This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic. Presenter: Dr Vijayan P Panirselvam, Advanced Acute Internal Medicine at Hospital Tengku Ampuan Rahimah, Malaysia. #dengue #WorldNTDDay #BeatNTDs #BestScienceforAll

1. ULTRASOUND imaging in Dengue Fever :
In COVID Pandemic
Dr Vijayan
Advanced Acute Internal Medicine
Hospital Tengku Ampuan Rahimah

2. Disclaimer
• This slide was prepared for the Webinar Series on COVID-19 session on
Feb 12th 2022, by Dr Vijayan , Hospital Tengku Ampuan Rahimah ,
Malaysia.
• This is intended to share within healthcare professionals, not for public.
• This webinar is organised by Malaysian Society of Infection Control and
Infectious Diseases (MyICID) & Institute for Clinical Research, NIH in
conjunction of World NTD Day 2022.

3. The outcome of today’s presentation
❖able to master probe positioning
❖interpreting formed image to guide on clinical
assessment and treatment in dengue

4. Outline of presentation
Part 1 : the basic on focus - principal of ultrasound for dengue in
covid pandemic
Part 2 : detail discussion on ultrasound in dengue , including
pitfalls

5. Part 1 : the basic on focus - principal of ultrasound for
dengue in covid pandemic
• Ultrasound equipment & cleaning
• Diagnostic ultrasound :
➢Echo
➢IVC
➢Lung
➢Abdomen (perinephric)
➢Gall bladder
Infection control
Probe position, scanning tips, normal images &
abnormal images, literature review & pitfalls

6. Ultrasound equipment
• All the parts that does not required ,
need to be removed
• Type of transducer used → S4-1
broadband array for lung/cardiac/abdo
scanning
• Clean the machine with wipes – wait for
2 mins after cleaning pre-scan, and
clean again after using it ( clean the
whole machine)

7. PART 2
ULTRASOUND IN DENGUE
INCLUDE :
ECHO, IVC, LUNG & ABDOMEN
• PROBE POSITION, SCANNING TIPS, NORMAL IMAGES
& ABNORMAL IMAGES, LITERATURE REVIEW &
PITFALLS

8. ECHO WINDOW
SEVERAL STANDARD POSITION ON THE CHEST WALL WHERE
THERE ARE “ECHO WINDOW “
ECHO WINDOW

9. Placing probe for parasternal view – long axis
placing the transducer to the
left of the sternum in 3rd or
4th intercostal space with the
orientation marker toward
patient’s right shoulder or 10 o’
clock

10. PARASTERNAL VIEW- LONG AXIS

11. Let’s advance to dengue shock patient
( severely leaking→ hypovolemic)
• The lumen of the LV may even be obliterated and the ventricular walls are seen
to be “kissing”
• Hyperdynamic LV with normal or higher than normal ejection fraction and
normal myocardial thickening found
Leung JM, Levine EH. Left ventricular end-systolic cavity obliteration as an estimate of intraoperative hypovolemia.
Anesthesiology. 1994;81:1102–9.
The use of LV end-systolic cavity obliteration is a potentially useful “alarm”
suggesting the development of hypovolemic

12. Parasternal view in dengue shock
( hypovolemia)

13. Comparison of LV in hypovolemic shock
& post fluids resuscitation
Pre-resuscitation
Post –resuscitation

14. View appear as ventricles walls are
touching each other , but actually
slicing the ventricles at the side, not
in the middle.
Need to push the probe side to side

15. PARASTERNAL VIEW- LONG AXIS PERICARDIAL EFFUSION

16. CORRELATION OF
INFERIOR VENA CAVA
ULTRASOUND IN
DENGUE FEVER
WE DISCUSS :
PROBE POSITION
IVC MEASUREMENT AND COLLAPSIBILITY
PITFALLS

17. PROBE
POSITION
FOR IVC
SCAN

18. Inferior vena cava (behind liver) draining to right atrium
liver
RA
IVC

19. The biggest challenge would
be to differentiate between
IVC and descending aorta.
The video will show IVC scan ,
then immediately probe tilt to
descending aorta

20. SEVERAL FEATURES TO DIFFERENTIATE BETWEEN IVC AND DESCENDING
AORTA
• THE AORTA RELATIVELY TO PATIENTS LEFT AND IVC TO PATIENTS RIGHT
• AORTA = CIRCULAR AND IVC = ELLIPTICAL
• AORTA = PULSATILE , IVC NOT PULSATILE
• AORTA NOT COMPRESSIBLE UNDER GENTLE PRESSURE BUT IVC DOES
• AORTA DON’T CHANGE DURING RESPIRATION/ SNIFFING

21. EXAMPLE OF MEASUREMENT OF IVC
IVC – 2.0cm exp – 2.0cm
Ins - 1.5cm
IVC collapsibility index :
2.0cm – 1.5cm × 100% = 25% (caval index)
2.0cm

22. Correlation
between IVC
& CI with
CVP
Jambeih R, Keddissi JI, Youness HA, IVC measurements in critically ill patients with acute renal failure. Critical care research and
practice.2017; https: // doi.org Review Article | SLJR 10 /10.1155 /2017/ 3598392: Article ID 3598392

23. AS A GUIDE FOR RESUSCITATION
Randomized Controlled Trial of Ultrasound-guided Fluid
Resuscitation of Sepsis-Induced Hypoperfusion and Septic
Shock
Khrongwong Musikatavorn, MD*† Poj Plitawanon, MD* Suthaporn Lumlertgul, MD* Khuansiri Narajeenron, MD* Dhanadol Rojanasarntikul, MD* Tanawat
Tarapan, MD* Jutamas Saoraya, MD*‡
Western Journal of Emergency Medicine, Volume 22, no. 2: March 2021
➢ 106 and 105 eligible patients were randomized to the usual-care and UGFM treatment arms, respectively
➢ no significant difference in 30-day mortality between the two groups & no significant difference between the
treatment groups in six-hour lactate clearance, SOFA score at 72 hours or the length of hospital stay
➢However, the rate of vasopressor use and the cumulative fluid
administration in 24 hours was lower in the UGFM arm

24. Ultrasound to look for 3rd space fluid loss
❖pleural effusion
❖pericardial effusion
❖intraperitoneal fluid collection
❖gallbladder wall oedema

25. 12 EXAMINING POINTS
The 12-Point exam has been described in helping Italian and Chinese physicians diagnose COVID-19 (Buensenso 2020 and
Peng 2020).
LUNG SCAN

26. LUNG SONOANATOMY -
NORMAL LUNG
PARENCHYMAL
• THE BAT SIGN
• A LINE

27. DIFFERENCE BETWEEN A LINE & B LINE
– COVID PATIENT

28. Curtain sign – normal lung finding

29. LUS in severe dengue with leaking

30. Severe dengue with 3rd space leaking
(pleural effusion)

31. ABDOMEN SCAN
AIM :
THIRD SPACE FLUID LOSS &
PERINEPHRIC COLLECTION

32. PERINEPHRIC FLUIDS IN SEVERE
DENGUE WITH LEAKING

33. Gallbladder scan :
Gallbladder wall thickening (GBWT)
• Gallbladder wall thickening (GBWT) is one manifestation of increased capillary
permeability [1]
• GBWT above 3mm is significantly associated with more severe cases of dengue, and a
thickness greater than 5mm could identify dengue patients with a higher risk of developing
hypovolemic shock [2]
1.Simmons CP. Dengue
2.Setiawan MW, Samsi TK, Pool TN, Sugianto D, Wulur H. Gallbladder wall thickening in dengue hemorrhagic fever: an ultrasonographic
study. J Clin Ultrasound. 1995;23: 357–362. pmid:7673451

34. ULTRASOUND OF DENGUE PATIENT, CRITICAL PHASE 26, HCT 48, LACTATE 2.2
4mm
IVC – 1.8cm
Caval index-
75%

35. TAKE HOME MESSAGE
❖ need trained personal, as accuracy of finding influenced by
training and experience
❖Overall assessment , not dependant at single finding alone
❖Risk of infection control – follow the SOP
ALWAYS INTEGRATE ULTRASOUND FINDING WITH THE OVERALL
CLINICAL PRESENTATION, PHYSICAL EXAMINATION & LABORATARY
TEST

36. THANK YOU