Dengue management

1. Dengue management
in children
By Dr Nurul Adha

2. Outline
• Classification
• Course of dengue
• Admission criteria
• Outpatient management
• Fluids resuscitation
• Compensated shock
• Decompensated shock

3. Dengue Classification

4. Course of Dengue Illness
Shock

5. Diagnosis
HISTORY
LABORATORY TEST
• NS1 Antigen
• IgM/IgG antibodies
• Full blood count
• Liver function test

7. Stepwise Approach in Dengue
Management
STEP 1
History taking
Physical examination and mental assessment
Investigation including routine lab and dengue specific investigation
STEP 2
Diagnosis, assessment of disease phase and severity
STEP 3
Disease notification
Management decisions depending on clinical manifestations
Group A : outpatient
Group B : refer for inpatient management
Group C : require emergency treatment and urgent referral

8. STEP 1 : History Taking
• Date of onset of fever
• Symptoms and severity
• Three Golden questions
» 1) How much fluid intake : Quantity and quality
» 2) How much urine output: Frequency, volume and time of most recent voiding?
» 3) What activities could the patient do during the illness
• Other fluid losses: diarrhoea, vomiting
• Present of Warning Signs
• Family or neighbour with dengue OR travel to dengue-endemic area
• Risk Factors
• Infancy, pregnancy, obesity, diabetes mellitus, hypertension, etc.

9. General Assessment
Mental status, hydration status, haemodynamic
status
Clinical Examination
Bleeding
Liver enlargement
Abdominal tenderness
Fluid accumulation
Other important signs
Rash
Tachypneic / acidotic breath
STEP 2 : Clinical Assessment
5-in-1 manouvre – CCTVR
Colour
Capillary refilling time
Temperature
Pulse Volume
Pulse Rate

10. Haemodynamic Assessment

11. STEP 3 :
Management
• Dengue notification
• Divide into 3 main group
based on clinical
presentation

13. Group A : Outpatient management
Group A – send home if patient
meets all of the following criterias
• Intake : Adequate volume of oral fluids
• Output : Passing urine at least once
every 4 to 6 hours
• NO warning signs or features of severe
dengue
• Stable hematocrit and hemodynamic
status
• No coexisting conditions
• Age > 12 months old
1. Give anticipatory guidance
before sending home
2. Follow up daily with serial full
blood count
3. Identify warning signs

14. Home care advice
• Adequate bed rest
• Adequate fluid intake (6-8 drinks/day) – eg milk, fruit juices, oral
rehydration salt, barley water, coconut water
• Paracetamol and tepid sponging for fever control
• Use mosquito repellent or sleep under a mosquito net
• Eliminate mosquito breeding places

15. Avoid
NSAIDS
Steroids
Antibiotics are not required

16. Danger signs of Dengue fever
Lethargy or
poor feeding
Bleeding
Frequent
vomiting
Persistent
abdominal
pain
Drowsiness,
irritability or
seizure
Pale, cold and
clammy skin
Difficulty in
breathing
Reduced urine
output

17. Dengue Monitoring Record

18. Admission
Criteria
Group B and
Group C
• Age less than 12 months old
• Presence of warning signs
• Features of severe dengue
• Presence of comorbidities

19. Volume Replacement Therapy
General principles
• Isotonic crystalloids should be used during the critical phase
(normal saline [NS] or 5% dextrose NS; if <6 months – ½ NS or ½ NS with 5% dextrose)
• In obese patients, ideal body weight should be used for calculation
• Rate of intravenous (IV) administration should be adjusted according to the clinical situation
• Prophylactic platelet transfusion not recommended. Even in the event of severe bleeding with low
platelets, consider fresh frozen plasma (FFP) and then platelets.

20. IBW for obese child
If patient’s height is within 5th and 95th centile of age, use Moore method as below:
the IBW is the weight for age on the same percentile as height.
If patient’s height exceeds 95th centile for age, use McLaren method as below:
weight at the 50th centile for height age chart

21. Moore method
7 years old boy,
Ht 125cm
Wt 45kg
IBW : ?
: 75th centile
: 75th centile
25kg
McLaren method
10 years old boy,
Ht 155cm
Wt 60kg
IBW : ?
45kg

22. Dengue with
warning signs
Reassesment of hemodynamic status
Evidence of shock
Rising but vital
signs stable
Remains same or rises
minimally and vital signs
stable
Dehydration
Check HCT
Reduced fluids
3-5mls/kg/hr for 2-4 hours
2-3mls/kg/hr for 24-48
hours
* IV fluids can be reduced
or stopped if oral intake
improves
Adjust fluid to account
for dehydration (5-7.5%
dehydration)
Presence of
ongoing leakage
Reduce IV fluid gradually as to maintain perfusion
If patient has completed 7mls/kg/hr, fluid can be continued for another 1
hour
5mls/kg/hr for 4 hours and reduce further with repeat HCT and vital signs
monitoring
NO
Discuss with specialist
Next slides
NO
YES

23. Dengue in
compensated
shock
Reassesment of hemodynamic status
Reversal of shock
High
Check HCT
Reduced fluids
5-7mls/kg/hr for 1-2 hours
3-5mls/kg/hr for 2-4 hours
2-3mls/kg/hr for 24-48
hours
* IV fluids can be reduced
or stopped if oral intake
improves
Stop IV fluid if patient
shows signs of
reabsorption, usually 48
hours after entering
critical phase
Low
(consider occult
bleeding)
Further bolus of
crystalloid/colloid at
10-20mls/kg/hr over
1 hour
Transfuse fresh
packed red cell/
fresh whole blood
at 10-20mls/kg/hr
over 1 hour
Reversal of shock
NO
Reduced fluids to 7mls/kg/hr
YES
YES NO

24. Reassesment of hemodynamic status
Reversal of shock
High
Check HCT
Reduced fluids
10mls/kg/hr for 1 hour
5-7mls/kg/hr for 1-2 hours
3-5mls/kg/hr for 2-4 hours
2-3mls/kg/hr for 24-48
hours
* IV fluids can be reduced
or stopped if oral intake
improves
Stop IV fluid if patient
shows signs of
reabsorption, usually 48
hours after entering
critical phase
Low
(consider occult
bleeding)
Further bolus of
crystalloid/colloid at
10-20mls/kg/hr over
30mins- 1 hour and
faster if patient is
hypotensive
Transfuse fresh
packed red cell/
fresh whole blood
at 10-20mls/kg/hr
over 1 hour or
faster if active
bleeding
Reversal of shock
NO
YES
YES NO
Next slides
Dengue in
decompensate
d shock

25. Intubation to secure airway and ventilation
Concurrent bleeding and leaking
Look for source if clinically not apparent yet
Check coagulation profile
Transfuse fresh packed red cells/fresh whole blood or
blood components
Septic shock (co-infection)
Take blood culture and start IV antibiotics
(cefotaxime or ceftriaxone)
Consider inotropes (adrenaline or noradrenaline)
Cardiac dysfunction
Perform echocardiogram if available
Consider inotropes (adrenaline or dobutamine)
Correction of electrolytes imbalances and acidosis
Monitoring of intra-abdominal pressure (IAP) - control ascitic
fluid drainage with great caution if IAP elevated
Refractory Shock
In refractory shock (patient remains in shock despite 40 - 60 ml/kg of crystalloid/colloid solutions or
fresh packed red cells/ fresh whole blood), especially when HCT remain unchanged, consider:

26. Discharge criteria
Clinical criteria
• No fever for 24 - 48 hours
• Improvement in clinical status (general well-being, appetite,
haemodynamic status, urine output)
• Absence of respiratory distress
• Resolution or recovery of organ dysfunction
Laboratory criteria
• Increasing trend of platelet count
• Stable HCT without IV fluids

27. Reference
• CPG Management of Dengue in Children (second edition)