DENGUE MANAGEMENT- AS PER LATEST WHO GUIDELINES

A thorough review of management of dengue fever that every physician and doctor who is caring for dengue patients needs to know. An ICU based management is also included ranging from mild to severe infections

1. Management of Dengue Dr.N.Ravi Shankar Associate professor IIM & RGGGH

2. Case definition - Dengue fever ( DF ) Acute febrile illness for 2 – 7 days ( plus ) Two or more of the following Headache Retro orbital pain Arthralgia Myalgia Leucopenia ( < 4000 ) Thrombocytopenia ( < 1 lakh )

3. Case definition – Dengue haemorrhagic fever ( DHF ) Dengue fever ( plus ) Any one of the below Bleeding manifestations Petechiae , ecchymosis , purpura Mucosal bleeding ( Gum , epistaxis ) GI bleed Positive torniquet test Capillary leak GB wall edema , Ascites , pleural effusion > 20 % drop in hematocrit

4. Case definition – Dengue Shock Syndrome ( DSS ) Dengue fever ( Plus ) Evidence of circulatory failure Tachycardia Capillary refilling time > 3 sec Cold peripheries Pulse pressure < 20 mmHg SBP < 90 mmHg

5. Four treatment groups Group A – Dengue Fever Group B – Dengue Haemorrhagic fever Group C – Dengue Shock syndrome – compensated Group D - Dengue Shock syndrome – Hypotensive

6. Suspected , Probable , Confirmed Dengue Suspected Dengue Only by case definition Probable Dengue Case definition with Positive Dengue NS1 Ag or Dengue IgM – done by RDT Confirmed Dengue Case definition with Positive Dengue NS1 Ag or Dengue IgM – done by ELISA

7. Natural History 3 phases of infection Febrile phase Critical phase Recovery phase

8. Febrile phase 2 – 7 days Fever , headache ,retro orbital pain , arthralgia , myalgia Rashes – 3 rd or 4 th day

9. Dengue Rashes Vs Petechiae Rashes Petechiae

10. Critical phase – Leakage phase Occurs after 3-4 days after the onset of fever Last for 36-48 hrs Plasma leakage Hemo concentration Shock Haemorrhage

11. Recovery phase After 6-7 days of fever Last for 3-5 days Fluid in extravascular space returns to intravascular compartment Pulmonary edema may occur

12. Management Group A – Dengue Fever Group B – Dengue Haemorrhagic fever Group C – Dengue Shock syndrome – compensated Group D - Dengue Shock syndrome – Hypotensive

13. Group A – Dengue fever Can be managed at home Fever – tepid sponging and Paracetamol tablets Oral hydration – ORS, Fruit juices , tender coconut water Adequate rest Information about warning signs

14. Admit the patients with … Coexisting conditions such as pregnancy, Old age, diabetes, mellitus, renal failure, COPD, immune suppressed, Obesity. Social circumstances such as living alone, living for from hospital Existing warning signs

15. Warning signs Abdominal pain or tendemess Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy, restlessness Liver enlargement >2 cm Laboratory. Increase in HCT concurrent with rapid decrease in platelet count.

16. Fluid management Rescue 15 – 60 minutes Resuscitate 1- 2 hrs Replace 2 – 6 hrs Reduce 6 – 48 hrs

17. Fluid management Aim for Improvement in SBP > 90 mmHg Improvement in signs of perfusion Improvement in Hematocrit > 20 % Urine output 0.5 ml/kg / hr

18. Group B – DHF ( Without Shock ) Rescue - Resuscitate 0 - 2 hrs 7 ml / kg/ hr Replace 2 – 6 hrs 5 ml / kg/hr Reduce 6 – 48 hrs 3 - 2 ml /Kg / hr

19. Group C – DSS – compensated Rescue - Resuscitate 0 - 2 hrs 10 ml / kg/ hr Replace 2 – 6 hrs 7 ml / kg/hr Reduce 6 – 48 hrs 5 - 2 ml /Kg / hr

20. Group D – DSS – Hypotensive Rescue 15 mins 10 - 20 ml /kg Repeat 3 times if there is no improvement Resuscitate 0 - 2 hrs 10 ml / kg/ hr Replace 2 – 6 hrs 7 ml / kg/hr Reduce 6 – 48 hrs 5 - 2 ml /Kg / hr

21. Indications for blood transfusion (Hypotensive shock) Persistent Shock after 3 fluid bolus Rapidly falling hematocrit Major bleeding – hematemesis , hematochezia , malena Whole blood 10 ml / kg or Packed RBC 5 ml / kg over 1 hour Fresh blood is preferred

22. Indications for platelet transfusion Platelet count < 10,000 Platelet count < 20,000 with bleeding If bleeding occurs when platelet is > 20,000 – look for coagulation abnormalities.

23. CRITERIA FOR DISCHARGING PATIENTS Absence of fever for at least 48 hours without antipyretics Return of appetite Good urine output Minimum of three days after recovery from shock No respiratory distress from pleural effusion and no ascites Platelet count of more than 1,00,000/mm 3

24. Don’ts for doctors Avoid Aspirin, NSAIDS Avoid IM injections Avoid giving intravenous therapy before there is evidence of hemorrhage and bleeding. Avoid giving blood transfusion unless indicated. Avoid giving steroids. Do not use antibiotics.