Dengue

1. Management of
Dengue in ICU
Dr Anupal Singh Kahlon
Attending Consultant Fortis Escorts Hospital

2. For a disease that is complex in its
manifestations, management is
relatively simple, inexpensive and very
effective in saving lives, so long as
correct and timely interventions are
instituted.

3. Introduction
• Fever with
Thrombocytopenia.
• Vector Borne
– Aedes Aegypti
• Classically known as
Break Bone Fever:
– true to its name
• severe myalgias
• retro-orbital pain
• malaise
• Flavi-viridae
– Self Limiting disease
• May follow a turbulent
course
– from asymptomatic to severe
form
– management depends on the
clinical stage
– Mortality rate of less than 1%.
– When treated, dengue
hemorrhagic fever has a
mortality rate of 2-5%.

4. COURSE OF DENGUE

5. Febrile phase
• high-grade fever.
• facial flushing, skin erythema, generalized
body ache, myalgia, arthralgia, retro-
orbital eye pain, photophobia, rubeliform
exanthema and headache.
• Mild haemorrhagic manifestations such as
petechiae and mucosal membrane
bleeding

6. Critical phase
• Classically appears when fever subsides i.e.
day 3–8 of illness
• increased capillary permeability plasma
leakage
• rapid decrease in platelet count
• haemoconcentration
• WARNING SIGNS

7. Warning signs of dengue
• Excessive Nausea, Persistent vomiting and severe
abdominal pain
• Extreme lethargy
• Weakness, dizziness or postural giddiness indicate
Hypotension i.e. progression into the shock state.
• Spontaneous mucosal bleeding or bleeding at previous
venepuncture sites.
• Tender Hepatomegaly.
• Polyserositis.
• Tachypnea, Tachycardia.

8. Recovery phase
• a gradual reabsorption of extravascular
compartment fluid
• General wellbeing improves, appetite
returns, gastrointestinal symptoms abate,
haemodynamic status
• stabilizes, and diuresis ensues

9. NEWER CLASSIFICATION

10. Predictors of Severe Dengue
• Young age (esp infants)
• Caucasian race
• AB blood group
• Warning Signs
– Abdominal Tenderness
– Hepatomegaly
– Lethargy
– Cold extremities
– Bleeding
– PC <75000/cu mm
– Hct value >50 or rise >22%
from baseline
• Viral load assessment
• Viral serotype testing
• NS1 level semi-quantitive
measurement
• Measurement of
plasma/serum cytokine,
elastase, hyaluronan,
soluble thrombomodulin,
NO level
• Detection of circulating
endothelial cells

12. Group C: Require emergency treatment
• Severe plasma leakage leading to dengue
shock → LOSS OF PLASMA
• Severe haemorrhage → LOSS OF BLOOD
• Severe organ impairment →LOSS OF
ORGAN FUNCTION

13. Before Admission
• Is it dengue?
• Phase?
• Warning Signs?
• Heamodynamic status?
• Hydration?

14. AIRWAY AND BREATHING
• Airway is usually clear, look for signs of heamorrhage
• Respiratory rate
• Respiratory effort
• B/L Air entry
• B/L Chest movements
• Noisy breathing
• Cyanosis
• Mental status

15. Circulation – Assessment of shock
• Heart rate
• Peripheral pulses
• Central pulses
• Colour
• Temperature
• Capillary filling test
• Blood pressure
• Mental Status
• Urine Output

18. Goals of fluid resuscitation
Improving central and
peripheral perfusion
• Decreasing tachycardia
• Improving BP and pulse
volume
• Warm and pink extremities
• CFT<2 sec.
Improving end organ
perfusion
• Stable conscious level
• Urine output more than
0.5 ml /kg /hr
• Decreasing metabolic
acidosis

21. ROLE OF COLLOIDS ?????

22. Parameters to be monitored
• Mental status
• Vital signs
• Peripheral perfusion
• Pleural effusion and Ascites
• Arterial line
• Blood gas and/or lactate analysis
• Urine output HOURLY

23. Inotropes
• As a temporary measure to prevent life-threatening
hypotension in dengue shock and during induction for
intubation, while correction of intravascular volume is being
vigorously carried out--> DOPAMINE
(Vasopressors – maintain the central BP but without improving
end organ perfusion. May exacerbate tissue hypoxia and lactic
acidosis)
• For myocarditis or ischemic heart disease--> DOBUTAMINE
• In concomitant septic shock --> DOPAMINE / NORADRENALINE

24. Hemorrhagic manifestations
• Persistent acidosis → Coagulopathy → DIC
• Thrombocytopenia
Only minor prolongations in PT, APTT but moderate to severe
depression of plasma fibrinogen concentrations
Levels of the anticoagulant proteins were normal or depleted
at the time of admission to the hospital and decreased
significantly during the subsequent 24 h.
Briget A Wills et al; Coagulation Abnormalities in Dengue Hemorrhagic Fever in 167 Vietnamese children with dengue shock

25. High risk patients
• have profound/prolonged/refractory shock;
• have hypotensive shock and multi-organ failure
or severe and persistent metabolic acidosis;
• are given non-steroidal anti-inflammatory
agents;
• have pre-existing peptic ulcer disease;
• are on anticoagulant therapy;
• have any form of trauma, including
intramuscular injection.

26. RECOGNISE EARLY!!!
• Severe bleeding should be recognized in the
following situations:
– persistent and severe bleeding in the presence of unstable
haemodynamic status
– a decrease in haematocrit after boluses of fluid resuscitation together
with unstable haemodynamic status;
– refractory shock that fails to respond to consecutive fluid resuscitation
of 40–60 ml/kg;
– hypotension with inappropriately low/normal haematocrit;
– persistent or worsening metabolic acidosis with a well-maintained
systolic BP, especially in those with severe abdominal tenderness and
distension.

27. TREAT EARLY!!!
• Attempts should be made to stop bleeding if the source of
bleeding is identified e.g. severe epistaxis may be controlled by
nasal adrenaline packing.
• Replace blood urgently; 5−10 ml/kg of fresh -packed red cells
or 10−20 ml/kg of fresh whole blood (FWB).
• No evidence that supports the practice of transfusing platelet
concentrates and/or fresh-frozen plasma.
• Care when inserting NG tube or bladder catheters.
• Central venous line – under USG guidance.

29. Fluid overload
• Some degree of fluid overload is inevitable in patients with severe plasma
leakage.
• The skill is in giving them just enough intravenous fluid to maintain
adequate perfusion to keep them alive, while waiting it out until the
plasma leakage process spontaneously reverses, and at the same time
avoiding excessive fluid overload.
The RIGHT FLUIDmanagement
Fluids have to be given at just the right time, in
the just the right volume, of just the right type
and for just the right duration

30. Fast
breathing on
the 4th day
of illness
PLEURAL
EFFUSION
FLUID
OVERLOAD
PNEUMONIA

31. Investigations
• ABG
• CXR cardiomegaly, pleural effusion,
upward displacement of the
diaphragm by the ascites and varying
degrees of “bat’s wings” appearance
± Kerley B lines, suggestive of fluid
overload and pulmonary oedema
• ECG to exclude
ischaemic changes and
arrhythmia
• Echocardiogram for EF,
IVC assesment

32. Management of fluid overload
• Furosemide bolus 0.5-1mg/kg two to three
times daily
• Furosemide Infusion 0.05-0.4mg/kg/hr
• Peritoneal dialysis, CVVH

33. Pulmonary edema and ARDS
• PEEP
– non-invasive ventilation continuous positive
airway pressure (CPAP)
– mechanical ventilation.
• patients who have shock and are restless,
combative or confused;
• respiratory failure from acute pulmonary
oedema/ARDS ± shock;
• patients who fail to respond to non-invasive
ventilation

34. Tracheal intubation risky
• Sedation and induction agents will precipitate
hypotension and cardiac arrest in a hypovolaemic
patient.
• Unless the tidal volume and respiratory rate (RR) are
increased to match those of the patient’s own
respiratory effort, muscle relaxants will worsen the
metabolic acidosis.
• The compliance is diminished so higher pressures for
adequate ventilation and oxygenation.
• Trauma to the airway will cause bleeding.

35. Myocarditis
• EF <50% was found in 6.7%, 13.8%, and 36% of
patients with DF, DHF, and DSS during the toxic stage,
respectively (p <.01)
• DSS patients with poor ventricular function had
significantly more tachycardia and hepatomegaly.
• While end-diastolic volumes were similarly reduced,
patients with lower EF tended to have lower cardiac
output, developed larger pleural effusion, and had
higher incidence of respiratory embarrassment
Apichai Khongphatthanayothin et alk; Myocardial depression in dengue hemorrhagic fever: Prevalence and clinical
description. Pediatr Crit Care Med 2007; 8:524 –529

36. • Optimize Hb
• Optimize preload with fluids if indicated
(slow bolus – 10ml/kg)
• Decrease WOB by supplemental O2
• Consider early intubation
• Early ionotropes Dobutamine
• Role for ECHO – for EF, Contractility and
IVC status
• Lesser role for CVP now-a-days

37. Glucose control
Hyperglycemia
• Neuroendocrine stress
response
• Osmotic diuresis
• Increased morbidity and
mortality
• IV insulin (not s/c)
Hypoglycemia
• Starvation, severe liver
involvement
• Seizures, mental confusion,
unexplained tachycardia
• Treat as emergency with
0.1-0.5g/kg
• Maintain with fixed rate of
glucose-isotonic solution

38. Electrolyte imbalance
• Hyponatremia – GI losses, hypotonic solution
• Hyperkalemia – severe acidosis, AKI
• Hypokalemia – GI losses, Stress induced
hypercortisol state
• Calcium – repeated blood transfusions,
bicarbonate infusions
• Hyperchloremia – large volume of 0.9% NaCl

39. Abdominal compartment syndrome
Signs
• Worsening of ventilator
parameters
• Oliguria
• Unexplained metabolic
acidosis
• Tense ascites
• Reduced cardiac output
Treatment
• Sedatives, head end
elevation, Neuromuscular
blockade
• NG Decompression, enema
• Lasix
• Paracentesis
• Decompressive Laparotomy

40. CNS Involvement
Rajesh Verma et al; Neurological complications of dengue fever: Experience from a tertiary center of north India.
Ann Indian Acad Neurol. 2011 Oct-Dec; 14(4): 272-278

41. ACUTE KIDNEY INJURY
• Renal hypoperfusion
• After the critical period of plasma leakage
• Renal replacement therapy
– Continuous veno-venous haemodialysis (CVVH)
– Peritoneal dialysis

42. When to stop IV fluids?
• signs of cessation of plasma leakage
• stable BP, pulse and peripheral perfusion
• haematocrit decreases in the presence of a
good pulse volume
• apyrexia (without the use of antipyretics)
for more than 24–48 hours
• resolving bowel/abdominal symptoms
• improving urine output.

43. CO-INFECTIONS
• Gram-negative bacteria in patients with
diabetes mellitus and renal failure.
• Other tropical diseases such as leptospirosis,
typhus, malaria, chikungunya and enteric
fever.
• High degree of suspicion in atypical
presentations such as prolonged fever,
pulmonary haemorrhage, unexplained renal
failure or liver failure in the absence of shock.