fluid management Dengue Monitoting in hospital .ppt

fluid management Dengue Monitoting in hospital

1. 3. Documentation and
Monitoring of Dengue Patients
Dengue Expert Advisory Group

2. •To differentiate DHF from DF
•Assessing onset of Critical Phase of DHF
•Smooth manipulation of fluids averting
prolonged shock and fluid overload
•Early detection of complications
•Recognition of unusual presentations

3. •Pulse rate
•Pulse pressure
•CRFT
•Respiratory rate
•FBC - HCT
•Intensity of monitoring depends on
•Phase of the illness
•Severity
•Aggressiveness of fluid therapy
•Accurate fluid balance charts

4. Ministry of Health Sri Lanka

7. •Dengue or not?
–Clinical
–FBC
•Leucopaenia + thrombocytopaenia
•DF or DHF ?
–Plasma leakage + or –
•If DHF – what is the phase ?

8. • Critical phase
–Time of entry
–Predicted time of end
•Aggressive monitoring
•Calculate the fluid quota
•Dynamic approach to fluid therapy
•Final diagnosis – precise (DF or DHF &
grade)

9. •Dropping Platelets
•HCT rise of more than 20% of base line
Conforms DHF as it signify leak.
Even If
HCt rise less than 20% but pleural
effusion/ascites present conforms diagnosis
of DHF/DSS( it is mostly due to early
volume replacement or bleeding).

10. •Febrile phase
•Critical phase
•Convalescent phase
•Day of the illness ?
•Evidence of plasma leakage ?
•Convalescent rash ?
Assess

11. •Detection of shock
•Pulse pressure < 20 mm Hg
•CRFT > 2 secs
•HCT increase of 20% or more from baseline
• Efficacy of IV fluid therapy
•Pulse pressure, capillary refill time, hypotension
•To keep urine output at least 0.5 – 1.0 ml/kg/hr
•Early detection of Fluid overload
•Respiratory rate > 20/mt
•Lung bases
•SaO2 < 92%
•CXR

12. •Misjudging of critical phase
which could begin as early as day 3 (if
fever
drop on day 3).
• Delay in doing the WBC, platelets and Hct
determinations.
which help predict the critical stage/shock


Lead to misdiagnosis and/or delay until shock

occur.

13. Dengue
Fever
D4 without
Fever
D3 with Fever
WBC
<5000/mm
3
N-40% L-58%
TT + ve
Hct
%

14. Entry in to critical phase
D4 with Fever
TT + ve, WBC
<5000/mm
3
N-40% L-58%
Tender Liver

15. 17
th

8 am
D3
18
th
8 am
D4
18
th

8 pm
D4
19
th
8 am
D5
19
th
8 pm
D5
20
th

8 am
D6
20
th

8Pm
D6
21
st
8 am
D7
21
st
8 pm
D7
WBC 32002800 1900 2900 3700 4500 6000 7000 7300
N % 53 41 31 26 25 31 33 43 58
L % 44 56 68 71 73 67 66 55 41
PCV
%
39 36 39 42 43 39 44 43 38
Plt 25200
0
12100
0
11000
0
610002200018000120008000 19000
Onset End

16. Phase of the illness – be fully aware
•Adequacy of fluid therapy
•Pulse Pressure >20 mmHg
•CRFT <2 sec
•Pulse Rate <80/mt
•UOP > 0.5 ml/Kg/hr
•HCT
•Early detection of fluid overloading
Respiratory rate > 20/mt
•Lung bases
•SaO2 < 92%
•CXR
Shift
ICU

17. HCt
Urine output
(based on IBW)
General condition
Appetite
Vomiting
Bleeding
Peripheral Perfusion
Pulse volume
Skin colour
Skin Temp.
CRFT
Fluid Therapy
PR
RR
BP/PP

18. •If Afebrile Pt.
•Restless
•Irritable
•Pulse rate
•Pulse volume poor
•CRFT>2 sec
•Skin cold
•Pulse pressure<20
•HCT
•Urine output<0.5 ml/kg
Decision
IV Fluid Bolus

19. •Afebrile
•Restless
•Confused
•Pulse volume poor
•Skin pale
•CRFT>2 sec
•Urine output < 0.5ml/kg/hr
•PR
•BP
•PP
•HCt
Decision
Blood Transfusion

20. Afebrile patient
•Puffy eyelids
•Distended
abdomen
•Tachypnea
•Dyspnoea
•orthopnea
•Respiratory
distress
Vital Signs
•Pulse volume
good
•Skin colour
normal
•Skin temp. normal
•Pulse pressure
• wide
•Urine output >
1ml/kg/hr
•CRFT< 2 sec
•PR
•BP
•HCt
Decision
Dextran 40
with frusemide

21. •Be vigilant to recognize DSS as most of the
patients remain in good conscious and have
narrow pulse pressure with increased
diastolic pressure(e.g.BP=110/90, 100/80mm
Hg) without hypotension.
•Avoid misdiagnosis of DHF in Infants(<1
year) with fits as sepsis/infection followed by
LP leading to bleeding/ hematoma(platelets )

22. •Your initial timing of critical phase may
prove to be sometimes wrong
Be prepared to
change what you decided earlier or shift
the timing based on more information you
receive while Mx.

23. •Try to Master the ways of giving
‘ THE SMOTHEST AND THE MOST
UNEVENTFUL RECOVERY’ for the
patient.
•Avoid both shock and fluid overload.
•Keep ‘CHECKING ON A TIME SCALE’…
R u heading for fluid overload? If so,
switch to a colloid.

24. •At ‘END OF LEAKING PHASE’ even if PCV
is high but patient is well, pulse, BP is OK
•Don’t try to correct PCV as re absorption
will start soon and PCV will come down so..



WAIT.

25. •About 60% of DSS can be successfully
resuscitated by using crystalloid solution only,
20% need colloidal and 15% need blood
transfusion (+blood components).
•With rapid recognition of shock and proper
treatment rapid and dramatic recovery is the
rule