Practical aspects of dengue management in children … discussed many bedside points and decision making in ICU based on clinical examination…

1. Dengue in children
where the art and science meet
An update
Dr.G.Sudhakar
Professor Of Paediatrics (Rtrd)
Consultant Paediatrician
KIMS Hospitals
Kurnool
Andhra Pradesh

2. DENGUE
• DNV 1-5
• Mostly children
• Treatable yet potentially fatal
• Primary and secondary infections
• Prodrome/ Leaks/ Bleeds
• Leukopenia/Thrombocytopenia/ Raised HCT
• IgG IgM NS1 Ag
• Notifiable
• Preventable
2

3. Primary infection produce both
Type specific neutralizing (TSNA) and
nonspecific non-neutralizing
antibodies(NSNNA). TSNA homologous
complexes are non-infectious
Nonspecific non-neutralizing
antibodies of primary infection
Complexes with heterologous
virus of secondary infection
which are infectious
These infectious complexes enter more monocytes and
macrophages where the virus replicates ie the viral
multiplication is being enhanced or being augmented…
that is why we call them as enhancing or augmenting
antibodies

4. Endothelial dysfunction with capillary plasma leaks is the hall mark of
Dengue pathophysiology behind the clinical picture
• When fever subsides 90% become active and recover.
• Around 10% become lethargic and enters “critical dengue”
• Critical dengue is with plasma leaks resulting in
1. Warning signs
1.Abdominal pain and tenderness
2.Persistent vomiting
3.Clinical fluid accumulations
4.Mucosal bleeds
5.Lethargy/restlessness
6.Increase in HCT and fall in platelets
2. Intravascular volume depletion and bleeds resulting in
Shock when volume loss is critical
3.Bleeds due to
Decreased platelets
Ischemic hepatitis with prolonged PT
DIC
Vasculitis with prolonged APTT

5. Clinical implications of pathophysiology…
• Febrile period without warning signs and without signs of shock
Non-Severe dengue without warning signs
• Afebrile period with warning signs but without signs of shock
Non-Severe Dengue with warning signs
• Afebrile period with warning signs and with signs of shock
Severe Dengue
1. Shock due to leaks and/or bleeds
2. Respiratory distress due to third spacing
3. Multiorgan disfunction
Hepatitis
Encephalitis
Renal failure
Myocarditis etc

6. Treatment implications of pathophysiology…
• With onset of critical dengue warning signs secondary to plasma leaks
and organ hypo-perfusion appear. Plasma leaks continue for 48 hours
• With critical depletion of IV volume signs of shock appear...
• After 48hrs the the leaked-out plasma re-enters circulation
• Replacing intravascular volume to maintain organ perfusion is critical
• But plasma re-entry during recovery plus the IV fluids given during
critical phase may add-up resulting in circulatory overload and
pulmonary oedema.
• Under our control is only what we infuse but not re-entry plasma.
• Attempts to correct raised HCT with IV fluids will inevitably result in
third space accumulations and respiratory distress.
• Replacement of volume should be restricted to 40-60% of
maintenance to give space for re-entry fluid to get accommodated,
otherwise it will be like tsunami with onset of recovery phase.

7. Therapeutic implications of pathophysiology…
HCT
EVV EVV
EVV EVV EVV
EVV
EVV EVV
IVV IVV IVV IVV
1.Normal IVV vs EVV Volume status
after plasma leaks
Volume status after IVF
for shock
Volume status after
Re-Entry during recovery
Plasma leaks Re-Entry of EVF +
Rapid fluid infsion
during recovery results
in fluid overload
Prodromal phase
Critical dengue
Warning signs and shock
Fluids to improve
tissue perfusion
Tsunami

8. 6 years old Irfan with fever of 5days duration. Afebrile since morning,
sick looking, generalized edema, abdomen distended and tender. Ns1Ag
and IgM are non-reactive and IgG is reactive. Can this presentation be
Dengue illness?
• IgG +ve, IgM –ve, NS1Ag –ve suggests past infection in a febrile child
• IgG +ve, IgM +ve, NS1Ag +ve suggests secondary infection
• But in some secondary infections, IgM response is only transient or
appears after IgG
• IgG can appear very early in secondary dengue infections
• NS1Ag has weak reactivity in IgG sero-reactive children
• So IgG alone can be Positive and the other two being negative
• False positives are zero with IgG index value of >6.00 and 0.19 for
>3.00. With IgG IV of <3.00 false positives are likely( bacteremia,
leptospirosis, Q fever, CGV, CMV, EBV, Varicella, Enteric fever, UTI
etc.;)
• Ref: Iran J of Microbiology 2016 Dec; 8(6): 395-400

9. NS1Ag +ve with or without IgM and IgG is confirmatory. Bu IgM
alone is positive in Ramu with fever of 7days duration. 6cm non
tender soft to firm liver and 1cm soft spleen present. No
edema. No fast breathing. Diagnosis of Primary Dengue
infection of more than 6days duration is made. What are your
comments?
• A single IgM report is not confirmatory
• A weakly reactive IgM(<2.85 IV) may be false positive due to cross reactive
CGV
• A strong reactive IgM(>2.85 IV) can mean either Dengue of >6days
• <2.85 IV indicative of recent past infection of 2 to 3 months back and may
not be presently dengue. Detectable frequency was 68.2% and 35.9% at 6
& 12 months after primary infection. BMC Infct Dis. 2015; 15:167
• Suggestive clinical picture can favor Dengue in such situations
• Clinical assessment in Ramu is not s/o Dengue and needs further
evaluation like Blood for salmonella, leptospirosis, Rickettsia etc

10. A child with clinical picture s/o Dengue but Ns1Ag, IgM
and IgG are negative. What should be our take on this
issue?
• Fever subsiding with when leaks appear and the child becoming more
sleepy and lethargic favors clinical dengue even if all markers are
negative. A convalescent serum sample can be tested for markers
again (IgM and IgG). Previously -ve becoming +ve can be
confirmatory. IgM/IgG ratio of >1.2 suggests Primary and <1.2
suggests secondary infection. NS1Ag of <9EU is read as –ve.
• Fever increasing in intensity or continuing even after leaks appear
should make us think of Rickettsia, Leptospira, Enteric fever and
sepsis with plasma leaks.
• With continuing fever coinfections/secondary infections and HLH
complicating an infection too need consideration.

11. Please answer whether acute dengue is possible with following
lab results?
• NS1 Ag … Confirmatory of Acute dengue
• IgG alone positive (past infection) … Acute dengue possible
NS1Ag reactivity is poor in IgG reactive individuals
IgM may appear after IgG appears
• IgM alone positive (>6days)…. Need not be confirmatory
probable dengue only
recent past dengue (IgM may take up to 3-6months to disappear)
• All markers Negative… Acute dengue Possible
Ns1Ag sensitivity is 71-100% (0.5ug-2ug/ml)
IgM sensitivity is 0-50%
IgG sensitivity is IgG/IgM ratio >1.1 (100%)
specificity is (97.4%)
accuracy is (67.5%)

12. When to order FBC in a suspected dengue child?
Can normal FBC rule out dengue? When to admit?
• At the time dengue is suspected we should do FBC.
• Earlier the FBC done more the chances for FBC to be normal.
• It will not rule out Dengue.
• But helps us know baseline HCT and to follow trends there after
• To know the trends of falling WBC and platelets during febrile period
• So an early clue to Dengue diagnosis
• Admission in febrile period to those with co-morbids, infants and
those with warning signs.
• Ambulatory children with warning signs… admission is a must as rapid
development of shock can ensue.

13. NSD without warning signs
• Paracetamol
• Oral rehydration
• Watch for Warning signs
13
Presumptive Diagnosis
Endemicity and Fever plus
2 of the following
(1)Anorexia and nausea
(2)Rash
(3)Myalgias
(4)Leukopenia
(5)Torniquet test
(6)Vitals signs normal
(7)No warning signs
Warning signs
1.Abdominal pain and tenderness
2.Persistent vomiting
3.Clinical fluid accumulations
4.Mucosal bleeds
5.Lethargy/restlessness
6.Increase in HCT and fall in platelets
We do some minimum labs
1. Dengue kit test for NS1Ag. IgM, IgG
2. CBC on automated cell
3. SGPT, SGOT and Prothrombin time

14. NSD with warning signs
•Admit if warning
signs appear
•Paracetamol
•ORS/IV fluids
•Watch for signs
of severe Dengue
14
Multiple organ dysfunction
( Brain / Liver / Heart / Kidney )
Severe bleeds causing shock
Plasma leaks leading to
Shock and Respiratory distress

15. Severe dengue…Treatment of shock…
• Fluid bolus 10-20ml/kg of Isotonic crystalloid over 1hr in
compensated shock
• Resuscitation fluids (10-20ml/kg within 20 min for Hypotensive shock
• If responding, taper the fluids to maintain just enough circulation
over next 12 hrs to 48 hrs ( follow WHO algorithms)
• If still in shock, estimate HCT. If HCT is still high and not falling it is still
plasma leaks and give colloids 10-20ml/kg over one hour. If HCT is
falling, it is severe bleeds, give FWB 10-20ml/kg over 1-2hrs. ( falling
HCT below normal never happens in Leaky phase and always indicates
severe bleeds.
• Low pulse volume + Low HCT = Bleeds
• Low pulse volume + High HCT= Leaks
• High pulse volume + Low HCT = Fluid overload

16. Treatment of Group C

17. Treatment of Group C

18. Monitoring a child on fluid therapy
Pulse
volume+
Pulse
pressure
Systolic BP Signs of RD Hematocrit Urine
output
Alertness Activity
and
interaction
Clinical
Impression
Decreased Narrowing Normal or
Less
Fast
breathing
+/- RD
Increased Decreasing Decreasing Decreasing NT/HT
Shock due
to leaks
Decreased Decreasing Normal or
Less
Fast
breathing
+/- RD
Decreased Decreasing Decreasing Decreasing NT/HT
shock due
to bleeds
Increased Normal/
widening
Normal or
Increased
Fast
breathing
+/- RD
Decreased Increasing
trends
Improving improving Re-entry
fluid
overload
Abdominal girth, Liver size and tenderness,
VBG with Lactate, serum creatinine
also need to be Monitored similarly
Closely following the Trends or
journey of all findings
is critical for optimal outcome
General condition

19. Some useful clues to clinicians…
• Improving appetite, increasing urine output, increasing pulse volume,
improving alertness, decreasing abdominal girth, physician’s
assessment of improving general condition, inclination to play,
improving interaction with parents and decreasing abdominal pain, all
indicate onset of Recovery/re-entry phase.
• Trends in respiratory rate should always be assessed in correlation
with pulse volume and HCT values
• Trends in WBC, platelets and alone are useless.
• Trends in transaminases should be correlated with prothrombin time
( INR ) and well looking vs ill looking

20. Respiratory distress increasing… scenario 1
Child data
• Breathing difficulty with fast
breathing and chest retractions
• Pulse volume high
• Alert
• Increased urine output
• Accepting feeds well
• Lactate normal
• HCT low/normal/above baseline
but significant fall
• Stable circulatory status with fluid
overload
What we can do?
• Stop IV fluids if plasma leaks are
>48hrs and switch to ORS
• Watch for 2 hrs and follow RR
• If RR is falling and child is
comfortable continue with ORS
• If RD is rising despite stopping IV
fluids and consider diuretic
• Lasix 0.3 to 0.5mg/kg/dose 2-
4times a day or preferably
0.1mg/kg/hr as continuous
infusion

21. Respiratory distress increasing… scenario 2
Child data
• RD increasing
• Child is hemodynamically stable
• Alert
• Urine output increased
• Appetite improved
• But still with in <48 hrs of
plasma leaks
• Acid base balance and lactate
are almost normal
What we can do
• Reduce IV fluids or switch to
colloids at 1-2ml/kg /hr until
48hrs of plasma leak stage is
completed.
• RD due to overload is unusual
during plasma leak phase.
• Thinking RD as due to overload
and giving diuretic within plasma
leak phase is hazardous as it may
worsen shock state.

22. Respiratoy distress increasing… scenario 3
Child data
• Plasma leak phase of <48 hours
• Respiratory distress present
• Signs of shock continuing with
low pulse volume
• HCT remains high
• Third spacing is the cause of RD
due to rapid infusions of
hypotonic or crystalloid fluids
What we can do?
• IV fluids switched to colloids
with carefully titrated bolus of 5-
6ml/kg over 1-2 hrs.
• Reduce as per the need
• Stop all fluids at or after 48 hrs
of the critical period
• Lasix may be needed if high
pulse volume ensues with
increasing RD after 48 hrs time

23. Fluid overload scenario 4
Child data
• After fluid boluses Signs of shock
continue with low pulse volume
• HCT is low or normal
• Excessive fluid accumulations
• Most likely have severe occult
bleeds
What we can do
• Further IV fluids are with poor
outcome. Rather start dopamine
if hypotensive too.
• Early initiation of FWB 10ml/kg
and titrate the rate based on
clinical response, acid base
status and lactate
• Respiratory support may be
needed

24. Respiratory distress increasing… scenario 5
Child data
• Pulse volume is high
• Abdominal girth increasing
• Metabolic acidosis and high
lactate is persisting s/o
continuing shock
• Suggests fluid overload of both
extravascular and intravascular
compartments.
• Bleeds and leaks combined
• Often due to bleeds treated with
non-FWB
What we can do?
• FWB/PRBC and colloid infusions
carefully can help child come out
of plasma leaks with minimal
worsening of respiratory
condition
• Dopamine if hypotensive
• Watch for Respiratory failure and
support accordingly.

25. Some common dilemmas…
• 1. Can dengue shock occur during febrile phase?
• Yes… Around 10 to 15% of severe dengue occur during febrile phase…
or fever may sometimes get prolonged into critical phase too.
• 2. If dengue is detected very early, can we prevent development of
severe dengue with optimal care?
• No… even with the best treatment modalities we can not prevent
severe dengue , rather we can only treat severe dengue
• 3.Is it the primary or secondary HLH that complicates Dengue
infection?
• Both can occur. Best dictum is HLH complicating Dengue in less than
one year of age should be considered as primary HLH. Where as HLH
in dengue after 2 years of age secondary hyper-ferritinemia with
MODS is more common. To confirm, genetic testing for Primary HLH
should be done

26. Dilemmas regarding platelets and FFP…
• Platelet fall alone with out leukopenia is unusual in dengue that too
with only IgM+ve, we need to rule out ITP and other
thrombocytopenic disorders…
• Severe dengue in leaky phase with platelets of less than 10k or <20k
with bleeds can be indications for SDP.
• In recovery phase of dengue with good appetite and and activity, the
platelet count of even <10k does not warrant SDP.
• Dictum is “Well child-well platelets and sick child-sick platelets”
• INR of >1.5 is an indication for FFP at 10ml/kg run over 30 to 120min
• But giving FWB in overt bleeding is better than giving SDP and FFP as
correction of shock is of primary concern.

27. When the child is alert, BP is normal and accepting
orally but warning signs are present. ORS? or IVF?
Which is a better option?
• Data is insufficient to decide
• Being alert and having normal BP does not rule out circulatory
instability. They remain normal in compensated shock which requires
urgent fluid resuscitation to prevent hypotensive shock.
• Hence assessment of circulatory status with at least the following
four signs….
• Pulse volume, CRT, color and temperature of extremities to assess
peripheral tissue perfusion.
• Alertness, normal BP with no signs of shock… ORS
• Alertness, normal BP with signs of shock… IV fluids

28. A well perfused child with persistently elevated
HCT… to give or not to give fluids?
• Well perfused child needs no fluid infusion
• But Elevated HCT indicates ongoing plasma leaks and we incline to give fluids
and never ever aim to correct HCT during 48hrs of leaky phase as it inevitably
leads to more oedema and more third spacing.
• This should be understood as “child is compensating well for ongoing losses”
• Hence increasing IV fluids to correct HCT is likely to lead to fluid overload
• Continue to monitor over next 2-3 hrs… if still stable we can even attempt
stopping fluids… HCT usually resolves even without infusions as it is a balanced
state
• Lessons learnt is do not chase labs when child is stable.

29. A child with dengue with large pleural effusion and
ascites on IV fluids enters recovery phase but refusing to
take oral fluids. How to calculate IV fluids at this stage?
• This child is already in a big positive fluid balance state with large
pleural effusion and ascites and thirst is hampered
• The only way for pleural effusion and ascites to get absorbed is to
stop IV fluids
• The child’s thirst mechanism will kick-in when once diuresis sets-in.
• So best course of action at this point of time is to stop IV fluids and
allow the child to take orally at his will

30. In the critical phase if the child is anuric with elevated
creatinine a fluid bolus challenge followed by diuretic
should be tried?
• In the critical phase fluid challenge will invariably push fluids into
third space and the diuretic will produce urine by depleting
intravascular volume. So this procedure increases third spacing as
well as worsens shock. It can also result in hypokalemia
• When child is anuric urine output can’t be taken as a criterion to
guide IV fluid therapy rather should be guided by other signs of
perfusion.

31. When to advise antispasmodics and antacids
for abdominal pain in children with dengue?
• Never
• Abdominal pain rather heralds the onset of warning signs or onset of
shock due to plasma leaks at the time fever is turning into No-fever
• Causes are acute liver enlargement due to leaks, ischemic
hepatopathy and ischemic gastropathy
• Last two respond only to fluid replacement not to antacids.
Antispasmodics are useless and may contribute paralytic ileus and
neurological complications

32. Worsening or persistent abdominal pain/tenderness
after 24hrs of large volumes of fluid administration… do
we need to stop IV fluids or continue IV flids?
• Assessing intravascular volume status is the key. Peripheral perfusion,
pulse pressure, pulse volume, urine output and acid-base status
should be assessed.
• If perfusion is still less consider colloid infusions
• If perfusion is good consider stopping IV fluids
• Further IV fluids will increase abdominal distension and respiratory
distress

33. When to take help of nephrologist if renal
failure is encountered in dengue?
• RRT with CVVH during recovery phase is ideal and should not be
attempted in critical phase
• HD machine can’t draw blood effectively from hypovolemic shock
child and can not correct metabolic acidosis and oliguria
• Machine works well with volume repleted recovery phase and can
prevent life threatening pulmonary edema.
• Peritoneal dialysis can be an alternative if CVVH is not available

34. Metabolic disturbances seen with dengue
management?
• Metabolic acidosis with increased Lactate
• Metabolic acidosis uncorrected by adequate fluids suggest bleeds
• Metabolic acidosis with normal Lactate and hyperchloremia
• Hyponatremia due to vomiting and hypotonic resuscitation fluids
• Hyperkalemia due to renal failure and metabolic acidosis
• Hypokalemia due to GI losses or stress induced hyper-cortisol state

35. Hyperglycemia and hypoglycemia in dengue…
• Both can occur in the same child at different times in critical phase
• Beware of spurious “good urine output” secondary to hyperglycemia
• Osmotic diuresis can worsen shock in critical dengue
• Hyperglycemia can result from stress induced hyper cortisol state or
by using dextrose containing resuscitation fluids
• Hypoglycemia can cause seizures and mental confusion
• Hypoglycemia can be due to starvation young children, severe liver
involvement etc

36. When to plan FWB transfusion?
• overt bleeding with shock
• Severe occult bleeds need to be identified… even severe bleeds may
not result in fall of HCT below baseline if preceded by plasma leaks
• Hence falling HCT needs to be assessed. Fall in HCT with isotonic
crystalloids is usually negated by third spacing.
• Hence during critical phase a fall in HCT with low pulse volume and
narrow pulse pressure may indicate bleeds rather than effect of IV
fluids
• Persistent metabolic acidosis with adequate fluid therapy may point
to occult bleeds

37. DIVC regimen for severe bleeding…
• Decreased platelets, coagulopathy and DIC are the causes
• FFP, SDP and cryoprecipitate transfusions… poor response
• Bleeds and leaks continue resulting in severe third spacing
• Hence urgent FWB transfusion can be life saving to prevent life
threatening hemorrhagic shock and massive third spacing
• Repeated blood transfusions for continued bleeding but not FFP/SDP
• Bleeding usually stops after critical period

38. Refractory shock …
• Refractory shock is usually a combination of plasma leaks and
bleeding in uncorrected shock accompanied by Renal and Liver
impairments
• Usually the most common cause of death with 24-48 hrs after
admission
• Reassessment after every fluid bolus… if no improvement in
hemodynamics, estimate HCT. A rising HCT/still high suggests plasma
leaks … proceed with colloids…
• If no improvement in hemodynamic status and HCT is falling think of
bleeds and go with FWB transfusion

39. Pulmonary oedema and ARDS…
• Pulmonary >ARDS
• Both due to Rapid fluid infusions in
critical phase.
• Mechanical ventilstion indicated in
1.Child in Shock, confused,
restless and combative
2. Respiratory failure due to
Pulmonary edema/ARDS
3. Failed response to HFNC/CPAP
• Sedatives, induction agents, muscle
relaxants may cause hypotension
and cardiac arrest. Conscious
sedation is preferred .
• Poor lung compliance and trauma
to airway can increase pressure
requirements.
• FWB, Colloids, Inotropes, sedatives,
circulatory and respiratory monitoring
devices all should be readily available
• Careful titration of FiO2 and PEEP are
crucial.
• Principle to remember is to maintain
adequate oxygenation and ventilation
to maintain Ph at 7.35 than to
maintain normal PaCO2 to prevent
metabolic alkalosis.
• PEEP of <10cm of H2O and titrate
FiO2 accordingly
• If needed fine bore needle aspiration
of ascites and pleural effusions.
• Clinical, USG, Echo, ABG monitoring of
circulatory status
• Lactic acidosis/low or normal
Ph/unable to lower inotropic
support may warrant FWB.

40. What is abdominal compartment syndrome?
• Massive ascites accumulated in a short time and hence is under
tension. Precipitated by PEEP of >8cm of water if ventilated.
• Pressure on retroperitoneal structures, kidneys, renal veins, inferior
vena cava leads to decreased renal blood flow and oliguria even when
peripheral perfusion is adequate
• Hence in this situation oliguria can’t guide fluid management.
• May be positioned in reclining or lateral posture to relieve pressure
on retro-peritoneal structures. Stopping IV fluids with recovery can
ease itra-abdominal pressure spontaneously and urine output
improves… or diuretic can be tried during recovery if child is stable.
• Avoid using diuretic to decrease abdominal distension before re-entry
starts… it may worsen shock

41. How to differentiate from a surgical
abdomen?
• Trends in fever…
• Trends in HCT
• Trends in FBC
• Effect of 5-10ml/kg volume bolus over pain abdomen
• Abdominal wall oedema and other signs of generalized edema early
• USG abdomen reveals GB wall oedema

42. When to stop iv fluids
• Signs of cessation of plasma leakage
• Stable BP, pulse and peripheral perfusion;
• Hematocrit decreases in the presence of a good pulse
volume;
• Resolving bowel/abdominal symptoms
• Improving urine output.

43. Iv fluids… Too much and too less are bad
“Narrow therapeutic index” for iv fluid therapy.
Recognizing the cues to
discontinue intravenous fluid
therapy is just as important as
knowing when to start it.

44. Bleeding in SD
• have profound/prolonged/refractory shock
• have hypotensive shock and multi-organ failure or severe
and persistent metabolic acidosis
• are given non-steroidal anti-inflammatory agents
Patients at risk of severe bleeding are
those who:

45. Suspect bleeding in SD if …
NT / HT pt + persistent or worsening metabolic
acidosis + severe abdominal tenderness and
distension.
Fluid refractory shock
A decrease in hematocrit after boluses of
fluid resuscitation together with unstable
hemodynamic status;

46. Treatment - Bleeding in SD…
Give aliquots of 5−10 ml/kg of fresh -packed red
cells or 10−20 ml/kg of fresh whole blood
Consider repeating the blood transfusion if
no appropriate rise in hematocrit after blood
transfusion in an unstable patient.

47. Bleeding in SD…
No evidence to support the practice of
transfusing platelet concentrates and/or fresh-
frozen plasma for severe bleeding in dengue
For surgeries or invasive procedures, platelet
transfusion can be considered

48. Inotropes in DSS
• Limited role
• As a temporary measure to prevent life threatening
hypotension or during induction for intubation
• Cardiogenic shock due to myocarditis
• Concomitant septic shock

49. Urine output monitoring during both febrile and
afebrile critical phase is essential. True or False?
• During febrile phase a child passing urine for 4 to 6 times is adequate
• But in critical phase measuring urine output is critical.
• Goal of urine output of 0.5ml/kg/hour is optimum to maintain “just
enough circulation” to avoid fluid overload
• Urine output of >0.5ml/kg/hour is an indication to reduce IV fluid
therapy.
• IMPORTANT: avoid using diuretic for urine output of <0.5ml/kg/hour
as it may produce some urine output but exacerbates shock. Oliguria
is often pre-Renal in origin. So oliguria should be treated with IV fluid
therapy until urine output reaches 0.5ml/kg/hour

50. When is the urine output not a good guide to fluid
therapy in dengue?
• RBG of >10mmol/Lit
• AKI with elevated Creatinine
• Underlying CRF, DM or uncontrolled hypertension
• Moderately high PEEP >10cm of H2O
• Intra abdominal hypertension >10cm of H2O
• Diuretics or hypertonic fluid usage

51. Complications …
• Renal failure – Most portant risk factor is shock
• Other risk factors – Hepatic failure , prolonged Prothrombin time ,
obesity
• J Pediatr. 2010 Aug;157(2):303-9. Epub 2010 Apr 1.
• CVVH is mode of choice

52. Seizures or altered sensorium in a child with
dengue should be treated like AES. True or false?
• False
• During febrile phase Febrile seizures is the most common cause and
hence should be treated accordingly and rarely dengue viral
encephalitis could be the cause
• Less common cause is hyponatremia frequently seen in dengue,
causing encephalopathy and seizures
• Most common scenario is… Seizures and altered sensorium in critical
phase are mostly due to decreased cerebral perfusion. Perfusion to
brain is the last to decrease. So sudden collapse can occur if IV fluids
are not give promptly.
• Attempts to do procedures like LP, CT brain etc take away the valuable
time and may delay critical step of fluid resuscitation.

53. Severe dengue with Hepatic dysfunction…
• Infective hepatitis is rare
• Ischemic hepatopathy is almost always the cause
• Hence SGOT/SGPT ratio is always >1
• Transaminases can cross 10,000units
• Increased prothrombin time with bleeds complicates critical dengue
that is unresponsive to Vitamin K.
• Measures to improve tissue perfusion usually results in resolution of
hepatic dysfunction
• Role of N-Acetyl cystine though controversial it is commonly used
allover in PICUs.
• Hepatic dysfunction coupled with seizures and hyper-ferritinemia
more so in infants… consider Primary HLH

54. Take home points
True/ False
•IgM/Ns1Ag +ve is a must to say Dengue
•IgG helps differentiating primary from secondary
infection
•Plasma leaks and bleeds are warning signs
•Severe dengue is with Shock/RD/MODS
•Guarded Fluids is the corner stone of therapy
•Fluid overload is the most common cause of
death
•Platelet transfusions are life saving
False
True
True
True
True
True
False

55. True/false…..
•Trends in alertness , urine output , pulse volume , RR , Liver
size , appetite is pivotal
•Alert child with Increasing pulse volume and increasing RR
is an indication for ORS / Lasix
•Lethargy with decreasing PV and increasing RR being on
fluids … a danger sign s/o contnuing leaks
•Inotropes only with myocarditis/septic shock
•Always refer children with ARF/ARDS.
True
True
True
True
True

56. THANK YOU ALL