Management of Dengue by National Guideline of Bangladesh

Management Of Dengue Bangladesh

1. Management Of Dengue Dr. Fahim Shahriar Intern Doctor Dept of Medicine Central Medical College & Hospital Cumilla

2. Swahili phrase “Ka- Dinga pepo”, meaning “Cramp-Like-Seizure caused by an evil spirit”. The Swahili Word ‘ Dinga ’ may possibly have its origin In the Spanish Word “ Dengue ” meaning “ Fastidious or careful, painful gait.” Chinese Medical encyclopedia from the ‘ Jin Dynasty’ which referred to a “water poison” associated with flying insects”

3. 1635- First Outbreak in French West indies 1780- Simultaneous outbreaks happened in Asia, Africa & North America 1789- Dr.Benjamin Rush; Philadelphia “Break-Bone Fever” The Disease is now endemic in more than 100 countries

4. Vector Biology Acute Viral Infection – Main Vector is Aedes Aegypti and Aedes Albopictus. Belongs to Flavivirus genus. They Possess 4 distinct serotypes DEN1,DEN2,DEN3,DEN4 Infection With 1 serotype confers Lifelong immunity to that serotype, Elicit cross protection for only few months to other. A Second Infection with a different Serotype is associated with enhanced risk for severe disease

5. Pathophysiology AD Enhancement Complement activation T cell mediated immunopathology Cytokine abundance

6. Natural Course Of Dengue After the incubation period, the illness often begins abruptly with fever and will follow three phases:   Febrile      Critical Recovery

7. Symptoms Of Dengue 1. Febrile Phase Sudden-Onset Fever Muscle and Joint Pains Eye Pain Rash Headache Mouth and N ose Bleeding Bone Pain Nausea Diarrhea Vomiting 2 . Critical Phase Hypotension Ascites Pleural Effusion Gastrointestinal Bleeding 3. Recovery Phase Altered Level of Consciousness Itching Seizures Slow Heart rate

8. Lab Test For Diagnosis 1. NS1 Antigen: rapid test- + within minutes of starting symptoms. This test becomes (-) from day 4-5 of illness. 2 . Dengue IgM/IgG: Can be detected after 5days of the onset of fever and highest level achieved after 7days. *In primary dengue infection –IgM more than IgG. *Level of IgG Persists at low levels for decades,indicating Past infection. *In Secondary Dengue infection –IgG higher levels and Low levels of IgM 3 . Nucleic acid detection : Rt-PCR or Real Time PCR. 4. Dengue Virus Isolation & culture.

9. Other Required Investigations: Complete Blood Count- ( Hct /Platelet count/WBC count) SGPT, SGOT Blood Urea, S Creatinine, S. Electrolyte,CRP . Blood Sugar Chest Xray USG Of abdomen with special attention lower part of the chest.

10. Dengue Warning Sign Severe Abdominal Pain Persistent Vomiting Hepatomegaly Mucosal Bleeding High hematocrit/ Thrombocytopenia Lethargy or Restlessness Serosal Effusion

11. Isolated Organopathy

12. Group A OPD Management (Mild) Symptomatic Treatment : * Paracetamol 4g max per day in adults. *Adequate Fluid Intake 2-2.5L/day. *Adequate Rest *Antiemetic /Antihistamine if required. *Tepid sponging. Advised : *Avoid Aspirin, Mefenemic acid,Ibuprofen or other NSAIDs, steriods,antibiotics *Advice for immediately return to hospital if development of any warning sign. &No urine output for 4-6hours

13. Group B- Hospital Care (Moderate) Rx: Encouragement for oral fluid If not tolerated, start intravenous fluid therapy 0,9% saline or Ringer Lactate at maintenance rate. Obtain reference Hct before fluid therapy Give Isotonic solution such as 0.9%saline, Ringer lactate, start with 5-7 ml/kg/hr for 1-2 hours, then reduce to 3- 5 ml/kg/hr for 2-4 hr, and then reduce to 2-3 ml/kg/hr or less according to clinical response

14. Febrile phase • Limit IV fluids. • Early IV therapy may lead to fluid overload especially with non- isotonic IV fluid Critical phase • IV fluids are usually required for 24–48 hours NOTE: For patients who present with shock, IV therapy should be <48 hours Recovery phase • IV fluids should be stopped so that extravasated fluids can be reabsorbed When to start and stop intravenous fluid therapy

15. Total Fluid Requirement= Maintenance+5%Defict 5%Deficit= 50ml×Kg up to 50kg. Calculation of Normal Maintenance: Holliday Segar formula. Constant periodic reassessment is needed, fluid rate should be adjusted according to the clinical condition, vital sign, Urine output and haematocrit level.

16. For overweight /obese pt Calculate normal maintenance fluid Based on Ideal Body Weight(IBW) using the Following Formula: Female: 45.5kg+0.91(Height-152.4) cm.Or 45.5kg+2.3×every inch more than 5 Feet. Male: 50.0kg+0.91(Height-152.4) cm.Or 50.0kg+2.3×every inch more than 5 Feet. Maintenance Fluid Should not exceed More than 3L/day

17. Group C: Emergency Management Pt with Shock: Adult: Compensated Shock- 5-10ml/kg for 1 hour Hypotensive Shock – 10-20ml/kg for 15-30minute Children: Compensated Shock- 10-20ml/kg for 1 hour Hypotensive Shock –20mL/kg for 15-30minute.

18. Profound shock Signs of shock, hypotension(BP undetectable, High HCT(>20% rise From baseline Immediate rapid volume replacement:give 10-20 mL/kg crystalloid solution as rapid bolus over 15-30 min Improvement in VS&HCt No improvement in VS Repeat 10-20ml/kg crystalloid/colloid*second bolus over 15-30min Reduce the rate of IV F To 7->5->3->1.5ml/kg/ hr (in adults 250->150->100->80->40->KVO)and then stop at 24+hr Check HCT Further improvement in VS Discontinue IV after 24-48h) Improvement in Hct &VS Hct rises or >45% IV colloid/crystalloid 10-20ml/kg over 1hr No improvement Improvement In VS Hct falls Suspected Bleeding Blood transfusion (10 mL/kg wholeblood )(5 mL/kg packed RBC) Refractory Hypotension Look ABCS No improvement In VS IV inotropes with crystalloid Oxygen

19. Colloids are used in case of- • Hypotensive shock • Repeated shock – 2nd or 3rd shock and onwards • After >20 to 30 ml/kg of crystalloids • If Hct does not decrease after crystalloid administration in shock DOSE: Limited to 30 to 50 ml/kg/day

20. Indications for Blood Transfusion: Overt bleeding(More than 10% or 6-8ml/kg) Significant drop of HCT<40(<45for males) after fluid resuscitation Hypotensive Shock+low /Normal HCT Persistent or Worsening metabolic acidosis Refratory shock after fluid 40-50ml/kg Platelet Transfusion Is not recommended For Thrombocytopenia (No prophylaxis Platelet transfusion).

21. Flow diagram for the Management of Fluid Overload Dextran 40 rate 10ml/kg/ hr(in adults 500ml/hr) Furosemide 1mg/kg/dose iv (in adults 40mg)given midway of dextran Discontinue IV fluid Furosemide 1mg/kg/dose IV (40mg in adults) Stop iv fluid and follow up vital signs +amount of urine output Repeat Furosemide if signs/symptoms of fluid overload persist FWB 10ml/kg or 1unit in adults Ch eck ABCS again, consider mechanical ventilation , Pleural and/or peritoneal tapping Plan for dialysis(Peritoneal/Hemodialysis) Signs of fluid overload : Puffy eyelids, very distended abdomen Dyspnea/Tachypnea Positive lung signs: crepitation, wheezing, rhonchi Give Oxygen Insert urinary catheter Check ABCS and correct Check Hct NCPAP Reabsorption phase Critical (High +wide pulse pressure) >36hrs after shock/>60hrs after onset of leakage Improved With good urine output >1ml/kg/hr(>50ml/hr in adults) Not improved Hct ↓<10 points Hct ↓>10 points Or below baseline Critical / early convalescence phase Shock or signs of fluid overload

22. Following parameter should be Monitoring: Cardiac Index : Four ‘P’ – Pulse, Blood Pressure, CV Pressure, Pallor, Peripheral Warmth, Leg edema . Respiratory Index : Respiratory Rate (Target < 35), Pulse Oxymetry (SPO2), Pulmonary Edema (Basal Creps ), Breath Sound (Pleural Effusion) Renal Index: U/O > 0.5 ml/kg/ hour. General Index : Abdominal Girth, Appearance: Puffiness, Cyanosis, Abdominal distension & leg edema Breathing Pattern: Chest in drawing, supra, infra-clavicular & intercostal in drawing, GCS, Pyrexia

23. Discharge Criteria of a Dengue Pt: All Flowing criteria must be present: No fever for 48 hours Improvement in clinical picture Increasing trend of platelet count No respiratory distress Stable haematocrit without intravenous fluids

24. Dengue In Pregnancy First trimester: Abortion, Secondary infections Second Trimester: Severe bleeding ,abruption , threatened preterm labour, deranged coagulation profile, frequent transfusions Third trimester: Abruption ,increased incidence of Caesarean section, DIC, PPH, Haematoma formation, Infections , Delayed wound healing Maternal death due to DIC , Coagulopathy Low birth weight babies, Pre maturity Effects of Dengue Fever on Pregnancy:

25. • Conservative medical and obstetrical management is the treatment of choice. • Outcome seemed to correlate with the gestational age at which dengue infection was acquired. • No vaccination & only supportive medication. • Pregnancies complicated by dengue infection require close monitoring for potential maternal and fetal complications. • Timely Referral to higher centres Advice:

26. Dengue In Paediatric Age Group Features of Dengue in Neonates: Full spectrum of disease can occur • Fever, skin rash • Bleeding manifestation: - Purpura - Nose bleeding Gi bleeding - Pulmonary haemorrhage - Intracranial bleeding • Hepatic & Multi-organ failure • Maternal Dengue near term: May be an important clue • Anaemia, leucopenia , thrombocytopenia • CloseD /D – Neonatalsepsis,CongenitalInfection **Strong clinical Suspicion required for Diagnosis

27. “Flu” like features: High fever Running nose Cough Conjunctival congestion Vomiting, nausea, anorexia Irritability / excessive cry. Diarrhoea Like Presentation Bleeding Gum, nose, easy bruisability - Common Positive Tourniquet Test – Infants sensitivity of 33%, specificity of 76%. Clinical features of DF in infants:

28. Advice What should be done? • Adequate bed rest • Adequate fluid intake : Daily intake plus 5% Deficit (50ml/kg/day) • Note: Plain water alone may cause electrolyte imbalance . Oral rehydration solution (ORS) or barley/rice water/coconut water • Paracetamol - every 6 hours (maximum 4 doses per day) • Tepid sponging What should be avoided? • Do not take acetylsalicylic acid (aspirin), mefenamic acid, ibuprofen or other NSAIDs or steroids. • Do not take combination of paracetamol with above mentioned drugs. • Antibiotics are not necessary • Educate parents regarding warning signs • Close monitoring • Prevent spread of dengue within house

29. Dengue Prevention Check for Symptoms Use Insect Protection Avoid Public Spaces Use Air Cooling Prevent Entry

30. Thankyou Everyone