5. Group C: Require emergency treatment
• Severe plasma leakage leading to
dengue shock
• Severe haemorrhage
• Severe organ impairment
• Loss of plasma
• Loss of blood
• Loss of organ function
5WHO Handbook for clinical management of Dengue, 2012
6. 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
Jeanne A. Pawitan; Dengue Virus Infection: Predictors for Severe Dengue; Acta Med Indones-Indones J Intern Med
7. DIAGNOSIS
1. Is it dengue?
2. Which phase?
3. Warning signs?
4. Hydration/ Hemodynamic status?
5. Admission?
10. Circulation – Assessment of shock
• Heart rate
• Peripheral pulses
• Central pulses
• Colour
• Temperature
• CFT
• BP
• Mental Status
• Urine Output
PALS Guidelines – American Heart association
11. COLD SHOCK WARM SHOCK
Heart rate ↑ ↑
Peripheral pulses Feeble Bounding
Central pulses Well felt/↓ Well felt
Colour Pale, mottled Pink
Temperature Cold Warm
CFT >3 seconds Flash
PP Narrow Wide
Mental Status Normal altered Toxic sick child
Urine Output ↓ ↓
12. Dengue Shock (VS Septic shock)
• Less likely to have SIRS
• Less likely to have tachycardia
• Narrow pulse pressure
• Mental status better
• Higher Hct
• Thrombocytopenia more common
• Spontaneous clinical bleeding more common
• Required less fluid bolus
S. Ranjit et al; Early differentiation between Dengue and Septic Shock; Pediatric Emergency Care, Vol 23, Number 6, June 2007
15. 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
15WHO Handbook for clinical management of Dengue, 2012
19. Bolus – Slow and steady!!
Compensated shock
• 1st: over 1hr
• 2nd: over 1hr
• 3rd: over 1hr
Hypotensive shock
• 1st: over 15mins
• 2nd: over 30-60mins
• 3rd: over 30-60mins
WHO Handbook for clinical management of Dengue, 2012
20. Aggressive fluid resuscitation??
• Patients in the W group received less fluids in the 1st hour compared
with the P group (median 20ml/kg vs 30ml/kg)
• Incidence of acute respiratory distress syndrome significantly greater
in the W group
• Duration of ventilation and length of ICU stay longer in P group
• Mortality higher in W group
S. Ranjit et al; Aggressive management of dengue shock syndrome may decrease mortality rate. Pediatr Crit Care Med
2005; 6: 412-419
21. Monitoring
• Mental status
• Vital signs every 15-30mins till pt is out of shock
• Peripheral perfusion then 1-2 hourly
• BP monitoring – Arterial line
• Urine output - hourly till patient is out of shock, then 1-2 hourly
21WHO Handbook for clinical management of Dengue, 2012
22. Role of early colloids
• Colloids may be the preferred choice if the BP has to be restored
urgently. Colloids have been shown to restore the cardiac index and
reduce the level of haematocrit faster than crystalloids in patients
with intractable shock
• After two to three boluses of crystalloid without haemodynamic
stability and particularly if the haematocrit is still elevated, it is
essential to consider the switch to colloid resuscitation which is more
effective in lowering the haematocrit
• Dung NM, Day NP, Tam DT. Fluid replacement in dengue shock syndrome: a randomized, double-blind
comparison of four intravenous fluid regimens. Clinical Infectious Diseases, 1999, 29:787-794.
• Ngo NT, Cao XT, Kneen R. Acute management of dengue shock syndrome: a randomized double-blind comparison
of 4 intravenous fluid regimens in the first hour. Clinical Infectious Diseases, 2001, 32:204-213.
• Wills BA et al., Comparison of three fluid solutions for resuscitation in dengue shock syndrome. New England
Journal of Medicine, 2005, 353:877-889.
23. No advantage of colloids over crystalloids
• No difference in mortality between groups who received crystalloids
and colloids” - Colloids versus crystalloids for fluid resuscitation in Dengue fever patients – a review
by Dr Pablo Perel
• “Resuscitation of patients with DSS who already have third space fluid
accumulation with crystalloid boluses on priority basis may contribute
to recovery phase pulmonary oedema” - Premaratna et al.: Should colloid boluses be
prioritized over crystalloid boluses for the management of dengue shock syndrome in the presence of
ascites and pleural effusions? BMC Infectious Diseases 2011 11:52
24. Ionotropes
• 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
WHO Handbook for clinical management of Dengue, 2012
25. Role of steroids
• Dengue shock is a hypovolemic state due to plasma leakage (unlike
Septic shock which is a catecholamine depleted state )
• Serum cortisol levels are high in children with dengue shock.
• “There is no good-quality evidence that corticosteroids are helpful for
DSS”
Panpanich R, Sornchai P, Kanjanaratanakorn K: Corticosteroids for treating dengue shock syndrome. Cochrane
Database Syst Rev. 2006; 3:CD00348
26. Role of IVIg
• The immunological basis of the life-threatening manifestations of
severe dengue together with the potentially beneficial
immunomodulatory effects of intravenous immunoglobulins (IVIG)
suggest a possible place for treatment with this expensive therapy.
• Trials so far have not shown significant benefit in terms of survival or
improvement in clinical parameters with IVIG
Senaka Rajapakse; Intravenous immunoglobulins in the treatment of dengue illness. Transactions of the Royal Society of
Tropical Medicine and Hygiene (2009) 103, 867—870
27. • Child day 4 of fever
• on IVF 7ml/kg/hr
• PCV 39% 32%
• What will you do?
28. 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. Levels of all of the remaining proteins, except TFPI, were elevated
significantly at admission and also decreased during the next 24 h
Briget A Wills et al; Coagulation Abnormalities in Dengue Hemorrhagic Fever in 167 Vietnamese children with dengue shock
29. Patients at risk of severe bleeding
• Prolonged/refractory shock
• Persistent metabolic acidosis
• Renal or liver failure
• Non-steroidal anti-inflammatory agents
• Any form of trauma, including intramuscular injection.
• Haemolytic conditions are at risk of acute haemolysis with
haemoglobinuria
29WHO Handbook for clinical management of Dengue, 2012
30. Treatment of hemorrhagic complications
• Epistaxis – pressure, nasal adrenaline packing
• NO role of platelet/FFP transfusion – “transfusion of platelet
concentrates and fresh frozen plasma in dengue were not able to sustain
the platelet counts and coagulation profile”
• GI bleed – H2 blockers and PPI used, but efficacy not been studied
• Care when inserting NG tube or bladder catheters
• Central venous line – under USG guidance
• 5–10ml/kg of fresh-packed red cells or 10–20 ml/kg of fresh whole blood
30WHO Handbook for clinical management of Dengue, 2012
31. • Blood transfusions only when PCV has fallen to low levels
• Do not wait!! PCV will drop to low levels after several boluses of fluid
resuscitation, or if the bleeding is very severe
• Change from crystalloid/colloid infusion to blood transfusion
• DIC regime for severe bleeding
• Target for multiple transfusions of FFP, Platelets and Cryo
• Plasma leakage and bleeding go on unabated!!
• “unless transfusion with fresh whole blood is given urgently, the patient will
succumb to H’agic shock with massive third space fluid accumulation”
• Blood transfusion in a shocked patient with ↑PCV
• Give colloid bolus 10-20ml/kg – over 1hr if compensated, over 15mins if not
• Blood transfusion in a stable patient with ↓PCV
• Not needed – possibly due to hemodilution
WHO Handbook for clinical management of Dengue, 2012
37. • Child with dengue develops fast breathing on day 4 of illness….
? Fluid overload
? Pleural effusion
? pneumonia
38. • Shortness of breath misinterpreted as fluid overload or due to pleural
effusion or pneumonia
• Metab acidosis – quiet tachypnea
• Look for shock
• PCV
• ABG ± Lactate
WHO Handbook for clinical management of Dengue, 2012
39.
40. • Prophylactic IVF in febrile phase because NS1 Ag Positive
• No role – leads to fluid overload
• Maintain on oral fluids
• If unable to take, IVF for least possible time, switch to oral
• Step up fluid therapy in a well perfused patient with persistently high
PCV
• Continue same fluids; Step up monitoring
• IVF in recovery phase because patient is not drinking
• Huge positive balance
• Lets patient’s thirst mechanism kick in after the diuresis
WHO Handbook for clinical management of Dengue, 2012
41. 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
42. Acute respiratory distress and failure
• Severe metabolic acidosis from severe shock
• Fluid overload – large pleural effusions and acites
• Acute pulmonary oedema
• Acute respiratory Distress Syndrome
43. Role of Non invasive ventilation
Premaratna et al.: Should colloid boluses be prioritized over crystalloid boluses for the management of dengue shock
syndrome in the presence of ascites and pleural effusions? BMC Infectious Diseases 2011 11:52
44. Role of diuretics in ARDS
• The efficacy of furosemide infusion with respect to changes in the
arterial blood gas demonstrates its role in respiratory function.
• In patients with ARDS, diuretics should be tried, which could improve
oxygenation and avoid the need for mechanical ventilation.
KR Bharath Kumar Reddy et al; Furosemide Infusion in Children with Dengue Fever and Hypoxemia. Indian pediatrics Vol 51
APRIL 15, 2014
45. 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
WHO Handbook for clinical management of Dengue, 2012
46. 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
WHO Handbook for clinical management of Dengue, 2012
47. Metabolic acidosis
• Compensated MA – early sign of hypovolemia and shock
• Lactic acidosis
• Sodium bicarbonate – ph<7.1
(W/F sodium and fluid overload, increase lactate, decreased Ca)
WHO Handbook for clinical management of Dengue, 2012
49. • Sedatives, head end elevation, Neuromuscular blockade
• NG Decompression, enema
• Lasix
• Paracentesis
• Decompressive Laparotomy
50. Myocarditis
• Optimize Hb
• Optimize preload with fluids if indicated (slow bolus – 10ml/kg)
• Decrease WOB by supplemental O2
• Consider early intubation
• Consider early ionotropes Dobutamine
• Role for ECHO – for EF, Contractility and IVC status
• Lesser role for CVP now-a-days
51. 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
52. 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
53. 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
54. • Seizures and altered sensorium – diagnosed as neuroinfection
Febrile phase – febrile seizure
Treat as febrile seizure, WATCH FOR WARNING SIGNS
Critical phase – Acute cerebral ischemia
FLUID FLUID FLUID FLUID FLUID FLUID
Any delay (CT scan) Cardiorespiratory collapse and irreversible shock
WHO Handbook for clinical management of Dengue, 2012
56. • During critical phase, target UO of 1ml/kg/hr as criterion of adequacy
of IVF
• Expectation should be scaled down to 0.5ml/kg/hr to avoid fluid overload
• Use of Furosemide for oliguria in critical phase
• May worsen hypovolemia while keeping you happy with UO
• “Fluid bolus challenge furosemide” for reduced urine output
• Averted oliguric renal failure?!?!
• NO!!!! Fluid gone into extravascular space, fluid removed from intravascular
space worsening of hypovolemia
• RRT in critical phase for severe metabolic acidosis and oliguria
• RRT only reserved for recovery phase – Haemodynamically stable child
• Fluid in critical phase will take care of acidosis and oliguria
WHO Handbook for clinical management of Dengue, 2012
57. 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.
WHO Handbook for clinical management of Dengue, 2012
