PROBLEMS AND MANAGEMENT OF DENGUE FEVER .pptx

Dengue Fever

1. DENGUE SAYA

2. EPIDEMIOLOGY one of the most important arthropod-borne viral diseases in terms of human morbidity and mortality affects tropical and subtropical regions around the world, predominantly in urban and semi urban areas cases in Malaysia shows an increasing trend

3. VIROLOGY Enveloped single-stranded RNA virus of flavivirus gp in the Flaviviridae family. transmitted by female Aedes aegypti and Aedes albopictus . 4 distinct serotypes, DEN-1, 2, 3 and 4

4. Dengue fever: acute febrile infectious ds transmitted by infected female Aedes mosquitoes. Viral NS1 protein adhere to heparan sulfate of endothelial cell  increased permeability. Life-long protective immunity after 1 st infection (towards homologous serotype) Secondary infection from different serotype will be worst than the 1 st d/t low grade Ab from 1 st serotype >>↑virus entrance into cell. ( Ab dependent enhancement phenomenon).

5. CLINICAL MANIFESTATIONS AND PATHOPHYSIOLOGY IP is 4-7 days (range 3-14) Febrile Phase ≥38.5C⁰ lasts 2-7 days (if >7d, consider other ddx ) a/w headache, retroorbital pain, generalised body ache, myalgia, arthralgia (break-bone fever), facial flushing, skin erythema. URTI sx ?? + ve Hess test Bld ix: progressive leukocytopenia (first abnormality in fbc followed by platlet

6. Hess test or torniqouet test ???????

7. Critical Phase around defervescence (3rd-5th day of illness but may go up to 7th day) T <38C⁰ 24-48 hours Systemic vascular leak syndrome Hematoconcentration (early marker), hypoproteinemia , pleural effusion, acsites (late marker) C linical warning signs: Abdominal pain, persistent vomiting, restlessness, altered conscious level, clinical fluid accumulation, mucosal bleed or tender enlarged liver Can lead to compensated shock and decompensated shock

8. Plasma leakage sympoms in severe dengue Skin- coolness, pallor, delayed crt Cvs - raised diastolic pressure and narrow pulse pressure < 20mmhg Renal- reduce urine output (IMPORTANT) Git - persistent vomitting , persistent diarrhea, abdominal pain Cns - restlessness, reduce consciousness Respiratory- tachypneic

9. Recovery Phase plasma leakage stops and is followed by reabsorption of extravascular fluid. Patients’ general well being improves Watch out for fluid overload in pt with CCF, NYHA class 4, kidney disease. ( Reabsorption hemodilution , hypervolaemia , pulm . Edema) “isles of white in the sea of red” or pruritus

10. Notification All suspected dengue must be notified within 24 hours

11. INVESTIGATION Wcc and platlet - it may normal in early febrile phase. Will reduce later Hematochrit Male < 60 y/o :46 Male >60 y/o : 42 Female all age group : 40 Diagnostic test Ns1- non structural protin-1( the sensitivity of ns1 may drop on day 4-5 of illness igM –can be detected after day 5-7 of illness (primary infection) igG - can be detected after day 7 of illness ( secondary infection) Can be used if igM is still – ve after day 7 (for primary infection) Pcr / viralolation / postmorterm - expensive

12. Severe dengue Blood gases and serum Lft / ast , renal function Creatininne kinase ( myocarditis or rhabdomyolisis ) GSH Imaging Ultrasound( pevidence of plasma leakage) Collapsibility of IVC

13. Management Dengue with no warning sign Dengue with warning sign Severe dengue with compensated shock Severe dengue with decompensated shock

14. Dengue without warning signs May be sent home Able to tolerate orally well,good urine output Examination:haemodynamic stable, not tachypneic,no hepatomegaly, no bleeding tendency, no altered mental status, Treatment Advice for: o Adequate bed rest o Adequate fluid intake Monitoring o Daily review for warning signs (until out of critical period) Daily fbc nearest clinic o Advice for immediate return to hospital if development of any warning signs

15. Dengue with warning signs Need referral Warnign sign Inable to tolerate orally Bleeding menifestations Reduce urine output Seizure Sign: dehydration, shock, organ failure,bleeding Special situation: old, DM, HPT, pregnant, renal failure, chronic liver disease

16. Obtain baseline hct before strt iv therapy Give crystalloid solutions??? Iv therapy – start 5 ml/kg/ hr for 1-2hr then reduce to 3ml/kg/ hr for 2-4 hr , then reduced 2ml/kg/ hr Monitor fluid status every 4-6 hour If clinical parameters rising, increase the infusion rate Review clinical status, repeat Hct

17. Special issues Mx of UGIB- transfused, PPI, endoscopy if indicated Mx of hepatitis in dengue- self limiting, NAC ( insufficient evidence to support) Mx cardiac compliocation in dengue Mx neuro complication in dengue Mx dengue in pregnant Allegnant mothers should be managed in hospital setting by physician and obstetrician Blood product will transfused if only indicated SVD ( mode of delivery ) Dengue serology and NS1 should be performed in neonates to comfirm congenital dengue (vertical transmitted)

18. Discharge criteria Improved general well being Afebrile 24-48 hours Rising wcc followed by platlet Stable hematochrit Resolution/recovery organ dysfunction

19. Metabolic acidosis- tissue hypoxia and hypoperfusion - give fluid Abg - monitor every 4-6 hour Electrolyte Suspect significant bleeding Hct is not high as expected for the degree of shock to be explained by plasma leakage A drop in haematochrit without clinical improvement instead of adequate resscussitation Metabolic acidosis and end organ dysfunction

20. Note: Low plt doesn’t indicate bleeding. Duration of shock does When to tx ? If bleeding + v/s not stable. No need for invasive mx ie long line/ ijc /chest tube even after critical phase in view of coagulopathy . Give fluid when necessary regardless other factors ie kidney dz , etc which can be mx during reabsorption phase. But do it carefully not to overload No inotropes during critical phase unless during severe metabolic acidosis. Always give fluid 1 st .

21. Thank you!