENGUE IgM TEST
 IgM capture MAC ELISA
 Positive from Day 5

33. 1)1-3 days of fever/febrile phase/first contact
Suspect dengue in any child who presents especially during an
outbreak with at least 2 of the following with fever:
- Headache - Lethargy
-Retroorbital pain -Rash
-Mylagia -Arthralgia
-bleeding manifestation(including positive tourniquet test)
-TC less than 5000
-Plt less than 1.5
-Rising haematocrit by more than 10-15%

34.  Paracetamol 10mg/kg q6h.
 Avoid nsaids, steroids, antibiotics
 Encourage plenty of oral fluids like ORS, salted kanji, coconut
water etc
 Plain water leads to hyponatremia and may contribute to leakage
of fluid into interstitial space

35.  Avoid IV fluids during this stage
 If IV fluids are given - isotonic iv fluids DNS or plasmalyte at
1.5ml/kg/hr
 Ensure adequate urine output of >1ml/kg/hr and normal vitals
 Only 1/3rd of the fluid administered will remain in the intravascular
compartment
 Rest will go into the interstitial compartment
 Resorption will occur only during the resorptive phase

36. 2)3-5 days of fever/critical phase:
Step 1-categorise as DF or DHF
- classically DHF is defined as evidence of haemorrhage
(spontaneous or positive tourniquet test) and capillary leak in a pt
with fever and platelet count less than 1 lakh
 Evidence of capillary leak includes
- increase in haematocrit by more than 20%
- ascites or pleural effusion by chest XRAY, USG or clinical examination
- gall bladder edema
- S.albumin less than 3.5g/dl
A low ESR < 10mm/hr differentiates dengue shock from septic shock

37.  CBC with PCV and ESR
 Blood grouping
 Dengue NS1/IgM
 PT,APTT,INR
 RFT,LFT,S Alb
 Blood glucose

38. - Look for warning signs or signs of severe dengue
- Early stages of shock are characterised by narrow pulse pressure as,
in dengue there is no circulation of lipopolysaccharides
- Wide pulse pressure shock may occur if there is coinfection with
bacteria ,hepatic failure or in neurogenic shock due to dengue
encephalitis.

39.  S.Ca
 Trop T or I
 ABG
 Blood culture
 Urine analysis/myoglobin
 USG and Echo

40.  Start with 6ml/kg/hr with target urine output of 1ml/kg/hr
 Escalate or deescalate according to urine output every hr
 Extra fluid in this stage deleterious -- fluid will accumulate in the
interstitium compromising respiration, fluid and nutrient delivery
 Monitor hourly vitals and haematocrit 4th hourly
 If the child requires more than three 10ml/kg/hr bolus without
improvement or rising haematocrit , it should be considered as severe
dengue and managed accordingly

43.  Start O2 by NRM
 Administer crystalloid –NS or plasmalyte @ 20ml/kg/hr if pulses are
absent (WHO recommends 20ml/kg over 15 to 30min)
 Monitor vitals every 15min.
 Once the pulse appears, decrease rate to 10ml/kg/hr
 Measure haematocrit 2 to 4hrly.
 If the pt does not improve, continue 10 – 20ml/kg/hr

48.  if 60ml/kg of crystalloids have been given -- consider colloids
 Dextran 40 preferred over hexa starch-dose 10ml/kg/hr
 Dextran 10ml/kg decreases PCV by 10 points
 If more than that - consider bleed
 If no improvement- second dose given
 Limit – 30ml/kg/day

49. A -acidosis
 Give bicarbonate 1ml/kg if ph < 7.3 with bicarbonate less than 15
( In septic shock- bicarbonate is given if ph < 7.15 with refractory
shock not responding to inotropes and fluids)
B -bleed –
Whole blood 10ml/kg or packed cell 5ml/kg

50.  Clinically severe bleed > 6 – 8 ml/kg of body wt
 Worsening metabolic acidosis
 Unstable vitals with normal or low pcv
 Rise in PCV of less than 20% with persistent shock
 Refractory shock inspite of 60ml/kg of fluids

51.  Mandatory to check PCV before and after transfusion
 If PCV does not rise – consider continuing bleed and repeat blood
transfusion if vitals remain unstable
 Rate of transfusion
– in hypotensive shock – give over 1hr
Otherwise at 2- 5ml/kg/hr

52. C – coagulopathy –
Priority is for fluid and blood transfusion, but if severe bleeding
continues, correction of coagulopathy is given
 If fibrinogen levels < 100mg/dl, give cryoprecipitate @ 0.15 u/kg or
2units per 10kg or 5 – 10ml/kg
 Cryo can also be used when there is fluid overload with coagulopathy
and bleed.

53.  Tranexemic acid 15mg/kg f/b 2mg/kg/hr for aTLeast 8hrs or till
bleeding stops
 In case of massive bleed (> 40ml/kg in 3hrs or > 3ml/kg/min),
transfuse PRC: FFP: platelet – 2: 1: 1
 C – calcium-
treat hypocalcemia with calcium gluconate 1ml/kg slow iv
 D – dextrose
treat hypoglycaemia with D 10 2-4 ml/kg and increasing
concentration of dextrose concentrations

54.  Consider inotropes if child does not respond to above fluid
management- maintenance plus 5% plus inotropes
 Unrecordable BP as a salvage inotrope- Adrenaline @ 0.05 –
0.3 mcg/kg/min
 Wide pulse pressure shock –Noradrenaline @ 0.05 –
1mcg/kg/min
 BP normal with poor perfusion, worsening acidosis –
dobutamine @ 5 – 20 mcg/kg/min

55.  Cardiogenic shock – Dobutamine
 Hypotensive cardiogenic shock- Adrenaline
 Cardiogenic shock with severe tachycardia – Milrinone
0.3 – 0.7mcg/kg/min
 Levosimendan – used in diastolic dysfunction,in presence of severe
tachycardia, pulmonary hypertension or if the child is not
responding to dobutamine esp after 72hrs.
 If BP is not maintained at Adrenaline 0.3mcg/kg/min give
Hydrocortisone 2 -4 mg/kg /day in divided doses

56.  Ventilation- consider NIV early in the course of disease if child has
respiratory distress, shock not responsive to fluids or
catecholamine refractory
 IV access-try to secure iv lines early.

57.  IV dextran 10ml/kg over 1hr
 Usually BP is restored in 10- 30min -- then give Inj furosemide 0.1mg/kg
 Monitor vitals every 15min as child can go into shock due to diuresis
 In case of severe fluid overload, dextran may be repeated with repeat
furosemide at 30-60min interval but subsequent should be titrated
according to urine output
 Even in spite of large doses of lasix and decreased urine output,if IVC is
full,it may indicate renal failure and need for RRT

58.  Death usually occurs due to massive brain edema leading to
herniation. Can present with brainstem involvement during any
phase of dengue
 Treat seizures or add prophylactic fosphenytoin
 Give 3% NS 5ml/kg over 1hr
 Target S.Na of 145-150meq/l
 Use isotonic fluids for resuscitation

59.  Intubate if GCS< 8 or rapidly decreasing by more than 3 points
 Hyperventilate with bag and mask
 Sedate with lora 0.1mg/kg and fentanyl 1mcg/kg
 Give lignocaine 1mg/kg to prevent ICP surge due to gagging
paralyse with vecuronium 0.1mg/kg and intubate
 Post intubation keep a higher pCO2 30 – 35mm Hg in the first 24
hrs

60.  Characterised by improvement in general well being, increase in
s.albumin and stabilisation of vitals
 fall in PCV and increased urine output
 WATCH FOR PULMONARY EDEMA
 stop iv fluids completely
 if child is not diuresing, consider furosemide @ 0.1 – 1mg/kg/hr

61.  Loss of blood (overt blood) - 10 per cent or more of total blood
volume - preferably give whole blood or components to be used
 Refractory shock despite adequate fluid administration and
declining haematocrit
 Replacement volume should be 10 ml/kg body weight at time
and coagulogram should be done
 If fluid overload is present packed cells are to be given

62.  Prophylactic platelet transfusion may be given at levels of <10000
in the absence of bleeding manifestations
 Prolonged shock with coagulopathy and abnormal coagulogram
 In case of systemic bleeding, platelet transfusion may be needed
in addition to red cell transfusion

63.  Absence of fever for at least 24 hrs without use of antipyretics
 No respiratory distress from pleural effusion or ascites
 Platelet count > 50000
 Good urine output.
 Return of appetite
 Minimum of 2- 3 days after recovery from shock
 Visible clinical improvement

65.  Difficult to distinguish symptoms and signs because of their
overlapping initial clinical presentations and laboratory
parameters
 both have an unpredictable clinical course and both
generally require in-hospital monitoring for management
 Most of the hospitals are busy with managing COVID-19 at
present, and a very little window is open to tackling another
disease outbreak.
 Most of the cases of COVID-19 and dengue are asymptomatic
(about 80%). In a setting of coinfection, one might enhance
the severity of the other

66.  IV fluid therapy is challenging in coinfected patients due to
early development of ARDS/pulmonary oedema
 Treatment with Low molecular weight heparin for
management of COVID-19 may enhance bleeding in the
presence of dengue, especially with low platelet count
 False positivity is also reported among co-infection, which
may create a diagnostic challenge
 Both viral diseases do not have any specific antivirals drugs

69. 1. FLUID MANAGEMENT:
 Can proceed as usual
 If SARI, aggressive fluid therapy- worsen oxygenation
 IVC guided fluid therapy
2. LMWH :
 If thrombocytopenia, should be careful
 Stop immediately, if active bleed
3. STEROIDS :
 can be given as per COVID protocol

70.  National guidelines clinical management of dengue
 PARK SPM TEXTBOOK
 SAT Protocol