DR CHAN SEE YUNHRPBIPOH

� Severe plasma leakage

� Severe haemorrhage

� Severe organ impairment

1 . Recurrent or persistent shock

2 . Respiratory support(non – invasive / invasive )

Indications for referral to Intensive Care

(non – invasive / invasive )

3.Significant bleeding

4.Encephalopathy or encephalitis

The management of DHF/ DSS in the intensive care unit (ICU) follows the general principles of

Intensive Care Management

care unit (ICU) follows the general principles of management of any critically ill patient in the ICU.

1st Indication :Dengue Shock Syndrome

• Early recognition and treatment of shock

• Early referral

• Severe dengue • Severe dengue • Dengue with warning signs

• Management of DSS is a medical emergency

• Early and effective replacement of plasma lossesresults in a favorable outcome

“ The key to success is

frequent monitoring and changing strategies

RECOGNIZE AND TREAT

depending on clinical and laboratory evaluations.”

In DSS, every minute counts towards a favorable outcome.

In dengue, hypotension is usually due to plasma leakage or internal bleeding.

Fluid resuscitation is crucial and should be initiated first.

Vasopressors may be considered when mean arterial pressure is persistently < 60 mmHg despite pressure is persistently < 60 mmHg despite ADEQUATE fluid resuscitation.

Inotropics and vasopressors support NOT the first line.

Main objectives of respiratory support

• support pulmonary gas exchange

2 nd Indication - Respiratory Support

• reduce the metabolic cost of breathing

� Reduces work of breathing & O2 consumption

� Improves oxygen delivery to tissues and allows

redistribution of blood flow to vital organs.

In general, respiratory support should be considered EARLY in a patient’s course of illness.

Respiratory Support

illness.

The decision to initiate respiratory support should be based on clinical judgement that considers the entire clinical situation.

� 1. Respiratory failure

� 2. Severe metabolic acidosis

� 3. Encephalopathy

Respiratory Support

1. Respiratory Failure

Time frame of plasma leakage

In early phase of plasma leakage, metabolic In early phase of plasma leakage, metabolic acidosis is secondary to tissue hypoperfusion. Appropriate management is fluid resuscitation and mechanical ventilation.

In late phase of plasma leakage, respiratory distress may be compounded by pleural effusion, ascites and acute pulmonary oedema.

2. Metabolic acidosis

In patients with metabolic acidosis,

Respiratory Support

In patients with metabolic acidosis, respiratory support should beconsidered despite the preservation of relatively normal arterial blood pH.

Respiratory Support

Severe shock is the result of inadequately treated plasma leakage ± bleeding.

Prolonged shock leads to metabolic acidosis

Severe metabolic acidosis is a late sign !

Prolonged shock leads to metabolic acidosis and multi-organ dysfunction.

Respiratory Support

Lactic acidosis in DSS

Lactate ( Normal < 2 mmol/l): end product of anaerobic glycolysis: end product of anaerobic glycolysis

1. An increase in blood lactate levels in patients who are haemodynamically unstable is taken as evidence of impaired oxygen utilization by cells / circulatory shock (Tissue hypoxia)

2. Liver failure

Recognize the decompensated patients :

When PaCO2 is higher than expected to compensate for the acidosis, the patient should be promptly intubated.

Respiratory Support

Formula to calculate the expected

PaCO2 = 1.5 x [HCO3-] + 8±2 mmHg

RECOGNIZE AND TREAT

3. Encephalopathy

Respiratory Support

In patients with encephalopathy and

GCS of < 9 , intubation is often required

to protect the airway.

Neurological impairment: possible causes

� Hypoxic encephalopathy

� Shock

Hyponatraemia � Hyponatraemia

� Metabolic acidosis

� Hepatic encephalopathy

� Dengue encephalitis

Types of Respiratory Support

Oxygen therapy delivering systems:

non – invasive :

� nasal prongs, simple face masks ,

venturi masks, high-flow masks ,

CPAP/BIPAP masks

invasive :

� endotracheal intubation

Oxygen therapy should be given to ALL

patients in shockpatients in shock

1. Central venous catheter (CVC) insertion

No studies on dengue patients with regards to invasive procedures and bleeding risks.

Volume resuscitation does not require a CVC if

Guide on safety and risk of invasive procedures

Volume resuscitation does not require a CVC if sufficient peripheral intravenous access can be obtained (e.g. 14- or 16-G intravenous catheters).

Peripheral intravenous catheterisation may bepreferable because a greater flow rate can be achieved.

Thrombocytopaenia and other bleeding diathesis are relative contraindications to CVC placement.

Guide on safety and risk of invasiveprocedures

Central venous catheter (CVC) insertion

relative contraindications to CVC placement.

High femoral, low internal jugular, and subclavian venous punctures are difficult to compress and confer an increased risk of uncontrolled bleeding.

Incidence of bleeding in patients with coagulopathy varies (0-15.5%).

Guide on safety and risk of invasive procedures

Central venous catheter (CVC) insertion

• Volume resuscitation does not require CVC if sufficient peripheral IV access can be obtained

• When CVC is indicated, it should be inserted by a skilled operator, preferably under ultrasound guidance

• Subclavian vein cannulation should be avoided as far as

possible.

• Intra-arterial cannulation is useful - enables

continuous arterial pressure monitoring and repeated

arterial blood gas sampling.

2. Arterial catheter insertion

arterial blood gas sampling.

It has a very low incidence of bleeding (1.8 – 2.6%)

• An arterial catheter should be inserted in DSS patients

who require intensive monitoring and frequent blood

taking for investigations.

If a gastric tube is required, the nasogastric route should be avoided.

3. Gastric tube

should be avoided.

Consider orogastric tube as this is less traumatic.

Intercostal drainage of pleural effusions should be avoided as it can lead to severe haemorrhage and sudden circulatory collapse.

4. Pleural tap and chest drain

Intercostal drainage for pleural effusion is not indicated to relieve respiratory distress.

Mechanical ventilation should be considered.

Take Home Messages

1. Recognize the severe cases.

2. Early referral to intensive care.

3. The management of DSS is a medical emergency and the key to success is frequent monitoring and changing strategies

4. Early recognition and treatment of shock improves outcome.

5. Worthwhile to admit the dengue patients to ICU.

6. Consider early respiratory support.

7. Metabolic acidosis is a late sign, don’t wait till patient collapses.

8. Inotropic and vasopressor support is not the answer to DSS, prompt and adequate fluid replacement is.

Take Home Messages

DSS, prompt and adequate fluid replacement is.

9. CVP monitoring is often not indicated but establishment of CVP may be necessary in the management of the severe cases that are not easily reversible.

10. Avoid invasive procedures e.g. chest drain, ascitic drainage as they can be hazardous.