Fluid management in dengue hemorrhagic fever

Fluid management in dengue hemorrhagic fever

1. 2. Fluid Management in 2. Fluid Management in
Dengue Hemorrhagic FeverDengue Hemorrhagic Fever
Dengue Expert Advisory Dengue Expert Advisory
GroupGroup

2. Dengue Virus InfectionDengue Virus Infection
•AsymptomaticAsymptomatic
•Symptomatic Symptomatic
– Undifferentiated Febrile Illness – Undifferentiated Febrile Illness
– Dengue – Dengue
Fever Fever
– Dengue Hemorrhagic Fever – Dengue Hemorrhagic Fever
 Non Shock Non Shock
 Shock Shock

3. Dengue Hemorrhagic FeverDengue Hemorrhagic Fever
•Febrile PhaseFebrile Phase
•Critical phase characterized by plasma Critical phase characterized by plasma
leakleak
•Convalescent PhaseConvalescent Phase

4. Dengue “Leak” FeverDengue “Leak” Fever
•Plasma leak during critical phase is the Plasma leak during critical phase is the
hall markhall mark
•Leading to 3Leading to 3
rdrd
space losses space losses
– peritoneal cavity – peritoneal cavity
– pleural cavity – pleural cavity
•Variable in magnitude and exact timingVariable in magnitude and exact timing

6. Pathogenesis of leakPathogenesis of leak
•Infection with a virulent dengue virus Infection with a virulent dengue virus
•Presence of antibodies that enhance Presence of antibodies that enhance
dengue virus infection (ADE)dengue virus infection (ADE)
•Intense immune activationIntense immune activation

7. PathogenesisPathogenesis
•Rapidly elevated cytokines (TNF-a, IL-2, Rapidly elevated cytokines (TNF-a, IL-2,
IL-6, IL-8, IL-10, IL-12, and IFN-g)IL-6, IL-8, IL-10, IL-12, and IFN-g)
•Malfunction of vascular endothelial cellsMalfunction of vascular endothelial cells
•Plasma leakage from intra to Plasma leakage from intra to
extravascular spaceextravascular space

8. PathogenesisPathogenesis
•In severe DHF the loss of plasma is criticalIn severe DHF the loss of plasma is critical
•Patient becomes hypovolaemicPatient becomes hypovolaemic
•Signs of circulatory compromiseSigns of circulatory compromise
•Progress to shock, organ failure, deathProgress to shock, organ failure, death

9. PathogenesisPathogenesis
•Cytokine StormCytokine Storm
•Self limitedSelf limited
•Ends after 48 hoursEnds after 48 hours

10. Clinical ImplicationsClinical Implications
•Extravascular fluid loss at variable rate Extravascular fluid loss at variable rate
that has to be matched ml for mlthat has to be matched ml for ml
•Lasting 48 hoursLasting 48 hours
•Resorption of fluid during convalescent Resorption of fluid during convalescent
phasephase

11. Key PointsKey Points
•Manage critical phase with appropriate Manage critical phase with appropriate
volume volume
– Don’t under transfuse – Don’t under transfuse
– Don’t over transfuse – Don’t over transfuse
•Meticulous monitoring during critical Meticulous monitoring during critical
phase to match rate of fluid infusion with phase to match rate of fluid infusion with
rate of leak rate of leak

12. Monitoring ParametersMonitoring Parameters
•Clinical Clinical
– Pulse Rate – Pulse Rate
– Blood and – Blood and
Pulse Pressure Pulse Pressure
– Capillary Refill Time – Capillary Refill Time
– Urinary Output – Urinary Output
•Lab Lab
– Hematocrit – Hematocrit

13. Fluid Management Fluid Management
Critical Phase Critical Phase

14. Amount of Fluid?Amount of Fluid?
•Based on weight Based on weight
•Adults Adults
– If less than 50kg use actual – If less than 50kg use actual
weight – If more take weight – If more take
weight as 50 kgweight as 50 kg
•Paediatrics Paediatrics
– Current OR Ideal body – Current OR Ideal body
weight whichever is lowerweight whichever is lower

15. Ideal Body WeightIdeal Body Weight
•Weight for height using a growth chartWeight for height using a growth chart
•Weight for ageWeight for age
•Formulae in emergencyFormulae in emergency

16. Growth ChartsGrowth Charts

19. FormulaeFormulae
•<1 year : Age (in Months)+ 9/2
•1-7 years : (Age x 2)+ 8
•>7 years : Age x 3
•APLS : (Age in years + 4) x 2

20. Fluid Quota Fluid Quota
•M + 5% = Maintenance + 5% of body
weight
•Over 48 hours if patient presents in the Over 48 hours if patient presents in the
beginning of critical phase (without shock)beginning of critical phase (without shock)
•Over 24 hours for patients coming in Over 24 hours for patients coming in
shockshock

23. M + 5% - AdultsM + 5% - Adults
•Maintenance Maintenance
– 1 – 1
stst
10 kg – 1000 mls 10 kg – 1000 mls
– 2 – 2
ndnd
10 kg – 10 kg –
500 mls – 500 mls –
Remaining 30kgs – 600 mls Remaining 30kgs – 600 mls
– Sum = 2100 mls – Sum = 2100 mls
•5% deficit – 50 x 50 = 2500 mls5% deficit – 50 x 50 = 2500 mls
• Total = 4600 mlsTotal = 4600 mls

24. Child 22 kgChild 22 kg
•Maintenance Maintenance
– 1000 + 500 + 40 = 1540 mls – 1000 + 500 + 40 = 1540 mls
•5% Deficit – 50 x 22 = 1100 mls5% Deficit – 50 x 22 = 1100 mls
•Total 2640 mlsTotal 2640 mls

25. Types of FluidTypes of Fluid
•Crystalloids Crystalloids
– 0.9% Saline – 0.9% Saline
– 5%Dextrose 0.9% – 5%Dextrose 0.9%
Saline Saline
– 5% Dextrose ½ saline– 5% Dextrose ½ saline

27. Monitoring – Critical Phase Monitoring – Critical Phase
•Vital parameters - hourlyVital parameters - hourly
•Fluid balance chart - assess three hourlyFluid balance chart - assess three hourly
•HCT - six hourlyHCT - six hourly

28. Fluid Management in Fluid Management in
Dengue Shock Dengue Shock
SyndromeSyndrome

29. CompensatedCompensated
•Body compensates for fluid lossBody compensates for fluid loss
•TachycardiaTachycardia
•Pulse Pressure narrowsPulse Pressure narrows
•Prolonged CRTProlonged CRT
•Fall in urine output to 0.5 mls/kg/hr Fall in urine output to 0.5 mls/kg/hr

30. DecompensatedDecompensated
•Pulse pressure narrows further leading to Pulse pressure narrows further leading to
unrecordable pulse and BPunrecordable pulse and BP
•Urine output falls less than 0.5 mls/kg/hourUrine output falls less than 0.5 mls/kg/hour
•Supply to myocardium and brain Supply to myocardium and brain
compromisedcompromised

31. Fluid ResuscitationFluid Resuscitation
•Crystalloids – N SalineCrystalloids – N Saline
•Colloids Colloids
– Dextran 40 in saline – Dextran 40 in saline
– 6% – 6%
StarchStarch
•All boluses part of fluid quotaAll boluses part of fluid quota

32. Indications for Colloid Indications for Colloid
•Failure of crystalloid boluses to normalize Failure of crystalloid boluses to normalize
pulse /BP pulse /BP
•Development of shock Development of shock
– with fluid overload – with fluid overload
– amount of fluid – amount of fluid
exceeding M + 5% deficitexceeding M + 5% deficit
•10 ml/kg over 1 hour10 ml/kg over 1 hour

33. ColloidsColloids
•Dextran may sometimes interfere with Dextran may sometimes interfere with
grouping and cross matchinggrouping and cross matching
•3 doses of Dextran 40 during a 24 hour 3 doses of Dextran 40 during a 24 hour
•5 doses of 6% Starch during 24 hour5 doses of 6% Starch during 24 hour
•Remain in circulation for much longerRemain in circulation for much longer

36. Refractory Shock - ABCSRefractory Shock - ABCS
•Blood Blood
– packed cells – packed cells
– whole blood – whole blood
•BicarbonateBicarbonate
•GlucoseGlucose
•CalciumCalcium

37. Monitoring During ShockMonitoring During Shock
•15 minute monitoring of vital signs 15 minute monitoring of vital signs
•HCT immediately before and after each HCT immediately before and after each
fluid bolus and then at least two to four fluid bolus and then at least two to four
hourlyhourly

38. Key Points – Managing DHFKey Points – Managing DHF
•Recognizing the start of critical phase of Recognizing the start of critical phase of
DHFDHF
•Predicting the rate of leak which may vary Predicting the rate of leak which may vary
from patient to patient and within the same from patient to patient and within the same
patientpatient
•Matching the rate of infusion to rate of leakMatching the rate of infusion to rate of leak
•Being cognizant of the end of critical Being cognizant of the end of critical
phasephase

39. Key Points – Managing DSSKey Points – Managing DSS
•Meticulous monitoringMeticulous monitoring
•Switching appropriately from crystalloids Switching appropriately from crystalloids
to colloidsto colloids
•Recognizing need for blood transfusionRecognizing need for blood transfusion