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Dengue the threat Slide dengue fever

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Dengue the threat Slide  dengue fever Powered By Docstoc
					            DENGUE
         IN
EMERGENCY DEPARTMENT

       Dr. Ananda Wijewickrama
 MBBS(COLOMBO), MD(COLOMBO), MRCP(UK), FCCP
          Consultant Physician
      Infectious Diseases Hospital
                 Colombo
                 Sri Lanka.
Why Dengue is important - 1
•
    2.5 billion people living in at-risk areas

       50 million dengue fever cases / yr

        500,000 severe dengue cases /yr



                  22,000 deaths / year
Current WHO Estimates
Why Dengue is important - 2
• 500 000 people with DHF require hospitalization
  each year, a very large proportion of whom are
  children. About 2.5% of those affected die.
• Without proper treatment, DHF fatality rates can
  exceed 20%. Wider access to medical care from
  health providers with knowledge about DHF -
  physicians and nurses who recognize its symptoms
  and know how to treat its effects - can reduce
  death rates to less than 1%.
• There is no specific treatment for dengue, but
  appropriate medical care frequently saves the lives
  of patients with DHF.
Temporal and Spatial Spread of Dengue Sri Lanka,
                 1996 - 2007
   1996
    1996   20020             2005
                               2005      2006
                2004                    2006    2009
            044




N=1294      N=15463          N=5994   N=11980   N=35007

                   Reported Cases
             DF/DHF cases by age groups Sri Lanka - 1996 and 2006
              400




                                                                                                                      1996
                                           318
               600
              300
                                                                      513
    Number




               500
                                    197
              200                                  181
                400                         352                               366
                                                               339
Number




               300                                  261              104      92      257
              100                    209                       73
                                                                                              189
               200                                                                    36      38        28
                                                                                                        141                             26
                           6                                                                                   15
                                                                                                               109      6       5
               100
               0                                                                                                        58              64
                            38                                                                                                  38

                    0   < 1 year    1-4    5-9    10-14    15-19     20-24   25-29   30-34   35-39    40-44   45-49   50-54   55-59    >60

                         < 1 year    1-4    5-9    10-14    15-19    20-24   25-29   30-34   35-39
                                                                                                       No. of cases analysed N= 1125
                                                                                                       40-44   45-49  50-54   55-59    >60
                                                                             Age group
                                                                               Age group             No. of cases analysed N= 2934

              1000                                                    904
                                                                              808
               800
Number




               600                                             532                   510
                                           493
                                                   395                                       425
               400                   327                                                               318
                                                                                                              260
                                                                                                                      198             218
               200                                                                                                            127
                            38
                    0
                         < 1 year    1-4    5-9    10-14   15-19     20-24   25-29   30-34   35-39    40-44   45-49   50-54   55-59   >60

                                                                              Age group
                                                                                                      No. of cases analysed N= 5553

                         Source: Epidemiology Unit Sri Lanka                                                                  Data as 22/01/2008
                                                                                                                                             6
Diagnosing Dengue
• An acute febrile illness of 2-7 days duration with two
  or more of the following manifestation:
   – headache,
   – retro-orbital pain,
   – myalgia,
   – arthralgia,
   – rash,
   – haemorrhagic manifestation,
   – lecuopenia

(WHO case definition – 1997)
              Features of DHF
•   Fever lasting 2-7 days
•   WBC <5000 /cumm
•   Thrombocytopaenia (<100,000 per mm3 )
•   Haemorrhagic manifestations
•   Signs of plasma leakage due to increased capillary
    permeability (the whole mark of DHF)
    – Pleural effusion, ascitis,
    – Rising Hct > 20%,
    – Shock if a critical intravascular volume is lost
    (Plasma leakage is continuous but last only for 48 hours.)
          In the Emergency Department
                                 37 yr old female with fever
A 52 yr old male admitted
                                   for 2 days, afebrile 1 day
  with H/O fever for 7 days.
  He had myalgia, retro-         She had headache, body
  orbital pain and was feeling     aches , had PV bleeding
  lifeless and ill.
                                 O/E Obese,Febrile & flushed
O/E Flushed skin, skin           BP 90/60 , pulse 100 /min,
  petichiae. Pulse 110/min.      Had R/pleural effusion,
  BP 100/80. Had R/pleural         hepatomegaly & ascites
  effusion.
WBC - 5000 HCT – 60.5            WBC-2100 HCT – 37.5
PLT - 12                         PLT - 26
           DHF with shock in ED
• How to resuscitate depends on
  haemodynamic status & the HCT.
• Judicious IV fluid resuscitation just sufficient to
  maintain the effective intravascular volume.
   – Too much fluid fluid overload
   – Too little fluid  prolonged shock
• In the critical period
   – Plasma leakage continues
   – Lasts only for 48 hrs
   – Leaked out fluid will be reabsorbed later.
• Other causes can contribute to shock:
  bleeding, acidosis, hypocalcaemia, hypoglycaemia
    Rising /persistently high HCT

Unstable vital signs
    Indicate active plasma leakage
    Require fluid boluses & replacement

Stable haemodynamic status + adequate
 UOP
    Does not require extra IV fluid
    Monitor closely
    It is likely that HCT will start to fall /next 24 hrs
       A decrease in haematocrit
Unstable vital signs (narrowing pulse pressure,
 hypotension, tachycardia, metabolic acidosis,
 poor urine output)
  – Indicates major haemorrhage
  – Need urgent blood transfusion.

Stable haemodynamic status and adequate UOP
  – Indicates haemodilution and/or reabsorption of
    extravasated fluids
  – STOP Intravenous fluids to avoid pulmonary oedema
          In the Emergency Department
                                 37 yr old female with fever
A 52 yr old male admitted
                                   for 2 days, afebrile 1 day
  with H/O fever for 7 days.
  He had myalgia, retro-         She had headache, body
  orbital pain and was feeling     aches , had PV bleeding
  lifeless and ill.
                                 O/E Obese,Febrile & flushed
O/E Flushed skin, skin           BP 90/60 , pulse – 100 /min,
  petichiae. Pulse 110/min.      Had R/pleural effusion,
  BP 100/80. Had R/pleural         hepatomegaly & ascites
  effusion.                      WBC-2100 HCT – 37.5
WBC - 5000 HCT – 60.5            PLT - 26
PLT - 12
              Management of DHF grade 3
       (Severe Dengue with Compensated Shock)
                      Check HCT
            350-500 ml N.Saline over 1 hour
Pulse, BP improved, HCT high     Pulse, BP not improved, HCT
                                     high
350-250 ml N.saline/hr for 2-3   Repeat fluid bolus
  hrs                            If same, HCT still high/rising
250-150 ml N. Saline/hr for 3-       give dextran
  4 hrs                          Correct hypocalcaemia, acidosis
100 ml N. Saline for 4-6 hrs         and hypoglycaemia.

Adjust fluid according to        If HCT is low or normal
  pulse, BP & UOP (0.5
  ml/kg/hr is adequate)          Urgent blood transfusion
Male with HCT 60.5             Female with HCT 37.5

500 ml of N.Saline in 1 hr    500 ml of N. Saline in 1 hr
Pulse, BP improves            1 unit of blood in 1 hr
Repeat HCT                    Pulse, BP improves. HCT 45
350 ml of N. Saline in 1 hr   N. Saline 250 ml/hr for 3 hrs
HCT 58                        Pulse, BP stable, HCT 44.
N.Saline 250 ml/hr for 3        UOP 40 ml/hr
  hrs                         N. Saline 150 ml/hr for 4 hrs
HCT 55. Stable.
UOP 30 ml/h
Total volume of fluid for critical period:
• 4600 ml for an average adult for critical 48 hour
  period.
• The minimal required volume
• Calculated as M+ 5%
    for the 1st 10 kg - 100 ml/kg
    for the 2nd10 kg - 50 ml/kg
    from 20 kg and above upto 50 kg – 20 ml/kg
  5% deficit 50 ml/kg BW upto 50 kg.

• Give fast first and then gradually reduce the rate
ml/hour




          M+5/48




                   Number of hours
              Fluid for shocked Patient
                  7-10 ml/kg


          1          2       5-7 ml/kg
                                           3                     53
105
                                                                 51
104
                               5-3 ml/kg
                                                           140   49
103
                                                                 47
102                              3-1 ml/kg                 120   45
101
                                                                 43
100
                                                           100   41
                                             KVO
99
                                                                 39
98
                                                           80    37
                         M + 5%                                  35
                                                           60




1     2       3          4          5          6   7   8
Indications for hypersomolar colloids
  • In patients with shock and high HCT, who do
    not respond to two boluses of crystolloids
  • In patients with shock and fluid overload
  • In patients who are being treated for shock
    and has high HCT and whose fluid quota
    (M+5%) is nearing completion

  40% Dextran or hyperosmolar starch solution
    are recommended. Given as boluses.
  Indications for Blood Transfusions
                   10-15% DHF patients may need blood

 Overt bleeding ( > 10% or 6-8ml/kg)
 Significant drop of HCT < 40 ( < 45 for males)
 Hypotensive shock + low/normal HCT
 Worsening metabolic acidosis
 Refractory shock after fluid 40-60 ml/kg

Circulatory failure with high HCT should be managed with colloids
                                 overloaded)
             ( + Lasix if fluid Rasnayaka M Mudiyanse before blood
                              Dr
       Success of management
• Prevention of shock and early detection of shock

• Proper Fluid Management

• Prevent overloading

• Transfuse blood when necessary.

• Transfuse hyperosmolar colloids when necessary

• Avoid NSAIDs, prophylactic transfusions of
  platelets, FFP, factor VII
Thank you !

				
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