This document provides information on dengue case management for the pediatric age group. It discusses: - The epidemiology of dengue fever globally and in India, noting it is a mosquito-borne illness transmitted by Aedes aegypti with seasonal peaks from July to November. - The genetic structure and life cycle of the dengue virus, which has four distinct serotypes. Secondary infections pose a higher risk of developing severe dengue. - Methods for laboratory diagnosis of dengue including NS1 antigen detection, serology tests, RT-PCR and virus isolation. Sensitivity and specificity of different tests are provided. - Considerations for dengue in specific pediatric populations like neonates and infants, who

1. Dengue Case Management:
Pediatric Age Group
Dr. Mihir Sarkar
Professor, Pediatrics
PICU in Charge
Medical College Kolkata

2. Introduction

3. Dengue Fever: Epidemiology
• Dengue Fever: A mosquito borne viral disease, is a severe, flu-like
illness, transmitted by the infective bite of Aedes aegypti mosquito with
Seasonality of July to November
• WHO estimates : Globally
 50-100 million cases in more than 100 endemic countries of Africa, America,
Eastern Mediterranean, South-East Asia and Western Pacific
 DHF: 250,000 – 500,000 cases & 24,000 deaths
 30-fold increase in global incidence over the last five decades.

4. • Factors responsible for Rapid Spread:
-unprecedented population growth
-unplanned urbanization
-inadequate water and waste management
-increased distribution and density of vectors
-lack of effective control of vectors
• Dengue viruses cause symptomatic infections or asymptomatic seroconversion.
• Persons even with asymptomatic infection are viremic and thus may be a source
of infection.
Dengue Fever: Epidemiology

5. Pooled estimate of Sero-prevalence in general population 56.9%
Case fatality 2.6%
Proportion of Primary & secondary Dengue infection among
lab confirmed cases
42.9 : 57.1
Distribution of predominant and co-circulating DENV
serotypes
In India, all serotypes are
circulating (DENV-2 & DENV-
3 most common)
In India
• In West Bengal, all serotypes are circulating
• In 2019 Most common Circulating Serotypes:
-DENV-2 & DENV-3 in South Bengal
- DENV-1 in North Bengal
• Circulating Serotypes keep on changing over time

6. • The dengue virus is a single stranded, small enveloped RNA virus
• They possess 4 distinct serotypes DEN1, DEN2, DEN3 & DEN4
• They possess antigens that cross react with YF, JE & WN viruses

7. Genomic Structure of Flaviviruses
• Dengue virus is a positive-stranded encapsulated RNA virus
• Belongs to the flavivirus genus of the Flaviviridae family.
• The genomic RNA is approximately 11 kb in length
• Composed of three structural proteins:
• Also 7 NS (Non-Structural) proteins: assumed to be involved in the replication of
viral RNA. NS1 Ag used for diagnosis.

8. Pathogenesis and Immunity of Dengue
• After inoculation the virus spreads rapidly to the regional lymph nodes
• Replicates primarily in phagocytic macrophages and monocytes - also possibly in
various lymphocyte populations
• Viraemia begins 3-7 days after infection/inoculation
• Onset of effective Ab responses – normally causes resolution of viraemia and recovery
• Immunity is Ab mediated
• After an acute phase of infection by a particular serotype there is lifelong immunity to
the infecting serotype but only temporary and partial protection against the other three
serotypes.
• Secondary or sequential infections are possible after variable time period. The waning
cross reactive heterotypic Ab is responsible for DHF in secondary infection.

9. Antigen-Antibody Response in Dengue Infection
• High concentrations of the antigen can be detected in patients with primary and
secondary dengue infections up to 9 days after the onset of illness.
• Antigen detection in the acute stage of secondary infections can be compromised
by pre-existing virus-IgG immune complexes.

10. DENV
SPECIFIC
HOST CELLS
R
viremia
LUNG
THYMUS
SPLEEN
LYMPH NODES
Mononuclear Phagocyte System
(Macrophage and Macrophage like cells)
BLOOD
MONONUCLEAR
SYSTEM
CD4+ NK
CD8+
DENDRITIC
CELLS
ENDOTHELIAL
CELLS
LIVER
TNF-α
IFN-
γ
Other cytokines*
First line
of
defense
Replication
and infection
Nitric
Oxide
(NO)
Endothelium
lining dysfunction
Increased vascular
permeability
DHF/DSS
Cytolysis
Cytolysis
Pathogenesis

11. Investigation for Diagnosis
From onset of Illness to 5 days of fever
Virus detected in serum, Plasma, circulating
blood cells and tissues
Virus isolation (upto 4th day)
Nucleic Acid Detection (upto 4th day)
NS1 Antigen Detection
From 6th Day onwards
Antibody Detection
First antibody to appear –IgM
Secondary Antibody – IgG
For practical purposes any one of the NS1Ag and IgM assays is
confirmatory for diagnosis of Dengue if done through ELISA method

12. Collection, storage and transportation of samples
• 3-5 ml clotted blood to be collected in screw capped vials or vacutainers.
• Samples to be transported in cold chain (2-8℃ e.g. vaccine carrier)
• Appropriate labeling is most important
• Serum must be separated before transportation
• No Frozen whole blood
• Storage, if necessary, also in 2-8℃ (not more than 1 week)

13.  NS1 Antigen Detection
 Serology: The study of the diagnosis of disease by measuring antibody levels in serum is
referred to as serology.
 IgM-captured enzyme-linked immunosorbent assay
(MAC ELISA)
 Haemagglutination-inhibition
 Neutralization
 Indirect IgG ELISA
 Rapid test
 RT-PCR and Real time RT PCR
 Virus Isolation and Culture
Laboratory Diagnosis of Dengue

14. Sensitivity and Specificity
• IgM ELISA (MAC ELISA):
Since IgM circulates for up to three months or longer, its presence might not be
diagnostic of a current illness. Hence laboratory results should be interpreted in
correlation with clinical findings
Sensitivity and specificity depend on kit quality but are generally > 95% and >
98% respectively
• NS1Ag ELISA:
Sensitivity and specificity are usually > 97% and > 98% respectively
Rapid Diagnostic Kits not recommended for dengue diagnosis because
sensitivity is highly variable and false positive results are common.

17. Interpretation of rising or persistently high Haematocrit
Haematocrit Vitals Interpretation Action
A rising or
persistently high
Haematocrit
+
Unstable vital
signs
=
Active plasma
Leakage
Need for further
fluid replacement
A rising or
persistently high
Haematocrit
+
Stable
Haemodynamic
status
=
Does not require
extra intravenous
Fluid
Continue to monitor
Closely.
HCT should start to
fall within next 24
hours as plasma
leakage stops.

18. Interpretation of a decrease in Haematocrit
Haematocrit Vitals Interpretation Action
A decrease in
Haematocrit
+
Unstable vital
signs
=
Major
haemorrhage
Need for urgent
Transfusion
A decrease in
Haematocrit
+
Stable
haemodynamic
status
=
Haemodilution
and/
or reabsorption of
extravasated fluids
IV fluids should be
reduced in step-wise
manner or discontinued
immediately to avoid
pulmonary oedema

20. Case Presentation

21. Case History
7 year old girl child(suspected Turner syndrome) presented to
our Emergency with h/o
1: Fever for 7 days
2:Respiratory distress 1 day

22. ❖ High grade, intermittent fever 3-4 times a day
❖ Associated with loose stool & vomiting, transient rash
❖ Pedal oedema 2 days
❖ No h/o convulsions, joint pain, bleeding manifestations

23. On Presentation
assessment: Airway: maintained
Circulation - 116/min,
Peripheral Pulse - palpable, periphery
cold,
BP -92/60 mmHg
Disability:Gcs:15/15,Cbg:88
Exposure :nothing significant
Breathing:RR-44/min,
Spo2:64%with o2@4lit/min,
Decreased air entry in Lt lower
axilla

24. Initial Reports
● CBC:hb- 9.4gm/dl,
● TC- 15420/cumm (N55,L42),
● PLT-20000/cumm
● CRP-36gm/dl,
● Urea-112 mg/dl, Creatinine -1.5 mg/dl
● MPDA – Negative
● T.bil-0.3mg/dl,SGPT-28,SGOT-62,ALP-92,ALB-2.3
● PT:>90sec,aPTT:>180sec,
D dimer:2.11(>0.5),fibrinogen:64gm/dl

25. Possibilities ??
● Scrub Typhus
● Pneumonia with MODS
● Severe Dengue
● Leptospira
● Vasculitis group
● ??Tuberculosis

26. 4 year old , 15 kg, day 4 of fever,
Non-specific rash, Pain abdomen
Outside dengue report pending,
Presents to your casualty with
tachypnea and anxiety
• Peripheral pulses not felt
• NIBP : 60/40
• Cold peripheries
Fever with Shock : Possibilities ?
Is it Septic Shock or Is it Dengue Shock
or MIS-C?

27. Best
practice
statement
Tropical fevers
Definition_2021
Essential
1. Fever > 380C for at least 48 hours duration with onset <14 days
2. No localizing signs (eg. Pneumonia/bronchiolitis, acute diarrheal illness, UTI, meningitis,
skin/soft tissue abscess etc.)
3. Clinical and/or laboratory evidence of one or more organ system involvement
(hematological, respiratory, circulatory, renal, hepatic)
Desirable
4. One or more systemic features such as edema, rash, hepatomegaly and/or
splenomegaly, encephalopathy
5. A seasonal trend in incidence 2014

28. Differentials
Tropical fevers
Etiology
Dengue, Scrub typhus
Enteric fever, Malaria
Leptospirosis
Acute encephalitis, acute viral hepatitis, Influenza pneumonia
bacterial sepsis, MIS-C
2014

29. Bench to bedside
Challenges
Clinical
presentation
• Most infections cluster during monsoon /post-monsoon
• Clinical presentation is overlapping;
more so, when they present with organ failures
• Atypical presentation is not uncommon
• A few cases of co-infections

30. Syndromic approach
Best
practice
statement
Undifferentiated
fever
Typhoid
Malaria
Dengue
Leptospirosis
Fever with
thrombo-
cytopenia
Dengue
Scrub typhus
Malaria
Leptospirosis
Meningococcemia
Fever with
ARDS
Scrub typhus
H1N1
Malaria
Dengue
Fever with
encephalopathy
Viral encephalitis
(Herpes, JE)
Scrub typhus
Cerebral malaria
Fever with
MODS
Scrub typhus
Bacterial sepsis
Dengue
Malaria
Viral hepatitis

31. Highlights
• Dengue in Neonates
• Dengue in Infants( may be upto 2 yrs)
• Assessment of Pediatric Patient
• Severe dengue – Bundle of intervention

32. DENGUE IN NEONATES
Is it common? Rare
How does it occur?
1. Vertical transmission
- In late third trimester of pregnancy
- Consider dengue incubation period
2. Vector transmission?
Observe the baby born to a mother with dengue infection for a
minimum period of two weeks after birth

33. Features of Dengue in neonates
Full spectrum of disease can occur
• Fever, skin rash
• Bleeding manifestation:
- Purpura - Nose bleeding
- Gi bleeding - Pulmonary haemorrhage
- Intracranial bleeding
• Hepatic & Multi-organ failure
• Maternal Dengue near term: May be an important
clue
• Anaemia, leucopenia, thrombocytopenia
• Close D/D –Neonatal sepsis, Congenital Infection
Strong clinical Suspicion required for Diagnosis

34. Dengue in infants
• Most susceptible: Babies between 4 to 9 months
• Severe dengue is common
•NS1Ag may be missed before 6months of age due to presence of maternal antibody
• Convulsions and hepatic dysfunction more commonly affect infants
• Dengue in infants can be severe (DHF/ DSS/ their complications) in primary infection .
• Complications of fluid overload were found more often in the infants
• Mortality in this age group is 4 times higher

35. Clinical features of DF in infants
• “Flu” like features:
 High fever
 Running nose
 Cough
 Conjunctival congestion
 Vomiting, nausea, anorexia
 Irritability / excessive cry
• Diarrhoea like Presentation
• Bleeding gum, nose, easy
bruisability – common.
• Positive tourniquet test -
infants - sensitivity of 33%,
specificity of 76%
Measly look + blanchable erythematous
flush /skin rash

36. DIFFERENCES IN DENGUE SEVERITY IN
INFANTS, CHILDREN, AND ADULTS

37. FEMS Immunol Med Microbiol, Volume 59, Issue 2, July 2010, Pages 119–130, https://doi.org/10.1111/j.1574-695X.2010.00670.x
The content of this slide may be subject to copyright: please see the slide notes for details.
Humoral immunopathogenesis of DHF/DSS in
primary DV infection among infants.

39. Laboratory Parameters
• Haematocrit of <30% is seen at a higher frequency among infants .
• Mean platelet count for infants (56 900 mm−3) is significantly less.
• Total white blood cell count and total lymphocyte count is significantly
higher in infants
Hematocrit in Children

40. Clinical features of DF in toddlers and
older children
• Abrupt onset high fever
• Headache
• Pain in orbits
• Extreme myalgia, arthralgia ( “Break bone fever”)
• Vomiting, pain abdomen
• Sore throat
• Skin rash
• Minor bleeding – nose/gum/easy bruisability

41. Natural History of DENV Infection
Infection
Asymptomatic
75%
Symptomatic
25%
Dengue Fever
95-99%
Severe
Dengue 1-5%
Survive
95 – 99.5%
Death -
0.5-5%

42. Case -1
• A 2 yr old male child. Wt 10 kg.
• OPD Fever clinic - H/o Fever 3 days up to 102-103◦ F – 3
spikes/day. Decreased apatite , nauseating, irritable. Taking water
and breast milk only.
• Urine passed 4 times in last 24hrs.
• Erythematous macular skin rash on D-2 – over trunk and limbs.
• No investigations done till now.
• How will you evaluate this patient ?
• What is your interpretation ?
• Will you admit this patient ?

43. Clinical evaluation of the patients in four steps
1. History taking
2. Clinical examination
3. Investigations
4. Diagnosis and assessment of disease phase and severity
Ask the 3 three golden questions:
1. Oral fluid intake-quantity and types of fluids
2. Urine output-quantify in terms of frequency and estimated volume and time
of most recent voiding
3. Types of activities performed during this illness (e.g., Playful? Interactive?
can the patient go to school, etc?)
Other issues:
• Other fluid losses
• Presence of warning signs.
• Epidemiological Pointer
• Medications
• Risk factors

45. Clinical examination
• Mental state
• Hydration status
• Peripheral perfusion
• Haemodynamic status
• Tachypnoea/acidotic breathing/pleural effusion
• Abdominal tenderness/hepatomegaly/ ascites
• Rash and bleeding manifestations
• Tourniquet test (repeat if previously negative or if there is no bleeding
manifestation)

46. Close Monitoring and possibly Hospitalization
A. Undifferentiated DF
B. F̽ever without
complication like
bleeding, hypotension
and organ
involvement
C. Without evidence
of capillary leakage
•Infants
•Old age
•Diabetes
•Hypertension
•Pregnancy
•CAD
•Hemoglobinopathies
•Immunocompromized
patient
•Patient on steroids,
anticoagulants or
immunosuppressants.
A. DF with warning signs and
symptoms
•Recurrent vomiting
•Abdominal pain/ tenderness
•General weakness/
letharginess/ restless
•Minor bleeding
•Mild pleural effusion/ ascites
•Hepatomegaly
•Increased Hct
B. DHF Gr I & II with minor
bleeds
A. DF with significant
A. Severe plasma leak
B. (i) DHF with significant
hemorrhage with or without shock
(ii) DHF III & IV̽ (DSS) with shock
with or without significant
hemorrhage
C. Severe organ involvement
(Expanded Dengue Syndrome)
D. Metabolites and electrolytes
abnormalities
Tertiary level care
Home Management

47. Criteria for admission of a patient
• DF with warning signs and symptoms
• Significant bleeding from any site
• Hypotension
• Persistent high grade fever
• Rapid fall of platelet count
• Sudden drop in temperature
• Evidence of organ involvement
• Social circumstances - Living alone; Living far from health
facility; Without reliable means of transport

48. Advice
What should be done ?
• Adequate bed rest
• Adequate fluid intake : Daily intake plus 5% Deficit (50ml/kg/day)
• Note: Plain water alone may cause electrolyte imbalance . Oral
rehydration solution (ORS) or barley/rice water/coconut water
• Paracetamol - every 6 hours (maximum 4 doses per day)
• Tepid sponging
What should be avoided?
• Do not take acetylsalicylic acid (aspirin), mefenamic acid, ibuprofen or
other NSAIDs or steroids.
• Do not take combination of paracetamol with above mentioned drugs.
• Antibiotics are not necessary
Educate parents regarding warning signs
Close monitoring
Prevent spread of dengue within house

49. Case - 2
• A 5 Yr old boy was having fever for 5 days with mayalgia
and pain abdomen, skin rash, Conjunctival congestion.
• Today he started having bleeding from gums.
• He was also having edema of hands, feet and Mild
respiratory distress.
• HR- 106/min, RR- 36/min, BP- 96/68 mmHg Urine passed
4 times in last 24 hrs.
• What are the Possibilities ?
• Dengue (with warning signs)
• Others..
• How will you evaluate this child?

50. Differential Diagnosis
Scrub Typhus
Chikungunya
Malaria
-Typhoid fever
Leptospirosis
Measles -
Kawasaki Disease
MIS-C

51. Investigations: For monitoring, assessment of complications
In all cases of children:
• CBC: TLC↓, ANC↓, Platelet↓, Haematocrit↑/↓
• LFT
• X-ray chest
In selective cases guided by clinical features:
• Blood urea, creatinine
• Blood bicarbonate/ lactate – ABG if facilities present
• Ferritin
• USG chest for pleural effusion
• USG of liver and gall bladder
• CSF study , Neuro-imaging
• ECG, Echocardiography

52. Role of Ultrasound
IVC Collapsibility Pleural Effusion

53. Management of DHF

54. The maintenance fluid should be calculated using the
Holliday-Segar formula as follows:
Maintenance Fluid Therapy
Body weight in kg Maintenance volume for 24 hours
<10kg 100ml/kg
10-20
1000+50 ml / kg body weight exceeding 10 kg
1000 + 50 x ( body weight in kg – 10)ml
More than 20 kg
1500+20 ml / kg body weight exceeding 20 kg
1500 + 20 x ( body weight in kg – 20)ml
•The fluid infusion should be just sufficient to maintain effective
circulation during the period of plasma leakage
•One should keep a watch for urine output, liver size and signs of
pulmonary oedema. Hypervolemia is a common complication.
•Normally intravenous fluids are not required beyond 36 to 48 hrs.
•Normally change should not be drastic. During any changes look for signs of
under and over hydration.
•ONE ML is equal to 15 DROPS. In case of micro drip system, one ml is
equal to 60 drops.

55. Case - 3
• 6 year old child presents to the ER with high fever for 5 days and irritability.
Mother states child was unwell and had taking less amount. Had rash on D3.
Started swelling of limbs and face for 1 day.
• She also noted rapid breathing and says that his head feels hot and limbs cold.
Child was admitted in primary health center . She was started on IV fluid(
0.45%NaCl) and referred.
• How will you assesses the Child?
• What is the diagnosis ? - Is it important ?

56. Pearls in Clinical Examination
Hold the patients hand to evaluate peripheral perfusion
 Save life in 30 seconds by recognizing shock.
The 5-in-1 Maneuver magic touch – CCTV-R
1
Colour
2
CRT
3
Temperature
4
Pulse volume
5
Pulse Rate

57. • Normal heart rates by age
• Newborn-3months:85-
205/min (140)
• 3months-2 years:100-
190/min (130)
• 2-10years:60-140/min (80)
• >10years: 60-100/min (75)
• Normal urine output
• Infants-young children: 1-2
ml/kg/hr
• Older children-adolescents:
0.5-1ml/kg/hr
• Least acceptable systolic
BP (mm of Hg)
• Birth -1 month - 60
• 1m- 1yr - 70
• 1 - 10 yrs
[Formula for approx.
calculation:
70+ (2 X age in years)]
• >10 yrs - 90
• MAP (50th percentile at
50th height percentile) =
1.5 x age in years + 55
Circulation

59. Case ..
• Drowsy
• HR – 154/Min
• Pulse - thready
• CRT – 4 SEC
• Temp – Cold extrimities
• BP- 76/60
Interpretation – Decompensated Shock

60. Management of Shock

61. Septic Shock
• Vaso dilatory state
• Low Diastolic pressure
• Wide Pulse Pressure
Dengue Shock
• Hypovolemic State
• High Diastolic pressure due
to high SVR
• Narrow Pulse Pressure
Septic Shock vs Dengue Shock
May Need Multiple fluid
boluses with early inotropes
Fluid Boluses are controlled in
Compensatory Shock
Will give early antibiotics and deescalate if cultures negative

62. NS
Good 1st choice
Excess cl in Nacl can cause
hyperchloremic Met Acidosis
RL
Has lower Na 131, Cl 114
Not good as 1st choice
Not good in hyponatremia
Not good in liver dysfunction
Which fluids as bolus in Dengue Shock
Colloids
Gelatin : Allergic reaction issues
Dextran : Coagulation issues
Albumin

63. Causes of Fluid Over Load
• Too much fluids in febrile phase
• Excessive and/or too rapid IV fluids
• Inappropriate IV fluids for “severe bleeding”
• Inappropriate - FFP, platelet & cryo
• Continuation of IV fluids after Critical phase
• Co-morbid conditions
– congenital heart disease
– chronic lung and renal diseases
– Obesity – Fluid not calculated for IBW

64. Rational Use of Fluid = Management of Dengue

65. Fluid Resuscitation
This appears good
We have to search for it
Have a specific pathway
Disaster because of fluid overload
No pathway
Destroys everything
Nice Waterfall Bad Flood

66. March
2018
Refractory Shock – Bolous > 30ml/kg
Malignant Edema
Exsanguinating Hemorrhage

67. Intervention #1: Restrictive resuscitation
and “albumin(colloid) rescue”

68. Treatment of shock potentiates the second problem:
Fluid overload
• Slippery slope between correction of
hypovolemia and fluid overload
• Patients quickly get bloated when they’re still
in hypovolemic shock

69. The Challenge: Correct hypovolemic
shock while minimizing fluid overload
• Aim for minimal circulating volume, low-normal
BP and perfusion: Urine output of 0.8-1ml/kg /hr
• If fluid infusion rates remain high, consider brief
period of vasoactive agents

70. • Can help in most: Improved circulation with lower fluid
infusion rates
• Can hurt in some: Undesirably worsens leak, increase
compartment issues
• Careful monitoring is key
• 1 g/kg as an infusion over 6 h in addition to crystalloid
Consider albumin with very careful monitoring!

71. Albumen: desirable end-points
• Improved perfusion and urine output
• Ability to dial down fluid rates
• Widening of pulse pressures
• Decreased hematocrit
• No worsening of respiratory status

72. Albumin use can decrease fluid overload and
positive fluid balance (PFB) in severe dengue
Grand PFB* 17.8 Litres vs 10.02 Litres, p= 0.009*
IJCCM March 2018
ST + group
Targeted Intervention
(albumin)
Standard therapy (ST)

73. • Intervention #2: Large volume ascites and intra-
abdominal hypertension

74. Consider Compartment syndromes
Severe Dengue shock: Initially responded to 10ml/kg/hr for 6hrs Then
urine output became a trickle, pulses hard to feel…HCT stable
Options:
Dial up fluid rates
Add Albumin
OR…

75. Compartment syndromes in severe dengue with
fluid overload
• Plasma leak in the abdomen can lead to tense ascitic fluid
collections and raised intra-abdominal pressures (IAP) resulting in
abd compartment syndrome (ACS) with organ failure
• ACS can develop rapidly during large-volume fluid therapy and
further exacerbate shock and oliguria prompting even more fluid
infusion and further IAP increase.
• While extensively reported in trauma and burns, dengue-associated
ACS has been infrequently reported and is quite likely to be under-
recognized.
• Proactive monitoring of IAP in SD receiving > 30 ml/kg in the first
2–3 h can prompt earlier recognition and control of IAP.

76. Management In ICU:
Fluid overload and compartment syndromes
• Measure abdominal compartment pressures early and regularly
• Ultrasound guided non-traumatic catheters placement should be
considered when IAP > 10 in presence of severe hypoxemia,
oliguria, acidosis, shock

77. Controlled hourly drainage
essential
Co-administration of albumin
may be considered
Pigtail catheter for ACS in
severe dengue

78. • Intervention #3: Prevention and management of major
hemorrhage

79. Prevent/minimize the “Lethal Triad”
As relevant in hemorrhagic dengue as in trauma

80. BE SMART! about invasive lines and tubes
• Avoid nasal tubes (oro-gastric tubes preferable)
• IV access: 2 good peripheral lines, including ext jugular
may suffice in most: Central lines must be earned!
• If CVC essential, femoral sites better than neck,
experienced person to place under ultrasound guidance.
• Place radial arterial lines electively after fluid
resuscitation (if essential).
BIG risk of bleeding and hemorrhage!

81. Invasive lines: multi-edged swords
Why are arterial lines important?
• Non-invasive blood pressures
(NIBP) can be completely
misleading in severe pulseless
shock which persists despite initial
fluid and inotropes
• Placement of A-lines much more
reliable, must be placed by most
expert person available

82. • Intervention #4: Peri-intubation decompensation and the
high-risk intubation management protocol

83. Positive pressure ventilation has major negative
consequences in dengue shock
Precipitous hypotension and cardiac arrest
• Worsens already poor venous return
• Worsens RV afterload
• Sedation+ muscle relaxants add to negative impact
• Takes away adrenergic tone (stress response)
As far as possible, non-invasive vent should be attempted
Avoid intubation unless in extremis.
Some children tolerate NIV surprisingly well

84. During RSI/modified RSI
Beware of the HOP triad!!
Anticipate
Hypotension-
Pressors + 1/10
usual dose of
sedatives
Oxygenation
failure: NIV
pH
decompensation:
Avoid apnoea
84

85. Intervention #5: Fluid removal and renal
replacement therapy

86. Therapies for fluid removal
• Diuretic infusions
• Peritoneal and pleural drains/ dialysis
• CRRT
• SLED

87. Key Message
• Practise Syndromic approach of management of AFI
• Neonates and Infants are high risk group
• Meticulous monitoring and Judicious fluid management is the
key
• Understand the dynamicity of disease
• In critically ill children with dengue adhere to bundle of care.

88. Operational issues…….1
• All dengue cases and suspected dengue cases: Arrange PCV (also
called Haematocrit) and Platelet Count reports at least twice a day –
one morning sample and another sample in evening/ late afternoon.
• C.B.C. test for the fever cases in O.P.D. – as suggested in the Fever
Approach Algorithm. Utilize cell counter if available.
• Dengue Test Report and PCV & Platelet Report must reach the I.P.D.
early after test is done. Improvise as necessary.
- Fast tracking of dengue patient samples (urgent).
• Top Sheet to be maintained in I.P.D. for every dengue case and
suspected dengue case.
• Urine output to be recorded (not eye estimation) in each shift and
finally totaled for 24 hours.
- Use improvised means to measure urine.

89. Operational issues…….2
• MO, Staff Nurse and Sister in Charge to sign the Top Sheets.
• Utilize Top Sheet to
- monitor the cases
- identify cases at risk
- to generate alert (call the Doctor).
• Hospitals not having dengue testing facility will send daily samples
(serum) to identified labs by messenger.
• An Excel line list of samples to be sent to the lab in e-mail.
• Lab will perform tests and report back within 24 hrs to the sample
referring hospital.
- Results to be entered in line list and sent back in e-mail.
• Lab to upload details of positive cases in the State portal.
• Fund support for sample carrier and for lab data entry.
- NVBDCP or IDSP fund to be utilized.

90. Operational issues…….3
• Please do not refuse fever cases in apprehension of Covid-19.
• Use the guidelines to differentiate among Covid-19, Dengue &
other AFI-s as far as possible.
• If there is possibility of covid-19, keep in Isolation Ward until
test is done. Do not refer outright as far as practicable.
• Get the tests done as indicated.
Be watchful for co-infection of dengue & covid-19.
Report such cases to nCoVrep.wb@gmail.com with subject line
“Dengue & Covid-19 coinfection”.

91. Thank You