This talk was delivered by Dr. Shashikiran Umakanth on 10 Jan, 2016 as part of CME on Infectious Diseases conducted by the Indian Medical Association, Udupi-Karavali branch, Karnataka, India.

1. Dengue Fever
An Approach to Rational Management
Dr. Shashikiran Umakanth
Professor & Head, Department of Medicine
Dr. TMA Pai Hospital, Udupi
MMMC, Manipal University

2. Dengue - A Flavivirus
o Arboviral infection
• Aedes aegypti
o Incubation period
• 3-14 days
• average 7 days
o 2.5 billion people at risk (40% of world
population) in >100 countries
o Tropical and subtropical countries
o Other flaviviruses
• Yellow fever virus
• Japanese encephalitis
• West Nile virus
• St Louis encephalitis

3. Global burden
390 million cases/year
5 lakh admitted for severe dengue (DHF)
90% in children <5 years

4. Agenda
1) Clinical Phases of Dengue
2) Warning igns of impending complications
3) Classification of Dengue severity - Groups A, B C
4) Management of Group A, B & C Dengue fever
5) Advances in Prevention & Management

5. 1) Clinical Phases of Dengue
2) Warning signs of impending complications
3) Classification of Dengue severity - Groups A, B C
4) Management of Group A, B & C Dengue fever
5) Advances in Prevention & Management

6. Phases of Dengue
Illness
Day of Illness
Temperature
Potential
Clinical Issues
Lab Changes
Serology
& Virology
FEBRILE
1 2 3
CRITICAL
4 5
RECOVERY
6 7 8 9 10
Shock / Bleeding
Organ Impairment
Dehydration
Reabsorption /
Fluid overload
40 ºC
Platelets
Hematocrit
Viraemia IgM/IgG
1 2 3

7. 2) Warning signs of impending complications
3) Classification of Dengue severity - Groups A, B C
4) Management of Group A, B & C Dengue fever
5) Advances in Prevention & Management
1) Clinical Phases of Dengue

8.  Onset of critical phase is
 marked by plasma leakage
 occurs around fever defervescence
 Evidence of plasma leakage includes
 Rising hematocrit >10% (early marker)
 Hemodynamic instability
 Fluid accumulation in extravascular space (late
marker)
 hypoproteinemia

9.  Abdominal pain or tenderness
 Persistent vomiting
 Clinical fluid accumulation
 Mucosal bleed
 Lethargy; restlessness
 Liver enlargement >2cm
 Lab: ↑ hematocrit (HCT) &
rapid ↓ of platelets
Warning signs of Impending Critical Phase
Co-existing conditions/
situations
o Pregnancy
o Infancy & Old age
o Obesity
o Diabetes mellitus
o Hypertension
o Heart failure
o Renal failure etc.

10.  Clinical judgment is required regarding admission
 However, essential to admit the following:
 All patients with platelet count of ≤100,000/cumm
 Platelet count 100,000 - 150,000/cumm if dropping rapidly
 All patients with warning signs after day 3 of illness
Criteria for admission

11. 1. Severe plasma leakage (DSS)
2. Severe hemorrhage (DHF)
3. Severe organ impairment
without
Dengue ± warning signs Severe Dengue
with
warning signs

12. 3) Classification of Dengue Severity
4) Management of Group A, B & C Dengue fever
5) Advances in Prevention & Management
1) Clinical Phases of Dengue
2) Warning signs of impending complications

13. Severity of Dengue
Group
A
B
C
Features
No warning signs, esp. when fever subsides
Able to take orally; urine output every 6h
Near normal HCT and blood counts
Developing warning signs
Poor family/ social support
Increasing HCT, reducing platelets
Established warning signs
Critical phase
Severe plasma leakage
Hemorrhage
Organ impairment
Rx Setting
Home
Hospital
ICU

14. 4) Management of Groups A, B and C
5) Advances in Prevention & Management
1) Clinical Phases of Dengue
2) Warning signs of impending complications
3) Classification of Dengue severity - Groups A, B C

15.  Manage at home
 2.5 - 3.0 litres of oral fluids/day
 ORS, fruit juices, soups, water
 Avoid red/brown fluids (confusion with hematemesis)
 Avoid NSAIDs!
 Paracetamol is usual doses 500-1000mg q6h-q8h
 Daily blood counts, watch for warning signs
Management of Group A patients
A

16.  Hospital admission
 If admitted due to lack of family support
 Manage like Group A
 If warning signs/ critical phase (plasma leakage)
 IV fluids with normal saline or Ringer’s lactate
 Close monitoring of vital signs, fluid balance, HCT,
platelets, urine output, LFT, RFT, coagulation profile
Management of Group B patients
B

17.  Emergency management in ICU
 Compensated or decompensated shock
 IV crystalloids and colloids
 Individualized fluid requirement
 Colloids and blood transfusion in intractable shock
 Usually recovery in few hours, if not - consider
acidosis, electrolyte disturbances, myocarditis,
hepatic necrosis, internal bleeding
Management of Group C patients
C

18. Fluid Management

19.  Calculate total fluid quota for 48 hours:
 Maintenance + extra 5% fluid deficit
Impending or Early Critical Phase
Needs
IV fluids for 48
hours
Maintenance: 100-50-20 formula
100 mL/kg for first 10 kg of BW
+ 50 mL/kg for second 10 kg of BW
+ 20 mL/kg for every kg >20 kg up to 50 kg
5% fluid deficit (extra)
50 mL/kg of BW up to 50 kg
Example: 45kg BW
100x10 = 1000ml
50x10 = 500ml
20x2 = 100ml
50x45 = 2250ml
Total = 3850ml

20.  Halliday-Segar formula for total fluid
requirement
 4 ml/kg/hr for first 10 kg bw +
 2 ml/kg/hr for next 10 kg bw +
 1 ml/kg/hr for body weight >20kg
Alternative
Needs
IV fluids for 48
hours
Maintain at least
0.5ml/kg/hour
urine output
Strict I/O balance;
but does not help
in judging fluid
need

21. Need for Blood and Components

22.  Prophylactic use NOT recommended
 even if platelets are very low
 Use only if there is active bleeding with
thrombocytopenia
Platelet transfusion

23. Indications
 Significant overt bleeding
 Suspicion of concealed bleeding
 When HCT drops without clinical improvement
 Severe metabolic acidosis and end-organ dysfunction despite
adequate fluid replacement
 Use PRC at 5ml/kg once and repeat only if needed
 PRC contraindicated if HCT > 45%, even if active bleeding
Blood transfusion (PRC)

24. Special situations

25.  Fluid intake
 Same as for non-pregnant women
 Pre-pregnancy body weight should be used in the formula
 Detection of plasma leakage is difficult
 early ultrasonography is preferred
 Signs & symptoms may be confused with that of
HELLP syndrome
Dengue in Pregnancy

26.  Corticosteroids
 No major studies have shown efficacy in preventing
complications
 Antiviral drugs
 Many studies on Balapiravir
 Not effective
Experimental treatments

27. Convalescence & Discharge

28.  Recognized by improvement in
 Clinical variables
 Patient’s wellbeing
 Many patients develop diuresis
and hypokalemia
 Rashes and pruritus common
during recovery
Convalescence

29. Criteria for Discharge
48-hr
afebrile
Increasing
platelets
Stable
hematocrit

30. 5) Advances in Prevention & Management
1) Clinical Phases of Dengue
2) Warning signs of impending complications
3) Classification of Dengue severity - Groups A, B C
4) Management of Group A, B & C Dengue fever

31.  A tetravalent dengue vaccine
 Live attenuated genetically engineered Yellow Fever virus
 Available in Mexico, Philippines and Brazil
 Developed by Sanofi
 Not yet approved in India
Dengue Vaccine

32. Thank you
for your attention