Management of Dengue Fever and Dengue Hemorrhagic Fever

1. MANAGEMENT OF DENGUE FEVER DENGUE FEVER http://crisbertcualteros.page.tl

3. Seen in children in Southeast Asia during the 1950s. Its severe forms (hemorrhagic fever and shock syndrome) may lead to multisystem involvement and death Early diagnosis, close monitoring for deterioration & response to treatment are necessary in all cases.

7. Risk factors for developing DHF / DSS: Children are more prone to develop DHF / DSS than adults DHF / DSS is associated more with well nourished than with under nourished children Primary infection in infants born to dengue immune mothers Presence of underlying chronic illnesses (eg: heart disease, anaemia, chronic liver disease)

8. Special attention :High-risk dengue patients Infants under 1 year of age Overweight/obese patients Massive bleeding Change of consciousness,esp. restlessness,irritability or coma Presence of underlying diseases e.g. thalassemia, G-6-P deficiency, heart disease

9. Admission in Dengue Fever Abdominal pain – may be intense and sustained Bleeding tendencies with Positive tourniquet test Cold extremities Decreased urine output Platelet count < 1 Lakh and PCV rise by >20% Persistent vomiting Altered mental status -Restlessness or somnolence

11. TREATMENT No specific therapy – only symptomatic Rest and Plenty of oral fluids Use Paracetamol Avoid Aspirin and NSAIDs Follow up preferably everyday - from the 3rd day until afebrile for 24-48 hour

12. General measures Frequent monitoring of vital signs Essential nursing care. Stop bleeding with proper techniques (e.g. anterior nasal packing for massive epistaxis) Avoid blind invasive procedures (e.g. no nasogastric tube insertion, no gastric lavage)

13. Nutritional support Soft, balanced, nutritious diet, juice and electrolyte solution – plain water is not adequate Avoidblack- or red-colored food or drinks (may be mistaken for bleeding Sedation is needed in some cases to restrain agitated child: Chloral hydrate(12.5-50 mg/kg), orally or rectally recommended. Avoid Long-acting sedatives

14. NCPAP (Nasal Continuous Positive Airway Pressure): should be preferred if there is Acute respiratory failure associated with DSS Oxygen via face mask/nasal cannula: in case of shock/impending shock.

15. Other treatment H2-blockers (ranitidine): Recommended in case of GI bleeding Domperidone 1 mg/kg/day in three divided doses in case of severe vomiting for 1-2 days. Antibiotic: Not necessary; it may lead to complications

19. FLUID MANAGEMENT In young infants without shock- D5 0.3% NaCl In patients who already have volume overload, i.e., massive pleural effusion - colloid solutions Hydroxyethyl starch at 6%: preferred in children with severe shock; the use of dextran is associated with various adverse reactions

20. WHO guidelines are useful in that they offer an algorithmic approach to fluid resuscitation in DHF and DSS. However, the usefulness of these guidelines is limited beyond the immediate resuscitation do not address treatment of complicated forms of the disease, like fluid overload and multiple organ failure, which could cause disability or death.

21. If no response to IV fluids: Consider and correct: Massive plasma leakage Concealed internal bleeding – decrease in Hematocrit Hypoglycemia – Blood sugar < 60 mg/dL Hyponatremia, hypocalcemia – electrolytes Acidosis – indicates metabolic acidosis in blood gas analysis

22. Blood transfusion Platelet transfusion Thrombocytopenia with significant bleeding. Platelet count < 10,000/mm3 DOSE 10-20 mL/kg Platelets return to normal within 7-9 days

23. Fresh Whole blood / Packed red cell transfusion Significant blood loss > 10% (6-8 mL/kg) Concealed internal bleeding Hemolysis DOSE: Fresh whole blood 10 mL/kg/dose Packed red cells 5 mL/kg/dose

24. Role of Steroids Ineffective in preventing shock in DHF It may cause harm Treatment with methyl-prednisolone did NOT show any benefit in a double blind placebo-controlled trial in DSS

25. Complications of DF/DSS DIC Myocardial dysfunction incl. Cardiomyopathy Hepatitis Reye-like syndrome Encephalitis ARDS Glomerulonephritis

26. Fluid overload AVOID: Early IV fluid therapy- in the febrile phase Excessive use of hypotonic solutions Excessive use of hypotonic solutions Non-reduction in the rate of IV fluid after initial resuscitation Non-reduction in the rate of IV fluid after initial resuscitation Blood loss replaced with fluids in cases with occult bleeding Blood loss replaced with fluids in cases with occult bleeding Treatment: Judicious fluid removal: colloids with controlled diuresis (furosemide 1 mg/kg infusion over 4 hours) or dialysis

27. Electrolyte imbalance Hyponatremia Hypocalcemia – 10% Cagluconate 1mL/kg/dose, slow IV push every 6 hour

28. Large pleural effusion/ascites Careful titration of intravenous fluids. Avoid insertion of intercostal drains and tracheal intubation. Large pleural effusions during recovery phase after 48 hours Furosemide (0.25-0.5 mg/kg at 6 hours interval for 1 to 2 doses)

29. Disseminated intravascular coagulation Frequent Clinical assessment Regular Coagulation profile: PT, aPTT, fibrinogen, platelet Patients with bleeding & DIC have benefited from : Heparin therapy + Cryoprecipitate (1 unit per 5 kg body weight) Followed by Platelets (4 units/m2 or 10-20 mL/kg) within 1 hr and Fresh frozen plasma (FFP 10-20 mL/kg).

30. Prognosis Significant morbidity and mortality can result if early recognition and monitoring of severe forms are not done