This document discusses the challenges in diagnosing and treating dengue fever. It outlines the key clinical features of dengue fever including high fever, severe joint pain, headache, and flushed face. Diagnostic tests like NS1 antigen and antibody tests can help differentiate dengue fever from other viral infections. The document describes the warning signs that indicate a patient may be progressing to dengue hemorrhagic fever or dengue shock syndrome, such as vomiting, abdominal pain, bleeding, and signs of circulatory compromise. Meticulous monitoring of fluid balance and replacement is critical during the dangerous critical phase to avoid under- or over-hydration which can lead to shock or pulmonary edema, respectively. Timely detection and management of shock

1. Prof D.P S Gunasekera
MBBS,MD, FRCP,FSLCP
10th Annual Academic Sessions, USJP
April 2015

2. What are the challenges?
Is it viral fever OR Dengue fever?
Clinical features
 High remittent fever
 Severe arthralgia
 Headache (retro-orbital)
 Flushing of face

3. Pics –flushed face, petecahe

4. What are the challenges?
In diagnosis
 Is it viral fever OR Dengue fever?
 Diagnostic tests help – Dengue Ag test(NS1)
Dengue Ab test
 Dengue fever - simple Dengue fever?
OR DHF?

5. DF or DHF ?
Clinical features
Warning signs
 Ill looking – severe arthralgia
Headache (retro orbital)
 Vomiting
 RHC pain & tenderness (hepatomegally +)
 Drowsy/ irritable/confused
 Dizziness +
 Bleeding from sites – petechae, gum bleeds, coffee
ground vomitus
Deteriorates when
fever settles

6. DF OR DHF?
Warning signs
signs of circulatory compromise
 Low volume pulse, colds peripheries
 HR ↑
 Pulse pressure ↓ (<20mmHg)
 CRT > 2 sec
 UOP ↓
 Ix – HCT > 20% rise: pitfall- what is baseline HCT?
 If DHF → SHOCK/ NON SHOCK ?
What is the
baseline HCT?

7. DHF – what stage?
 Febrile phase – 2-7 days
 Critical phase – 48 -72 hours (leaking +)
 Convalescent phase

8. Clinical course of DHF
Source : WHO

9. In Management
Key issues
 Know clinical sequence of events
 Meticulous monitoring in critical stage
 replace lost fluid:
rapidly & adequately
 know when to stop!
*Do not overload*

10. Mx – critical phase
 Pitfalls – erratic rate of leakage
rapid leakage – in first 24 hours
extravasation of fluid –
into pleural &
peritoneal cavities
Patient ay
remain
conscious

11. Mx- critical phase (cont)
 METICULOUS monitoring
 RAPID replacement with IV fluid
 ADJUST IV fluid rates : (M + 5%) ↑↓
 Give ISOTONIC solution (Normal saline)
 Give colloids (Dextran 40) on time
CHALLENGE
 Too much fluid → more extravasation→
later→ pulmonary oedema
 Too little fluid → shock

12. Challenges : critical phase
Haemorrhage
 Massive, concealed H’age
 Pitfalls: hypovolemic changes already there
HCT already high → may not show
classic ‘Low’
 signs of H’age → HR↑, systolic BP↓,
M. acidosis +
 Look for ‘drop’ in HCT
Replacement with Dextran - 40 bolus → reduces HCT
by 10 (max)

13. Dengue Shock Syndrome(DSS)
Management -
 RAPID replacement of fluid:
 10ml/kg IV bolus of N. saline
 If no improvement → Dextran 40(10ml/Kg/hr)
 If no improvement → LOOK for concealed
H’age
Challenge
timely detection & Rx

14. Challenges in DSS
 early detection vital
 Rapid replacement of fluid/blood
 Prolonged shock → metabolic acidosis
organ dysfunction
liver failure, ARF, DIC
myocarditis
dengue encephalopathy

15. Convalescent Phase
 Clinical Improvement
 Convalescent rash
 Reabsorption of leaked
fluid
 Circ. Signs reversed -
HR↓
Pulse Pressure wide
CRT < 2 secs
UOP ↑

16. Challenges:Convalescent Phase
 Risk of pulmonary oedema
 Continue monitoring - HR↓, HCT↓, wide PP
 Look for signs of pulmonary oedema -
Cough, RR↑, lungs – rhonchi & crepts
 STOP IV fluid
 Furosemide IV SOS only

17. Conclusion
Key to success in Mx –
 Know clinical sequence
 Timely detection of leakage/shock
 Meticulous monitoring – critical stage
 Adequate replacement with IV fluid
 Timely blood Txn
 Rx associated problems – Met acidosis
hypocalcaemia
hypoglycaemia
 Stop fluid at Convalescence

18. Thank You