Management of Dengue Fever/ Dengue Hemorrhagic Fever


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Management of Dengue Fever and Dengue Hemorrhagic Fever

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Management of Dengue Fever/ Dengue Hemorrhagic Fever

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  3. 3. Seen in children in Southeast Asia during the 1950s.<br />Its severe forms (hemorrhagic fever and shock syndrome) may lead to multisystem involvement and death<br />Early diagnosis, close monitoring for deterioration & response to treatment are necessary in all cases.<br />
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  7. 7. Risk factors for developing DHF / DSS:<br />Children are more prone to develop DHF / DSS than adults<br />DHF / DSS is associated more with well nourished than with under nourished children<br />Primary infection in infants born to dengue immune mothers<br />Presence of underlying chronic illnesses (eg: heart disease, anaemia, chronic liver disease)<br />
  8. 8. Special attention :High-risk dengue patients <br />Infants under 1 year of age<br />Overweight/obese patients<br />Massive bleeding<br />Change of consciousness,esp. restlessness,irritability or coma<br />Presence of underlying diseases e.g. thalassemia, G-6-P deficiency, heart disease<br />
  9. 9. Admission in Dengue Fever<br />Abdominal pain – may be intense and sustained<br />Bleeding tendencies with Positive tourniquet test<br />Cold extremities<br />Decreased urine output<br />Platelet count < 1 Lakh and PCV rise by >20%<br />Persistent vomiting<br />Altered mental status -Restlessness or somnolence<br />
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  11. 11. TREATMENT<br />No specific therapy – only symptomatic<br />Rest and Plenty of oral fluids<br />Use Paracetamol<br />Avoid Aspirin and NSAIDs Follow up preferably everyday - from the 3rd day until afebrile for 24-48 hour<br />
  12. 12. General measures<br />Frequent monitoring of vital signs<br />Essential nursing care.<br />Stop bleeding with proper techniques (e.g. anterior nasal packing for massive epistaxis)<br />Avoid blind invasive procedures (e.g. no nasogastric tube insertion, no gastric lavage)<br />
  13. 13. Nutritional support<br />Soft, balanced, nutritious diet, juice and electrolyte solution – plain water is not adequate<br />Avoidblack- or red-colored food or drinks (may be mistaken for bleeding<br />Sedation is needed in some cases to restrain agitated child: Chloral hydrate(12.5-50 mg/kg), orally or rectally recommended. <br />Avoid Long-acting sedatives<br />
  14. 14. NCPAP (Nasal Continuous Positive Airway Pressure): should be preferred if there is Acute respiratory failure associated with DSS<br />Oxygen via face mask/nasal cannula: in case of shock/impending shock.<br />
  15. 15. Other treatment<br />H2-blockers (ranitidine): Recommended in case of GI bleeding<br />Domperidone 1 mg/kg/day in three divided doses in case of severe vomiting for 1-2 days.<br />Antibiotic: Not necessary; it may lead to complications<br />
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  19. 19. FLUID MANAGEMENT<br />In young infants without shock- D5 0.3% NaCl<br />In patients who already have volume overload, i.e., massive pleural effusion - colloid solutions<br />Hydroxyethyl starch at 6%: preferred in children with severe shock; the use of dextran is associated with various adverse reactions<br />
  20. 20. WHO guidelines are useful in that they offer an algorithmic approach to fluid resuscitation in DHF and DSS.<br />However, the usefulness of these guidelines is limited beyond the immediate resuscitation<br />do not address treatment of complicated forms of the disease, like fluid overload and multiple organ failure, which could cause disability or death.<br />
  21. 21. If no response to IV fluids:<br />Consider and correct:<br />Massive plasma leakage<br />Concealed internal bleeding – decrease in Hematocrit<br />Hypoglycemia – Blood sugar < 60 mg/dL<br />Hyponatremia, hypocalcemia – electrolytes<br />Acidosis – indicates metabolic acidosis in blood gas analysis<br />
  22. 22. Blood transfusion<br />Platelet transfusion<br />Thrombocytopenia with significant bleeding.<br />Platelet count < 10,000/mm3<br />DOSE 10-20 mL/kg<br />Platelets return to normal within 7-9 days<br />
  23. 23. Fresh Whole blood / Packed red cell transfusion<br />Significant blood loss > 10% (6-8 mL/kg)<br />Concealed internal bleeding<br />Hemolysis<br />DOSE:<br />Fresh whole blood 10 mL/kg/dose<br />Packed red cells 5 mL/kg/dose<br />
  24. 24. Role of Steroids Ineffective in preventing shock in DHF<br />It may cause harm<br />Treatment with methyl-prednisolone did NOT show any benefit in a double blind placebo-controlled trial in DSS<br />
  25. 25. Complications of DF/DSS<br />DIC<br />Myocardial dysfunction incl. Cardiomyopathy<br />Hepatitis<br />Reye-like syndrome<br />Encephalitis<br />ARDS<br />Glomerulonephritis<br />
  26. 26. Fluid overload<br />AVOID: Early IV fluid therapy- in the febrile phase<br />Excessive use of hypotonic solutions<br />Excessive use of hypotonic solutions<br />Non-reduction in the rate of IV fluid after initial resuscitation<br />Non-reduction in the rate of IV fluid after initial resuscitation<br />Blood loss replaced with fluids in cases with occult bleeding Blood loss replaced with fluids in cases with occult bleeding<br />Treatment: Judicious fluid removal: colloids with controlled diuresis (furosemide 1 mg/kg infusion over 4 hours) or dialysis<br />
  27. 27. Electrolyte imbalance<br />Hyponatremia<br />Hypocalcemia – 10% Cagluconate 1mL/kg/dose, slow IV push every 6 hour<br />
  28. 28. Large pleural effusion/ascites<br /> Careful titration of intravenous fluids.<br />Avoid insertion of intercostal drains and tracheal intubation.<br />Large pleural effusions during recovery phase after 48 hours<br />Furosemide (0.25-0.5 mg/kg at 6 hours interval for 1 to 2 doses)<br />
  29. 29. Disseminated intravascular coagulation <br />Frequent Clinical assessment<br />Regular Coagulation profile: PT, aPTT, fibrinogen, platelet <br />Patients with bleeding & DIC have benefited from :<br />Heparin therapy + Cryoprecipitate (1 unit per 5 kg body weight)<br />Followed by Platelets (4 units/m2 or 10-20 mL/kg) within 1 hr and Fresh frozen plasma (FFP 10-20 mL/kg).<br />
  30. 30. Prognosis<br />Significant morbidity and mortality can result if early recognition and monitoring of severe forms are not done<br />