The document discusses dengue virus, its transmission and clinical manifestations. Some key points: - Dengue virus is transmitted by Aedes aegypti mosquitoes and has 4 serotypes. It causes dengue fever and the more severe dengue hemorrhagic fever/dengue shock syndrome. - The disease progresses through febrile, critical, and recovery phases. During the critical phase, plasma leakage and bleeding can cause shock. - Symptoms range from mild fever to severe bleeding, organ impairment and shock. Thrombocytopenia is common. - Diagnosis is based on clinical criteria and confirmed with serology, antigen or PCR testing. There is no vaccine and treatment focuses

1. Dengue
in children
- C.S.N.Vittal

2. Virus
Is an arbovirus composed of single-stranded RNA
Has 4 serotypes (DEN-1, 2, 3, 4)

3. Vector
• Is an arbovirus composed of single-stranded RNA
• Has 5 serotypes (DEN-1, 2, 3, 4 and 5)
• Transmitted by mosquitoes of the Stegomyia family,
• Aedes aegypti, a daytime biting mosquito,

4. Aedes aegypti
• Dengue transmitted by infected female
mosquito
• Primarily a daytime feeder
• Lives around human habitation
• Lays eggs and produces larvae preferentially in
artificial containers

5. Replication and Transmission
of Dengue Virus
1. Virus transmitted to human
in mosquito saliva
2. Virus replicates
target organs
3. Virus infects white
blood cells and
lymphatic tissues
4. Virus released and
circulates in blood
3
4
1
2
 Infectivity Period
(about 7 days)
 Extrinsic Incubation
Period (8–12 days)
 Intrinsic Incubation
Period (3–14 days)

6. Replication and Transmission
of Dengue Virus (Part 2)
5. Second mosquito
ingests virus with blood
6. Virus replicates
in mosquito midgut
and other organs,
infects salivary
glands
7. Virus replicates
in salivary glands
6
7
5

7. Modes of Transmission
 Mosquito bite
 Perinatal transmission
 Blood transfusion
 Organ transplantation
 Needle stick injury or
laboratory accident

8. Vertical transmission &
Neonatal dengue infection
 Incidence 1.6 - 64%
 peripartum maternal infection may increase the likelihood of
symptomatic disease in the newborn
 Antibodies to the dengue virus in the dengue infected mother can cross
the placenta and can cause severe dengue in newborn infants
 Clinical:
• Mild illness such as fever with petechial rash, thrombocytopenia and
hepatomegaly, to severe illness with pleural effusion, gastric bleeding, circulatory
failure, massive intracerebral haemorrhage

9. Case Definition
Dengue Fever:
 An acute febrile illness of 2-7 days duration with
two or more of the following manifestations:
Headache, retro-orbital pain, myalgia, arthralgia,
rash, haemorrhagic manifestations.

10. Case Definition
Probable DF/DHF:
A case compatible with clinical description of dengue Fever during
outbreak:
OR
Non-ELISA based NS1 antigen/ IgM positive.
(A positive test by RDT will be considered as probable due to poor
sensitivity and Specificity of currently available RDTs.)

11. Case Definition
Confirmed dengue Fever:
 A case compatible with the clinical description of dengue fever with at
least one of the following
• Isolation of the dengue virus (Virus culture +VE) from serum, plasma,
leucocytes.
• Demonstration of IgM antibody titre by ELISA positive in single serum
sample.
• Demonstration of dengue virus antigen in serum sample by NS1-ELISA.
• IgG seroconversion in paired sera after 2 weeks with Four fold increase of
IgG titre.
• Detection of viral nucleic acid by polymerase chain reaction (PCR).

12. Grading of DF/DHF (old)
DF: Fever of 2-7 days with two or more of following- Headache, Retro orbital pain,
Myalgia,
Arthralgia with or without leukopenia, thrombocytopenia and no evidence of plasma
leakage.
DHF II Above plus some evidence of spontaneous bleeding in skin or other organs (black
tarry stool, epistaxis, gum bleeds) and abdominal pain.
Thrombocytopenia with platelet count less than 100000/ cu.mm and Hct rise more
than 20% over baseline.
DHF III
(DSS):
Above plus circulatory failure (weak rapid pulse, narrow pulse pressure < 20 mm
Hg, Hypotension, cold clammy skin, restlessness).
Thrombocytopenia with platelet count less than 100000/ cu.mm and Hct rise more
than 20% over baseline.
DHF IV
(DSS):
Profound shock with undetectable blood pressure or pulse. Thrombocytopenia with
platelet count less than 100000/ cu.mm and Hct rise more than 20% over baseline

13. Dengue Epidemiology - WHO
• Dengue is now endemic in over 100 countries.
• As many as 3.6 billion people
• 40% of the world's population, reside in dengue-endemic areas.
• Each year, 400 million people are infected with dengue virus,
• 100 million become ill with dengue
• 21,000 deaths attributed to dengue are detected.
• Early identification of cases and timely initiation of correct clinical
management can reduce the case fatality rate from 10% to 1%.

14. Pathogenesis
• Circulation of infection‐enhancing antibodies at the time of
infection e strongest risk factor for development of severe disease.
• Rapid activation of the complement system.
• Capillary damage ‐ internal redistribution of fluid, resulting in
• hemoconcentration,
• hypovolemia,
• increased cardiac work,
• tissue hypoxia,
• metabolic acidosis, and
• hyponatremia.

15. Pathogenesis of Severe Dengue
 Antibody-dependent enhancement (ADE)
• Occurs when nonneutralising antiviral antibodies enhance viral entry
into host cells. Once inside the white blood cell, the virus replicates
undetected, eventually generating very high virus titers leading to
more severe disease .
• In Dengue - nonneutralizing heterotypic IgG anti-DENV antibodies
produced during a person's first DENV infection (or sub-neutralizing
level of antibodies in the case of infants who acquired IgG passively
in utero) can form antibody-DENV complexes in the second
infection that can allow uptake of DENV by macrophages.
• DENV then replicates in these macrophages thereby increasing viral
production.

16. Clinical Manifestations of Dengue and
Dengue Hemorrhagic Fever

17. Dengue Viral Infection
Asymptomatic Symptomatic
Dengue Fever
Syndrome
Without
Hemorrhage
DHF
No Shock
With
Hemorrhage DSS
Dengue Hemorrhagic
Fever
Undifferentiated
Viral Syndrome
DF DHF

18. Dengue Clinical Syndromes
1
2
3
4

19. Dengue viral infection
Symptomatic Asymptomatic
Mild Moderate Severe
A. Undifferentiated
DF
B. Fever without
complication like
bleeding,
hypotension and
organ
involvement
C. Without evidence
of capillary
leakage
Home Management
DF with high risk and
comorbid conditions
DF with warning signs and
symptoms
• Infants
• Old age
• Diabetes
• Hypertension
• Pregnancy
• CAD
• Hemoglobinopathies
• Immunocompromized
patient
• Patient on steroids,
anticoagulants or
immunosuppressants
A. DF warning signs and
symptoms
• Recurrent vomition
• Abdominal pain/tenderness
• Generalized weakness /
letharginess / restless
• Mild pleural effusion /
ascites
• Hepatomegaly
• Increased Hct > 20%
B. DHF I & II with minor
bleeds
A. DF/DHF with significant
hemorrhage
B. DHF with shock (DHF III &
IV – DSS)
C. Severe organ involvement
(Expanded dengue
syndrome)
D. Severe metabolic disorder
Choose Monitoring and possibly Hospitalization Tertiary level care
2009 Dengue
Case Definitions

20. Suggested dengue case classification and
levels of severity

21. Expanded Dengue Syndrome
System Unusual or atypical manifestations
CNS involvement Encephalopathy, encephalitis, febrile seizures, I/C bleed
G.I. involvement Acute hepatitis / fulminant hepatic failure, cholecystitis,
cholangitis, acute pancreatitis
Renal involvement Acute renal failure, HUS, ATN
Cardiac involvement Cardiac arrhythmia, cardiomyopathy, myocarditis, pericardial
effusion
Respiratory involvement Pulmonary edema, ARDS, pulmonary hemorrhage, pleural
effusion
Eye Conjunctival bleed, macular hemorrhage, visual impairment,
optic neuritis
Hematology DIC, Secondary HLH

22. CRITERIA FOR DENGUE ± WARNING SIGNS
• Nausea, vomiting
• Rash
• Aches and pains
• Tourniquet test positive
• Leukopenia
Any warning sign
Warning signs*

23. CRITERIA FOR SEVERE DENGUE
• Shock
Severe plasma leakage - leading to:
• as evaluated by clinician
Severe bleeding
• Liver: AST or ALT >=1000
• CNS: Impaired consciousness
• Heart and other organs
Severe organ involvement

24. Risk Factors for Severe Dengue

25. The course of dengue illness
1. Febrile Phase
2. Critical Phase
3. Recovery Phase

26. The course of dengue illness
Febrile Phase
- Dehydration
- High fever
- Neurological
disturbances & febrile
seizures in young children
Critical Phase
- Shock from plasma
leakage;
- Severe haemorrhage;
- Organ impairment
Recovery Phase
- Hypervolaemia
- Worsening effusions
- Acute pulmonary
edema
Probable adverse events

27. Febrile Phase of Dengue
 Typical duration
of 0–7 days
 Biphasic fever
possible
 Monitoring
for defervescence
and warning signs
crucial to identify
progression into
the critical phase.
 Defervescence
occurs between
day 3 and day 8 of
the illness.

28. Febrile Phase of Dengue
 Abrupt onset of high temperature + any of the
following:
• Severe headache
• Retro orbital pain
• Myalgia
• Arthralgia
• Transient macular or maculopapular rash
• Minor hemorrhagic manifestations, for
example petechiae, ecchymosis,
purpura, epistaxis, bleeding gums, hematuria,
or a positive tourniquet test
• Facial flushing or erythema
• Injected oropharynx
• Anorexia
• Some persons with dengue may only have fever
Laboratory findings
• Leukopenia
• Mild to moderate thrombocytopenia
• h aspartate aminotransferase (AST)
• h alanine aminotransferase (ALT)
• Hyponatremia

29. Febrile Phase – Medical Complications
 Dehydration
 Hyponatremia
 Febrile seizures in young children
 Neurologic disease manifestations,
including encephalitis and aseptic meningitis

30. Critical Phase – Clinical Manifestations
 Rapid decline in platelet count with a rise in hematocrit (HCT)
 Leukopenia up to 24 hours before platelet drop is recognized
 Presence of warning signs for severe disease
Warning signs
• Clinical fluid accumulation, such
as ascites, pleural effusion
• Liver enlargement > 2 cm
• Severe abdominal painPersistent
vomiting (at least 3 vomiting
episodes within 24 hours)
• Mucosal bleed
• Lethargy or restlessness

31. Bleeding Manifestations in Patients with Dengue
 Mild hemorrhagic manifestations (in 1/3 cases)
• petechiae,
• purpura,
• epistaxis, and
• gingival bleeding Might be due to increased capillary fragility as a
result of thrombocytopenia or platelet dysfunction.
 Major mucosal bleeding
• gastrointestinal or vaginal - in dengue patients can be occult and is often
associated with prolonged shock and metabolic acidosis.

32. Causes of Bleeding in DF/DHF
• Abnormal coagulogram
• Thrombocytopenia
• Platelet dysfunction •
• Prothombin complex deficiency
secondary to Liver involvement
• Endothelial injury
• DIC and Prolong aPTT
• Decrease fibrinogen level
• Increase level of fibrinogen
degradation product (FDP)
• Increase level of D-Dimer
• Consumptive coagulopathy
(activation of mononuclear
phagocytes)
• Sequestration of platelets

33. Coagulopathy
 Due to loss of essential coagulation proteins due to plasma
leakage.
 Interactions between dengue virus nonstructural protein 1 (NS1)
and the endothelial glycocalyx layer may cause a change in
filtration characteristics, resulting in leakage of plasma proteins
and release of heparan sulfate into the circulation.
 Heparan sulfate, which can function as an anticoagulant, might
contribute to the coagulopathy

34. Thrombocytopenia
 Thrombocytopenia is defined by the World Health Organization
(WHO) as a platelet count of less than or equal to 100,000/μL.
 Causes
• Early pancytopenic suppression of the bone marrow either by direct
infection of progenitor cells or by macrophages that activate T-cells that
release cytokines that suppress hematopoeisis.
• Peripheral immune mediated platelet destruction via dengue virus binding
to platelet in presence of NS1 antibody, so that the half-life of platelets
are decreased in dengue patients.
• DIC
• Peripheral sequestration of platelets

35. Dengue virus infection
Production of
antibodies/presence of
enhancing antibodies
Antigen antibody reaction
with complement
activation
Deposition on vessels,
various tissues and
platelets
Clinical manifestations of
coagulopathy (bleeding)
Activation of T- cells
Production of various
chemical mediators
Increased vascular
permeability
Clinical manifestations of
vasculopathy (capillary
leakage)
• Hypotension/shock
• Pleural effusion
• Ascites
• Bleeding
• Organ involvement
Patho-physiology
of DF/DHF

36. Clinical Features of of DF/ DHF
• Undifferentiated dengue Fever (UDF)
• Severe dengue Fever
• Dengue Fever with warning signs and symptoms:
• Expanded dengue Syndrome (EDS)

37. Critical Phase – Lab Findings and Medical Complications
Laboratory findings
• Increase in HCT or hemoconcentration
• Moderate to severe thrombocytopenia
• Leukopenia
• Transient increase in activated partial-
throboplastin time (aPTT) with decrease
in fibrinogen
Medical complications during the critical
phase include the following:
• Hypovolemic shock from plasma leakage
• End organ impairment due to prolonged shock
• Severe hemorrhage
• Encephalopathy

38. Recovery Phase of Dengue
 Patient improvement
 Gradual reabsorption of extravasated fluid (such as from plasma leakage)
over 48–72 hours
 Increased diuresis (patient might wet bed)
 Hemodynamic status stabilizes
 Patient can temporarily become bradycardic (but hemodynamically stable)

39. Recovery Phase - Clinical Manifestations
 A second rash that might be macular or
erythematous with small circular
islands of normal, unaffected skin.
This convalescent rash can be very
pruritic and desquamate.
 Severe fatigue
Laboratory findings
• HCT stabilizes or is slightly lower due to a dilutional
effect of reabsorbed plasma (hemodilution)
• White blood count (WBC) begins rising soon after
defervescence
• Platelet count increases following WBC recovery

40. Recovery Phase - Medical Complications
 Hypervolemia and acute pulmonary edema can occur if intravenous fluid
(IVF) therapy has been excessive or extended too long.
 Organ impairment can result in the event of prolonged
or refractory shock. This might include ischemic hepatitis and hepatic
encephalopathy.
 Nosocomial or hospital-acquired infections, can occur, especially in
infants and elderly patients.

41. Causes of Death
 Unrecognized dengue without appropriate medical
management
 Unrecognized or prolonged shock
 Unrecognized occult hemorrhage
 Fluid overload
 Nosocomial infections
 Liver failure

42. Diagnosis

43. Tourniquet Test
1. Take the patient's blood pressure and
record it, for example, 100/70.
2. Inflate the cuff to a point midway between
SBP and DBP and maintain for 5 minutes.
3. Reduce and wait 2 minutes.
4. Count petechiae below antecubital fossa.
A positive test is 10 or more petechiae per
1 square inch.
• More likely to be positive near time of defervescence
• Less likely to be positive in patients with shock
 Pan American Health Organization: Dengue and Dengue Hemorrhagic Fever: Guidelines for
Prevention and Control. PAHO: Washington, D.C., 1994: 12.

44. Lab tests
 Antigen NS1 test
 ELISA- IgG, IgM antibodies
 Blood cultures- isolate the virus
 Full blood count
 Hct
 Liver function test
 PCR- Nucleic acid detection

46. Dengue diagnostic and sample characteristics
Clinical sample Diagnostic method Methodology Time to results
Virus
detection
and its
components
Acute serum (1-
5 days of fever)
and necropsy
tissue
Viral isolation Mosquito or mosquito cell
culture inoculation
One week or more
Nucleic acid
detection
RT-PCR and real time RT-
PCR
1 to 2 days
Antigen detection NS1 Ag rapid tests Minutes
NS1 Ag ELISA 1 day
Immuno-histochemistry 2-5 days
Serological
response
Paired sera
(acute serum 1-
5 days and 2nd
serum 15-21
days after)
IgM or IgG
seroconversion
ELISA
HIA
1-2 days
Neutralization test Min 7 days
Serum after day
5 of fever
IgM detection
(recent infection)
ELISA 1 or 2 days
Rapid tests Minutes
IgG detection IgG ELISA
HIA
1 or 2 days

47. Interpretation of dengue diagnostic tests
[adapted from Dengue and Control (DENCO) study]
Highly suggestive Confirmed
One of the following:
1. IgM +ve in a single serum
sample
2. IgG +ve in a single serum
sample with a HI titre of
1280 or greater
One of the following:
1. PCR +
2. Virus culture +
3. IgM seroconversion in
paired sera
4. Four fold IgG titer increase
in paired sera

48. Differential Diagnosis of Dengue
• Influenza
• Measles
• Rubella
• Malaria
• Typhoid fever
• Leptospirosis
• Meningococcemia
• Rickettsial infections
• Bacterial sepsis
• Other viral hemorrhagic fevers

49. A stepwise approach to the
management of dengue

50. Step I 1. History, including information on symptoms, past medical & family
history
2. Physical examination, including full physical and mental
assessment
3. Investigation, including routine laboratory and dengue-specific
laboratory
Step II Diagnosis, assessment of disease phase and severity
Step III 1. Disease notification
2. Management decisions.
Depending on the clinical manifestations and other circumstances,
patients may:
– be sent home (Group A);
– be referred for in-hospital management (Group B);
– require emergency treatment and urgent referral (Group C).
A stepwise approach to the management of dengue

51. Patient Assessment Steps
Step 1
• History Taking
Step 2
• Clinical Examination
Step 3
• Investigation
Step 4
• Diagnosis, phase of disease and severity

52. Patient Assessment Steps
Step 1 : History Taking
• Date of onset of fever
• Symptoms and severity
• Three Golden questions
• How much fluid intake: Quantity and quality
• How much urine output: Frequency, volume and time of most
recent voiding?
• What activates could the patient do during the illness

53. Patient Assessment Steps
Step 1 : History Taking
• Other fluid losses: diarrhoea, vomiting
• Present of Warning Signs
• Family or neighbour with dengue OR travel to dengue-endemic
area
• Risk Factors
• Infancy, pregnancy, obesity, diabetes mellitus, hypertension, etc.

54. Patient Assessment Steps
Step 2: Clinical Assessment
General Assessment:
• Mental state
• Hydration state
• Hemodynamic state
Clinical e/o. warning signs
• Bleeding manifestations: mucosal
bleeding
• Abdominal tenderness
• Liver enlargement
• Fluid accumulation,: pl effusion,
ascites
Other imp signs:
• Rash
• Tachypnoea/acidotic
breathing: indicates shock
• Torniquet test: repeat if –
ve

55. Hemodynamic Assessment
Clinical Parameters

56. Parameters
Conscious level
Capillary refill
time
Extremities
(color, temp)
Peripheral
Pulse volume
Heart rate
(HR)
Pulse pressure
(PP)
Blood pressure
(BP)
Respiratory rate
(RR)
Urine output
Organ perfusion (brain)
Cardiac output
Organ perfusion (kidney)
Peripheral perfusion
Respiratory compensation for tissue hypoxia

57. Parameters Stable condition Compensated shock
Conscious level Clear and lucid Clear and lucid
Capillary refill
time
Brisk(less than 2 sec) Prolonged (>2 sec)
Extremities
(color, temp)
Warm and pink Cold peripheries
Peripheral
Pulse volume
Good volume
Weak & thready
Heart rate
(HR)
Normal HR for age Tachycardia for age
Pulse pressure
(PP)
Normal PP for age Normal systolic pressure
Rising diastolic pressure
Blood pressure
(BP)
Normal BP for age Narrowing of PP
Postural hypotension
Respiratory rate
(RR)
Normal RR for age
‘Quiet tachypnea’
Urine output
Normal Reducing trend
Normal brain function
Reduced kidney perfusion
Tissue acidosis
Reduced
Peripheral
perfusion
Reduced cardiac
output

61. Parameters Stable condition Compensated shock Hypotensive shock
Conscious level Clear and lucid Clear and lucid Restless, combative
Capillary refill
time
Brisk(less than 2 sec) Prolonged (>2 sec) Very prolonged, mottled skin
Extremities
(color, temp)
Warm and pink Cold peripheries Cold and clammy
Peripheral
Pulse volume
Good volume
Weak & thready Feeble or absent
Heart rate
(HR)
Normal HR for age Tachycardia for age
Severe tachycardia or
bradycardia in late shock
Pulse pressure
(PP) Normal PP for age Normal systolic pressure
Rising diastolic pressure
Hypotension
Unrecordable BP
Blood pressure
(BP)
Normal BP for age Narrowing of PP
Postural hypotension
Narrowed pulse pressure
(< 20 mm Hg)
Respiratory rate
(RR)
Normal RR for age
‘Quiet tachypnea’ Kussamal breathing
Urine output
Normal Reducing trend
Oliguria or
anuria
Reduced brain function
Reduced
Peripheral
perfusion
No kidney perfusion
Severe tissue acidosis
Reduced
cardiac
output

62. Definition of hypotension
Adults:
• Systolic blood pressure of < 90 mm Hg or
• Meal arterial pressure < 70 mm Hg or
• Systolic blood pressure decrease of > 40 mm Hg or
• < 2 SD below normal for age (Hypertensive patients)
Children upto 10 year of age:
• The 5th centile for systolic pressure
• 70 + (age in years X 2) mm HG

63. Pearls in clnical examination of dentue patients
The “5-in-1 maneuver” magic touch – CCTV-R
Hold patient’s hand to evaluate peripheral perfusion
Save life in 30 seconds by recognizing shock
1
Color
2
Capillary
refill
3
Tempera
ture
4
Pulse
Volume
5
Pulse
Rate

64. Algorithm for management of Dengue
Warning Signs

65. Group A
Outpatient Management
 During the febrile phase (may last 2–7 days) and subsequent
critical phase (1–2 days), your clinic should
• Follow CBCs
• Watch for dehydration Watch for warning signs, including
decreasing platelet count and increasing hematocrit
• Watch for defervescence (beginning of critical phase)

66. Group A
Advise patient or their family to do the following
 Control the fever
 Prevent dehydration
 Prevent spread of dengue within your house
 Watch for warning signs as temperature declines 3 to 8 days after
symptoms began.
• Severe abdominal pain or persistent vomiting
• Red spots/patches on skin
• Bleeding from nose or gums
• Vomiting blood, Black, tarry stools
• Drowsiness or irritability
• Pale, cold, or clammy skin
• Difficulty breathing

67. Group B - Pts with Waning Signs
Admit
Obtain baseline
CBC
Monitor fluid I/O
Encourge oral fluids
Monitor vital sings q4h
Adequate?
• Check Hct
• IV fluids (NS.RL)
• 5-7 ml/kg/hr for 1-2 hrs
• 3-5 ml/kg/hr for 2-4 hrs
• Keep monitoring
• Check Hct
• Observe for shock,
warning signs of severe
dengue
• Group C management
If NO improvement or
Compensated or Hyootensive shock
If improvement - YES
• Reduce isotonic crystalloids
in stepwise manner
1. 5–10 ml/kg/hour for 1–2 hours
2. 3–5 ml/kg/hour for 2–4 hours
3. 2–3 ml/kg/hour for 2–4 hours

68. Group B - Pts with Waning Signs
Some patients in Group B have warning signs and are
hemoconcentrated but are not in shock. If they are in shock, they are in
group C. Before giving them IVFs, obtain a reference or baseline HCT.
Follow the algorithm below.
• Give isotonic IVFs at 5–7 mL/kg/hr.
• Reduce after 1–2 hours to 3–5 mL/kg/hr for 2–4 hours if clinical status allows and reassess the
patient’s condition (vital signs, capillary refill, urine output).
• Repeat the HCT.
• If the HCT remains the same or rises minimally, reduce rate to 2–3 mL/kg/hr for 2–4 hours, then
reassess HCT.
• If vital signs worsen and HCT rapidly rises, increase rate to 5–10 mL/kg/hr for 1–2 hours.
• Reassess the clinical status; repeat HCT and revise IVF rates accordingly.

69. Initiate Intravenous therapy @ 10ml/kg over 1 hour
Reassess Clinical Status
Reduce IV fluids stepwise
6ml/kg/hr for 2-4 hours
3 ml/kg/hr for 2-4 hours
3-1.5 ml/kg/hr for 2-4 hrs
Further improvement
If worsening 10-20
ml/kg for 1 hour
If improvement after 2nd bolus, reduce
to 7-10 ml/kg for 1-2 hours
If no improvement & if HCT decreases > blood
transfusion
Group C - Pts with Compensated Shock
HDHF Grades I & II
Hemodynamic status improved
Discontinue IV after 24-48 hr
Hemorrhagic tendencies, thrombocytopenia, Hct rise > 20%

70. Check Hematocrite
Improvement
Crystalloid/Colloid
10 ml/kg for 1 hr, then reduce to
o 5-7 ml/kg 1-2 hrs
o 3-5 ml/kg/hr for 2-4 hrs
o 2-3 ml/kg/hr for 2-4 hrs
If Hct increases or is high
adm 3rd bolus fluid (colloid)
10-20 ml/kg over 2 hrs
HCT decreasing
Consider significant
occult /overt bleed
Initiate blood transfusion
HCT increasing or high
Adm 2nd bolus fluid
(colloid) 10-20 ml/kg
over ½ to 1 hr
No improvement
Yes No
Stop
After
48 hrs
Group C - Pts with Hypotensive Shock
Fluid resuscitation with 20 ml/kg over 15 minutes isotonic crystalloid or colloid

71. Targets of fluid resuscitation
 Improving central and peripheral circulation
• Decreasing tachycardia
• Improving BP and pulse volume
• Warm and pink extremities with a capillary refill
• time < 3 seconds
 Improving end-organ perfusion
• Achieving a stable conscious level (more alert or less restless)
• Urine output ≥ 0.5 ml/kg/hour
• Decreasing metabolic acidosis.

72. Points to remember in fluid resuscitation
1) No hypotonic fluids.
2) Cautious with glucose containing fluids like DNS.
3) Targeting a minimally acceptable hourly urine output (0.5–1 mL/kg/hr) is an
effective and inexpensive monitoring modality.
4) A urine output of more than 1.5–2 mL/kg/hr should prompt reduction in fluid
infusion rates, provided hyperglycemia has been ruled out.
5) In case of persistent shock, after fluid resuscitation, if the hematocrit
continues to decline, internal bleeding should be suspected.
6) Blood transfusion is life-saving and should be given as soon as severe
bleeding is suspected or recognized.
7) Do not wait for the haematocrit to drop too low before deciding on blood
transfusion.
8) Prefer fresh blood.
9) Use Ideal Body Weight to calculate IV fluid rates in Obese children.

73. WHEN TO STOP INTRAVENOUS FLUIDS
 Features of intra vascular compartment overload •
• Hypertension with good volume pulse.
• Breathing difficulties, pulmonary edema.
 48 hours after defervescence.

74. Management of Dengue Patient - Summary
GROUP-A GROUP-B GROUP-C
Give anticipatory guidance prior
to sending patient home (Refer
to patient handout)
Admit patient to hospital In addition to Group B
management, do the following:
Follow-up daily Monitor hemodynamic status
frequently
Use colloids for refractory shock
Do serial CBCs Use HCT to determine
interventions
Monitor for occult bleeding
Identify warning signs early Use isotonic IVFs judiciously
Correct metabolic acidosis and
electrolyte abnormalities as
needed
*Do not use prophylactic platelet transfusions.

75. Discharge criteria
(all of the following conditions must be present)
Clinical • No fever for 48 hours.
• Improvement in clinical status
• general well-being,
• appetite,
• haemodynamic status,
• urine output,
• no respiratory distress
Laboratory • Increasing trend of platelet count.
• Stable haematocrite without intravenous fluids.

76. Dengue Vaccine?
 No licensed vaccine at present
 Effective vaccine must be tetravalent
 Field testing of an attenuated tetravalent vaccine currently
underway
 Effective, safe and affordable vaccine will not be available
in the immediate future

77. • Avoid mosquito bites when traveling in tropical areas:
• Use mosquito repellents on skin and clothing.
• Wear long-sleeved shirts and long pants tucked into socks.
• Avoid heavily populated residential areas.
• When indoors, stay in air-conditioned or screened areas.
• Use bednets if sleeping areas are not screened or air-conditioned.
• If you have symptoms of dengue, report your travel history
• Eliminate mosquito breeding sites in areas where dengue might occur:
• Eliminate mosquito breeding sites around homes.
• Discard items that can collect rain or run-off water, esp. old tires.
• Regularly change the water in outdoor bird baths and pet and animal
water containers.
Prevention

78. - Dr. C.S.N.Vittal