management of dengue infection in adults (revised 2nd ... reference dengue management.pdf ·...

1

MANAGEMENT OF DENGUE INFECTION IN ADULTS (Revised 2nd Edition) QUICK REFERENCE FOR HEALTHCARE PROVIDERS

2


DISEASE NOTIFICATION

SuSpECT A CASE OF DENguE

KEY MESSAgES

• Dengueisadynamicdiseaseandpresentedinthreephases-febrilephase,criticalphaseandrecoveryphase.

• Clinicaldeteriorationoftenoccursinthecriticalphaseandismarkedbyplasmaleakageandrisinghaemotocrit(HCT).

• Lookoutforwarningsignswhichmayindicateseveredengueorhighpossibilityofrapidprogressionorshock.

• Recognitionofshock in itsearlystageandpromptfluid resuscitationwithclosemonitoringoffluidadjustmentwillgiveagoodclinicaloutcome.

• Thereisnoevidencetosupportprophylacticuseofplatelettransfusion.

Apatienthasanacutefebrileillnesswithtwo or more features:•Rash•Myalgia•Headache•Arthralagia OR Dengueendemic/hotspot/outbreakarea

•Leucopenia•Retro-orbitalpain•Haemorrhagicmanifestations

SuSpECT A CASE OF DENguE

DISEASE NOTIFICATION Allsuspecteddenguecases*mustbenotifiedbytelephonetothenearesthealthofficewithin24hoursofdiagnosis,followedbywrittennotificationwithinoneweekusingthestandardnotificationform.

LABORATORY INTERpRETATION • In theabsenceofbaselineHCT,aHCTvalueof>40%inadult femaleand

>46%inadultmaleshouldraisethesuspicionofplasmaleakage.

DENguE SEROLOgY TESTS• IfthedengueIgMisnegativebeforeday7,arepeatsamplemustbetakeninthe

recoveryphase.• Denguenon-structuralprotein-1(NS1Antigen)canbehelpfulinearlyphase

(<day5)ofdengueinfection.

ThisQuickReferenceprovideskeymessagesandasummaryof themainrecommendationsintheClinicalPracticeGuidelines(CPG)ManagementofDengueInfectioninAdults(Revised2ndEdition)(2010).

DetailsoftheevidencesupportingtheserecommendationscanbefoundintheaboveCPG,availableonthefollowingwebsites:MinistryofHealthMalaysia:http://www.moh.gov.myAcademyofMedicineMalaysia:http://www.acadmed.org.my

*

3


WARNINg S IgNS• Abdominal pain or tenderness• Persistent vomiting• Clinical fluid accumulation (pleural effusion/ascites)• Mucosal bleed • Restlessness or lethargy• Liver enlargement >2 cm• Laboratory : Increase in HCT concurrent with

rapid decrease in platelet

Step 2 : Diagnosis, disease staging and severity assessment Basedontheabove,theclinicianshouldbeabletodetermine:

1.Denguediagnosis(provisional)2.Phaseofdengueillnessifdengueissuspected(febrile/critical/recovery)3.Hydrationandhaemodynamicstatusofpatient(inshockornot)4.Whetherthepatientrequiresadmission

Step 3 : Plan of management 1.Notificationisrequired2.Ifadmissionisindicated,refertoprerequisitesfortransfer3.Ifadmissionisnotindicated:

• Dailyormorefrequentfollowupisnecessaryespeciallyfromday3onwardsuntilthepatientbecomesafebrileforatleast24-48hourswithoutantipyretics

• SerialFBC/HCTmustbemonitoredasdiseaseprogresses(Table3)

Table1:STEPWISE APPROACH IN OUT PATIENT MANAGEMENT

WARNINg S IgNS• Abdominal pain or tenderness• Persistent vomiting• Clinical fluid accumulation (pleural effusion/ascites)• Mucosal bleed • Restlessness or lethargy• Tender enlarged liver• Laboratory : Increase in HCT concurrent with rapid decrease in platelet

Step 1: Overall assessment1. History

•Dateofonsetoffever/illness•Oralintake•Assessforwarningsigns•Diarrhoea•Bleeding•Changeinmentalstate/seizure/dizziness•Urineoutput(frequency,volumeandtimeoflastvoiding)•Pregnancyorotherco-morbidities

2. Physical examination Refertoclinicalparametersfordiseasemonitoring(Table3)

3. Investigationsi.FBCanddengueserologyshouldbetaken(assoonaspossible)ii.IfnofacilityforHCT,referpatienttothenearesthospital

Table2: WHEN TO REFER FOR ADMISSION

1. Symptoms:• Warningsigns• Bleedingmanifestations• Inabilitytotolerateoralfluids• Reducedurineoutput• Seizure

2. Signs:• Dehydration• Shock• Bleeding• Anyorganfailure

3. Special Situations:• Patientswithco-morbiditye.g.diabetes,hypertension,ischaemic

heartdisease,morbidobesity,renalfailure,chronicliverdisease• Elderly(>65yearsold)• Pregnancy• Socialfactorsthatlimitfollow-upe.g.livingfarfromhealthfacility,

patientlivingalone4. Laboratory Criteria:

• RisingHCTaccompaniedbyreducingplateletcount

Prerequisites for transfer to hospital1. Alleffortsmustbetakentooptimisethepatient’sconditionbeforeandduring

transfer.2. TheEmergency&TraumaDepartmentand/orMedicalDepartmentof the

receivinghospital must be informed prior to transfer.3. Adequateandessentialinformationmustbesenttogetherwiththepatientandthis

includesthefluidchart,monitoringchartandinvestigationresults.

Itisrecommendedtotriageallsuspectedcasesofdengueinordertoavoidcriticallyillpatientsbeingmisseduponarrival.Triage Checklist:1.Historyoffever2.AbdominalPain3.Vomiting4.Dizziness/fainting5.BleedingVital parameters to be taken:Mentalstate,bloodpressure,pulse,temperature,coldorwarmperipheries

PATIENT TRIAGING AT EMERGENCY AND TRAUMA /OuTpATIENT DEpARTMENT


Table3:DISEASE MONITORING FOR DIFFERENT PHASES OF DENguE ILLNESS

ParametersformonitoringFrequencyofmonitoring

Febrilephase Criticalphase Recovery

phaseCLINICALPARAMETERS

GeneralwellbeingAppetite/oralintakeWarningsignsSymptomsofbleedingNeurological/mentalstate

Dailyormorefrequentlytowardslatefebrilephase

Atleasttwiceadayandmorefrequentlyasindicated

Dailyormorefrequentlyasindicated

Haemodynamicstatus• Pink/cyanosis• Extremities(cold/warm)• Capillaryrefilltime• Pulsevolume• Pulserate• Bloodpressure• Pulsepressure

Respiratorystatus•Respiratoryrate•SpO2

4-6hourlydependingonclinicalstatus

2-4hourlydependingonclinicalstatus

In shock-Every15-30minutestillstablethen1-2hourly

4-6hourly

Signsofbleeding,abdominaltenderness,ascitesandpleuraleffusion

Dailyormorefrequentlytowardslatefebrilephase

Atleasttwiceadayandmorefrequentlyasindicated

Dailyormorefrequentlyasindicated

Urineoutput 4hourly2-4hourlyIn shock-Hourly

4-6hourly

LABORATORyPARAMETERS

FBCDailyormorefrequentlyifindicated

4-12hourlydependingonclinicalstatusIn shock- Repeatbeforeandaftereachattemptoffluidresuscitationandasindicated

Daily

BUSE/CreatinineLiverfunctiontestRandombloodsugarCoagulationprofileHCO3/TCO2/Lactate

Asindicated

AtleastdailyormorefrequentlyasindicatedIn shock-Crucialtomonitoracid-basebalance/ABGclosely

Asindicated

6


• ObtainabaselineHCTbeforefluidtherapy• Givecrystalloidssolution(suchas0.9%saline)• Startwith5-7ml/kg/hourfor1-2hours,thenreduceto3-5ml/kg/hrfor2-4hours,and

thenreduceto2-3ml/kg/hrorlessaccordingtotheclinicalresponse• IftheclinicalparametersareworseningandHCTisrising,increasetherateofinfusion• Reassesstheclinicalstatus,repeattheHCTandreviewfluidinfusionratesaccordingly

FLuID MANAgEMENTDengue with warning signsAll patients with warning signs should be considered for monitoring in hospitals:

Non-shock patient• Encourageadequateoralintake• Intravenous fluids are indicated in patients who are vomiting, unable to

tolerate oral fluids or an increasing HCT despite increasing oral intake.• Crystalloidisthefluidofchoice.

Estimated ideal body weight or IBW (kg) Normal maintenance fluid (ml/hour) based on Holiday Segar formula

5 1010 2015 3020 6025 6530 7035 7540 8050 9060 10070 11080 120

Notes:ForadultswithIBW>50kg,1.5-2ml/kgcanbeusedforquickcalculationofhourlymaintenancefluidregime.ForadultswithIBW<50kg,2-3ml/kgcanbeusedforquickcalculationofhourlymaintenancefluidregime.

Dengue Shock Syndrome RefertoalgorithmforintravenousfluidmanagementforDSS

Patientswithmildbleedingfromthegums,pervagina,epistaxisorpetechiaedonotrequirebloodtransfusion.Transfusionofbloodinpatientswithsignificantbleeding:• Transfused5-10ml/kgoffreshpackedredcellsor10-20ml/kgoffreshwholeblood

atanappropriaterateandobservetheclinicalresponse

• ConsiderrepeatingthebloodtransfusionifthereisfurtherbloodlossornoappropriateriseinHCTafterbloodtransfusion

• Treatingpatientwithunnecessaryfluidbolusbasedon raisedHCTas thesoleparameterwithoutconsideringotherclinicalparameters

• Excessiveandprolongedfixedfluidregimeinstablepatients• Infrequentmonitoringandadjustmentofinfusionrate• Continuationofintravenousfluidduringtherecoveryphase

COMMON PITFALLS IN FLUID THERAPY

WHEN TO SUSPECT SIGNIFICANT OCCULT BLEEDING?

MANAgEMENT OF BLEEDINg

• HCTnotashighasexpectedfordegreeofshocktobeexplainedbyplasmaleakagealone• AdropinHCTwithoutclinicalimprovementdespiteadequatefluidreplacement(40-60ml/kg)• Severemetabolicacidosis&endorgandysfunctiondespiteadequatefluidreplacement

_

7


HCT = haematocrit 1GXM: require first stage cross match or emergency O2fresh blood: less than 5 days

• IV crystalloid 5 - 7ml/kg/hr for 1 - 2 hours, then:

o reduce to 3 - 5 ml/kg/hr for 2 - 4 hours;

o reduce to 2 - 3 ml/kg/hr for 2 - 4 hours

• If patient continues to improve, fluid can be further reduced

• Monitor HCT 4 - 6 hourly

• If the patient is not stable, act according to HCT levels:

o if HCT increases, consider bolus fluid administration or increase fluid administration

o if HCT decreases, consider transfusion with fresh whole blood

• Consider to stop IV fluid at 48 hours of plasma leakage

/ defervescence

COMPENSATED SHOCK(systolic pressure maintained but has signs of reduced perfusion)

• Fluid resuscitation with isotonic crystalloid 5 - 10 ml/kg/hr over 1 hour• FBC, HCT, before and after fluid resuscitation, BUSEC, LFT, RBS, PT/APTT, Lactate/HCO

3, GXM1

Check HCT

Administer 2nd bolus of fluid

10-20 ml/kg/hr for 1 hr

Consider significant occult/overt bleed

Initiate transfusion with fresh blood2 (whole blood/packed cell)

• If patient improves, reduce to 7-10 ml/kg/hr for 1 - 2 hours

• Then reduce further

IMPROVEMENT

IMPROVEMENT

YES

YES NO

NO

or high

ALGORITHM A - FLUID MANAGEMENT IN COMPENSATED SHOCK

8


HCT = haematocrit GXM: require first stage cross match or emergency O fresh blood: less than 5 days

ALGORITHM B - FLUID MANAGEMENT IN DECOMPENSATED SHOCK

Consider to stop IV fluid at48 hours of plasma leakage/ defervescence

3

1 2

management of dengue infection in adults (revised 2nd ... reference dengue management.pdf ·...

Documents