DENGUE FEVER IN CHILDREN FOR NURSING STUDENTS

DENGUE FEVER IN CHILDREN

1. DENGUE FEVER

2. INTRODUCTION Dengue fever is a mosquito born acute illness caused by dengue virus Characterized by fever, myalgia, arthralgia and skin rash Severe dengue can leads to dengue haemorrhagic fever and dengue shock syndrome Transmitted by bites of infected aedes aegypti mosquitoes Dengue virus belongs to genus Flavivirus

3. PATHOPHYSIOLOGY When an infected mosquito bite a person the virus enters into the body and binds to enters into the white blood cells The WBC respond by producing certain signalling proteins such as cytokines, interferons which are responsible for flue like symptoms- fever, severe pain Viral multiplication Increased vascular permeability- plasma leakage-hypovolemia-shock Reduced platelets- coagulopathy- DIC- severe bleeding

4. MODE OF TRANSMISSION Dengue virus circulating in the blood of infected humans is ingested by female mosquitoes during feeding The virus then infects the mosquito mid-gut and after an extrinsic incubation period of 8-12 days

5. CLINICAL FEATURES Dengue is a systemic and dynamic disease and demonstrated in 3 phases Febrile phase : 2-7 days from the onset of sudden high fever Rash, leukopenia, myalgia, retro-orbital pain Headache, anorexia, nausea and vomiting

6. Positive tourniquet test Arthralgia Mild haemorrhagic manifestations like positive tourniquet test or petechia and mucosal membrane bleeding may be seen Critical phase Marked by plasma leakage Occurs after 3 rd day of fever It last about 24-48hrs

7. Progressive leukopenia followed by a rapid decrease in platelet count usually precedes plasma leakage in less severe case Patient recovers spontaneously or after a short period of fluid or electrolyte therapy In severe cases sweating, cool extremities, prolonged capillary refill time Pulse and diastolic pressure increase and pulse pressure narrows The patient can progress rapidly to profound shock and death if prompt fluid resuscitation is not instituted

8. Some children may develop organ dysfunction like hepatitis, myocarditis or severe bleeding Recovery phase Plasma leakage stops and is reabsorption of extravascular fluid Patients general wellbeing improves and hemodynamic status stabilizes Generalized pruritis, bradycardia, electrocardiographic changes are common during this stage

9. DENGUE CLASSIFICATION

10. DIAGNOSIS Packed cell volume- increased Platelet count- low Leukocyte count –decreased SGOT, SGPT- increased X-ray chest, ultrasonography of abdomen Confirmatory diagnosis- Direct viral isolation by culture, genome detection by PCR, NS1 antigen detection, indirect IgM detection, IgG detection

11. MANAGEMNET STEP 1- OVERALL ASSESSMENT History – date of onset of illness, quantity of oral intake, assessment for warning signs, diarrhoea, change in mental status, seizure or dizziness, urine output, family or neighbourhood dengue or travel to dengue endemic areas Physical examination- assessment of mental state, hydration state, hemodynamic state, tachypnoea, acidotic breathing, pleural effusion, abdominal tenderness, hepatomegaly, ascites, rash, bleeding , tourniquet test Laboratory investigations

12. STEP II- DIAGNOSIS, ASSESSMENT OF DISEASE PHASE AND SEVERITY On the basis of evaluations of the history, physical examinations and laboratory tests dengue diagnosis should be made and phase of illness and severity should be identified STEP II- MANAGMENT Disease notification- in dengue endemic areas confirmed cases should be notified as soon as possible Management decisions- depending on the clinical manifestations management is done

13. Management of grp A( without any warning signs) Encourage oral intake of ORS, fruit juices and other fluids containing electrolytes and sugar to replace losses from fever and vomiting Administer paracetamol for high fever every 6 hrs Do not give aspirin, NSAIDS as these may precipitate gastritis and bleeding Hospitalize immediately in any of the following occur: no clinical improvement, severe abdominal pain, persistent vomiting, cold and clammy extremities, lethargy or irritability/ restlessness( black stools or coffee ground vomiting), not passing urine for more than 4-6 hrs

14. Management of Group B patients( with warning signs) Obtain HCT before fluid therapy Give isotonic solutions such as 0.9% saline, Ringer’s Lactate Start with 5-7ml/kg/hr for 1-2 hrs, then reduce to 3-5ml/kg/hr for 2-4 hrs Then reduce 2-3ml/kg/hr according to clinical response Reassess clinical status and repeat HCT, if remains same or rise only minimally then continue 2-3ml/kg/hr for another 2-4hrs

15. If worsening of vital signs and rapidly rising HCT, increase rate to 5-10ml/kg/hr for 1-2 hrs Reassess clinical status, repeat HCT and review infusion rates accordingly Reduce iv fluids gradually when the rate of plasma leakage decreases towards the end of critical phase Monitor vital signs, HCT before and after fluid replacement . Blood glucose and other organ function

16. Management of Grp C( with severe plasma leakage with shock and fluid accumulation with respiratory distress, severe bleeding, severe organ impairment who require emergency treatment Treatment of Compensated shock Start IV fluid resuscitation with isotonic crystalloid solutions at 5-10 ml/kg/hr over 1hrs. Reassess patient’s condition If patient improves: IV fluids should be reduced gradually to 5-7 ml/kg/hr for 1-2hrs, then to 3-5ml/kg/hr for 2-4hrs, then to 2-3ml/kg/hr for 2-4hrs and then reduced further depending on hemodynamic status, IV fluids can be maintained up to 24-48hrs

17. If patient is still unstable: check HCT after first bolus, if HCT increases/ still high, repeat a second bolus of crystalloid solution at 10-20ml/kg/hr for 1 hr If there is improvement after second bolus, reduce rate to 7-10ml/kg.hr for 1-2hrs and continue to reduce as above If HCT decreases this indicates bleeding and need to cross-match and transfuse blood as soon as possible

18. Treatment of hypovolemic shock Initiate IV fluid resuscitation with crystalloids or colloid solution at 20ml/kg as a bolus for 15 minutes If patient improves- give crystalloids/ colloid solution of 10ml/kg/hr for 1 hr, the reduce gradually as above Treatment of haemorrhagic complications Give 5-10ml/kg of fresh packed red cells or 10-20ml/kg of fresh whole blood

19. Management of fluid overload If patient has stable hemodynamic status and is out of the critical phase (>24-48hrs of defervescence): Stop IV fluids but continue close monitoring If necessary give oral or IV frusemide 0.1-0.5 mg/kg/dose once or twice daily or continuous infusion of frusemide 0.1mg/kg/hr Monitor serum potassium and correct the ensuing hypokalaemia

20. If patient has stable haemodynamic status but is still within the critical phase: reduce IV fluid infusion accordingly Avoid diuretics during the plasma leakage phase because the may lead to intravascular volume depletion Patients with shock- suspect occult haemorrhage, careful fresh whole blood transfusion should be initiated

21. NURSING MANAGEMENT Nursing Assessment Fluid therapy Administration of medication Continuous monitoring Identification of warning signs Nutrition Health education

22. NURSING DIAGNOSIS Risk for bleeding  related to possible impaired liver function. Deficient fluid volume  related to vascular leakage. Pain  related to abdominal pain and severe headaches. Risk for ineffective tissue perfusion  related to failure of the circulatory system. Risk for shock  related to dysfunction in the circulatory syste m

23. PREVENTION Elimination of adult mosquitoes and larvae by vector control measures Avoid water logging to minimise breeding of mosquitoes Health awareness programme against spread of dengue