Dengue Guidelines for Hospitals NDMA Pakistan dengue fever

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Dengue Guidelines for Hospitals NDMA Pakistan dengue fever Powered By Docstoc
					         Guiidelliines ffor Reporttiing and Hospiittall Case Managementt off
         Gu de nes or Repor ng and Hosp a Case Managemen o
                Dengue Fever and Dengue Hemorrhagiic Fever
                 Dengue Fever and Dengue Hemorrhag c Fever

Introduction                                                 o   Positive tourniquet test-The tourniquet test is
                                                                 performed by inflating a blood pressure cuff to
Dengue is the most widespread mosquito-borne                     a point mid-way between the systolic and
infection in human beings, which in recent years has             diastolic pressures for five minutes. A test is
become a major international public health concern.              considered positive when 10 or more
It is usually found in tropical and sub-tropical regions         petechiae per 2.5 cm (1 inch) are observed.
around the world, particularly in urban and semi-                In DHF, the test usually gives a definite
urban areas. Over the last 15 years, we have                     positive result (i.e. >20 petechiae). The test
witnessed a dramatic increase in the global                      may be negative or mildly positive during the
incidence of dengue and its severe manifestations                phase of profound shock.
such as Dengue Hemorrhagic Fever (DHF) and                   o
Dengue Shock Syndrome (DSS). Almost 95% of                   o
Dengue cases are amongst children under the age                  bleeding from gums), injection sites or other
of 15 years. Without proper management, Dengue                   sites
Hemorrhagic Fever case fatality rates can exceed             o
20%, however, with modern intensive supportive               o   Thrombocytopaenia (platelets 100,000/
therapy these rates can be reduced to less than 1%.              or less) and
                                                             o   Evidence of plasma leakage due to increased
                                                                 capillary permeability manifested by one or
                                                                 more of the following:
Clinical Presentation of DF/DHF                                     A > 20% rise in haemotocrit for age and
I-  Asymptomatic:      Patients may not present
                                                                    A >20% drop in haemotocrit following
    with symptoms.
                                                                        treatment with fluids as compared to
II- Symptomatic
    o Undifferentiated Fever
                                                                    Signs of plasma leakage such as pleural
    o Dengue Fever
                                                                        effusion, ascites or hypoproteinaemia.
            1. Without hemorrhage
            2. With unusual hemorrhage
    o Dengue Hemorrhagic Fever
            1. No shock                                    Dengue Shock Syndrome (DSS)
            2. DSS                                         All the above criteria of DHF plus signs of circulatory
                                                           failure manifested by rapid and weak pulse, narrow
                                                           pulse pressure (< or equal to 20 mm Hg);
                                                           hypotension for age, cold and clammy skin and
Recognition of Dengue Fever/Dengue
Hemorrhagic Fever (DF/DHF)
Dengue Fever is an acute febrile illness of 2-7 days
duration (sometimes with two peaks) with two or
more of the following manifestations:                      Disease Course
                                                           Most patients have a febrile phase lasting 2 -7
     o    headache
                                                           days, followed by a critical phase of about 2-3 days
     o    retro-orbital pain
                                                           duration. During this phase, the patient is afebrile,
     o    myalgia/arthralgia
                                                           and is at risk of developing DHF/DSS which may
     o    rash
                                                           prove fatal if prompt and appropriate treatment is not
     o    hemorrhagic manifestation
                                                           provided. Since haemorrhage and or shock can
     o    leucopenia
                                                           occur rapidly, arrangements for rapid and
In children, DF is usually mild. In some adults, DF        appropriate treatment should be always available.
may be the classic incapacitating disease with             By doing this, the case fatality rate can be
severe bone pain and recovery may be associated            substantially reduced. The disease course of
with prolonged fatigue and depression.                     DF/DHF is summarized below:
Dengue Hemorrhagic Fever is a probable case of
Dengue with hemorrhagic tendency evidenced by
one or more of the following:
Grading the Severity of Dengue Infection                          (2) Dengue Hemorrhagic Fever (DHF) Grades I and II
DF/DHF    Grade          Symptoms              Laboratory         As in DF, during the afebrile phase of DHF Grades I and II,
                                            Leucopenia            the patient has the same symptoms as during the febrile
                    Fever with two or                             phase. The clinical signs plus thrombocytopenia and
                    more of the following                         haemoconcentration or rise in haematocrit are sufficient to
DF                  signs: headache,
                                            may be present, no    establish a clinical diagnosis of DHF. During this phase,
                    retro -orbital pain,
                                            evidence of plasma    the patients should be observed for at least 2-3 days after
                    myalgia, arthralgia
                                            loss                  the fall in temperature, for rashes on the skin, bleeding
                    Above signs plus        Thrombocytopenia      from nose or gums, blue spots on the skin or tarry stools. If
DHF           I     positive tourniquet     <100,000, Hct rise    any of these signs are observed, the patients should be
                    test                    >20%
                                                                  brought to the hospital without delay. The only difference
                    Above signs plus        Thrombocytopenia
DHF          II     spontaneous             <100,000, Hct rise    between the DF and DHF Grade I is the presence of
                    bleeding                >20%                  thrombocytopenia and rise in haematocrit (>20%).
                    Above signs plus                              Patients with DHF Grade I do not usually require
                    circulatory failure     Thrombocytopenia      intravenous fluid therapy and ORT is sufficient.
DHF          III    (weak pulse,            <100,000, Hct rise    Intravenous fluid therapy may need to be administered
                    hypotension,            >20%                  only when the patient is vomiting persistently or severely,
                    restlessness)                                 or refusing to accept oral fluids. Patients with DHF Grade I
                    Profound shock with     Thrombocytopenia      who live far away from the hospital or those who are not
DHF          IV     undetectable blood      <100,000, Hct rise
                                                                  likely to be able to follow the medical advice should be
                    pressure and pulse      >20%
                                                                  kept in the hospital for observation.
Management of DF and DHF
                                                                  During the afebrile phase of DHF Grade II, the
Febrile Phase                                                     complications usually seen, in addition to those observed
In the early febrile phase, it is not possible to distinguish     during the DHF Grade I phase, are abdominal pain, black
DF from DHF. Their treatments during the febrile phase            tarry stools, epistaxis, bleeding from the gums, and
are the same, symptomatic and largely supportive:                 continued bleeding from injection sites. Immediately after
  o      Rest.                                                    hospitalization, haematocrit and platelet count must be
  o      Paracetamol (not more than 4 times in 24 hours)          carried out to assess the patient’s condition. A reduction in
                                              o                                                          3
         according to age for fever above 39 C.                   the platelet count to 100,000/mm or less than 1-2
  o      Do not give Aspirin or Ibuprofen. Aspirin can            platelets/oil field (average of 10 oil field counts) usually
         cause gastritis and/or bleeding. In children,            precedes a rise in haematocrit. A rise in haematocrit of
         Reye’s syndrome (encephalopathy) may be a                20% or more (e.g. increase from 35% to 42%) reflects a
         serious complication.                                    significant plasma loss and indicates the need for
  o      Do not give antibiotics as these do not help.            intravenous fluid therapy. Early volume replacement of lost
  o      Oral rehydration therapy is recommended for              plasma with isotonic solution can reduce the severity of
         patients with moderate dehydration caused by             the disease and prevent shock. Intravenous fluid therapy
         vomiting and high temperature.                           before leakage is not recommended. In mild to moderate
  o      Food should be given according to appetite.              cases of DHF Grade II, intravenous fluid therapy may be
                                                                  given for a period of 12-24 hours in hospital. Patients
In Children, with signs of some dehydration, oral                 should be monitored on an hourly for vital signs, the
rehydration solution which is commonly used in the                treatment should be reviewed and revised.
treatment of diarrhoeal diseases and/or fresh juices are
preferable (50ml/kg bodyweight fluids should be given             (3) DHF Grades III and IV
during the first 4-6 hr)s. After correction of dehydration, the   Common signs of complications observed during the
child should be given maintenance fluids orally at the rate       afebrile phase of DHF Grade III include circulatory failure
of 80-100 ml/kg bodyweight in the next 24 hrs. Children           manifested by rapid and weak pulse, narrowing of the
who are breastfed should continue to be breastfed in              pulse pressure and hypotension, characterized by high
addition to ORS administration. In adults, oral fluid intake      diastolic pressure relative to systolic pressure (for example
of 2.5-4 liters should be given per day.                          90/80) and the presence of cold clammy skin and
                                                                  restlessness. These complications occur because of
All dengue patients must be carefully observed for
                                                                  thrombocytopenia, abnormal haemostasis and plasma
complications for at least 2 days after recovery from
                                                                  leakage, or also from substantial blood loss. Immediately
fever. This is because life threatening complications
                                                                  after hospitalization, the haematocrit, platelet count and
often occur during this phase. Patients and
                                                                  vital signs should be examined to assess the patient’s
households should be informed that severe abdominal
                                                                  condition and intravenous fluid therapy should be started.
pain, passage of black stools, bleeding into the skin or
                                                                  The patient requires regular and sustained monitoring. If
from the nose or gums, sweating, and cold skin are
                                                                  the patient has already received about 1,000 ml of
danger signs. If any of these signs is noticed, the
                                                                  intravenous fluids and the vital signs are still not stable,
patient should be taken to the hospital.
                                                                  the haematocrit should be repeated and: (a) if the
The patient who does not have any evidence of                     haematocrit is increasing, intravenous fluid should be
complications and who has been afebrile for 2-3 days              changed to colloidal solution preferably Dextran, or (b) if
does not need further observation and may be discharged.          haematocrit is decreasing, fresh whole blood transfusion
                                                                  10ml/kg/dose should be given. During the afebrile phase
Protocol for management according to Phases of                    of DHF Grade IV, vital signs are unstable. The patient, in
DHF                                                               the early stage of shock, has acute abdominal pain,
                                                                  restlessness, cold and clammy skin, rapid and weak pulse.
(1) Dengue Fever
Constitutional symptoms in patients with DF after the fall of
fever are as during the febrile stage. Most patients will
recover without complication.
    A chart illustrating the volume replacement for patients with DHF with Grade III and IV
                                                             UNSTABLE VITAL SIGNS
                                                                Urine Output Falls
                                                                 Signs of Shock

                           Immediate rapid volume replacement initiate IV therapy 10-20 ml/kg/h Isotonic solution for 1 hr

                         Improvement                                                             No Improvement

         IV Therapy by isotonic successively reducing                                                 Oxygen
           from 20 to 10, 10 to 6, and 6 to 3 ml/kg/h

                    Further Improvement                                   Haematocrit                                  Haematocrit
                                                                            Rises                                         Falls

                   Discontinue intravenous
                   therapy after 24-48 hrs                         IV Colloid (Dextran 40) or
                                                                      plasma 10ml/kg/hr as                   Blood transfusion (10ml/kg/hr) if
                                                                  intravenous bolus (repeat if                  haematocrit is still >35%


                                                                                               IV Therapy by isotonic,
                                                                                           successively reducing the flow
                                                                                            from 10- to 6, 6 to 3ml/kg/hr
                                                                                            Discontinue after 24-48 hrs

Important Instructions for Treatment of                                         o     For correction of acidosis (sign: deep breathing),
                                                                                      use sodium bicarbonate.
o    Cases of DHF should be observed every hour.
                                                                                What not to do
o    Serial platelet and haematocrit determinations,                            o     Do not give Aspirin or Ibuprofen for treatment of
     drop in platelets and rise in haematocrit are                                    fever.
     essential for early diagnosis of DHF.                                      o     Avoid giving intravenous therapy before there is
o    Timely intravenous therapy – isotonic crystalloid                                evidence of haemorrhage and bleeding.
     solution – can prevent shock and/or lessen its                             o                                                  ed,
     severity.                                                                        reduction in haematocrit or severe bleeding.
o                                                                               o     Avoid giving steroids. They do not show any
     giving 20ml/kg/hr for one hour, replace                                          benefit.
     crystalloid solution with colloid solution such as                         o     Do not use antibiotics
     Dextran or plasma. As soon as improvement                                  o     Does not change the speed of fluid rapidly, i.e.
     occurs replace with crystalloid.                                                 avoid rapidly increasing or rapidly slowing the
o    If improvement occurs, reduce the speed from                                     speed of fluids.
     20 ml to 10 ml, then to 6 ml, and finally to 3                             o                       sogastric tube to determine
     ml/kg.                                                                           concealed bleeding or to stop bleeding (by cold
o                                                                                     lavage) is not recommended since it is
     ml/kg and then give crystalloid IV fluids at the                                 hazardous.
     rate of 10ml/kg/hr.
o    In case of severe bleeding, give fresh blood                               Reporting
     transfusion about 20 ml/kg for two hours. Then
     give crystalloid at 10 ml/kg/hr for a short time                           Based on case-definitions, all suspected, probable
     (30-60 minutes) and later reduce the speed.                                and confirmed cases of DF/DHF should be reported
o                                                                               to relevant health authorities at district, provincial
                                                                                and national level.
Annex I Hospital Daily Reporting Form

 Annex II Laboratory Request Form

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