qr management of dengue infection in adults (2nd edition)

7/25/2019 Qr Management of Dengue Infection in Adults (2nd Edition)

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MANAGEMENT OF DENGUE INFECTION IN ADULTS (2ndEdition) QUICK REFERENCE FOR HEALTH CARE PROVIDERS

KEY MESSAGES

Dengue is a sstemic and dnamic disease.

There are three phases in dengue infection-febrile phase, critical phase

and recover (reabsorption) phase.

Diagnosis should be clinical with guidance from laborator results.

Clinical deterioration often occurs in the critical phase (often 3rd

da of fever onwards) and is marked b plasma leakage. There isa continuum of circulator disturbances in dengue requiring frequent

monitoring of the dengue patient.

Rising haemotocrit (HCT)/packed cell volume (PCV) is a marker of

plasma leakage.

Look out for warning signs which ma indicate severe dengue or high

possibilit of rapid progression or shock.

Recognition of shock in its earl stage and prompt uid resuscitation

will give a good clinical outcome.

There is no role of prophlactic transfusion with platelets and fresh

frozen plasma in dengue patients.

This Quick Reference provides ke messages and a summar of the

main recommendations in the Clinical Practice Guidelines (CPG)Management of Dengue Infection in Adults (2ndEdition) (2008).

Details of the evidence supporting these recommendations can

be found in the above CPG, available on the following websites:

Ministr of Health Malasia : ht tp://www.moh.gov.m, or

Academ of Medicine Malasia : http://www.acadmed.org.m


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WARNING S IGNS

Abdominal pain or tenderness

Persistent omiting

Clinical uid accumulation (pleural effusion/ascites)

Mucosal bleed

Restlessness or lethargy

Lier enlargement >2 cm Laboratory : Increase in HCT concurrent with

rapid decrease in platelet

DISEASE NOTIFICATION

All suspected dengue cases* must be notied b telephone to

the nearest health ofce within 24 hours of diagnosis, followed

b written notication within one week using the standard

notication form.

LABORATORY INTERPRETATION

In the absence of baseline HCT, a HCT value of >40% in adultfemale and >46% in adult male should raise the suspicion ofplasma leakage.

DENGUE SEROLOGY TESTS

If the dengue IgM is negative before da 7, a repeat sample must

be taken in the recover phase. Dengue Non-structural protein -1 (NS1 Antigen) can be helpful

in earl phase (< Da 5) of dengue infection.

A patient has an acute febrile illness with two or more features : Rash

Malgia Headache Arthralagia

OR Dengue endemic/hot spot/outbreak area

Leucopenia

Retro-orbital pain Haemorrhagic manifestations

DISEASE NOTIFICATION

All suspected dengue cases* must be notied b telephone to

the nearest health ofce within 24 hours of diagnosis, followed

b written notication within one week using the standard

notication form.

WARNING S IGNS

Abdominal pain or tenderness

Persistent omiting

Clinical uid accumulation (pleural effusion/ascites)

Mucosal bleed

Restlessness or lethargy

Lier enlargement >2 cm Laboratory : Increase in HCT concurrent with rapid

decrease in platelet

SUSPECT A CASE OF DENGUE*

SUSPECT A CASE OF DENGUE


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Step 1: Oerall assessment1. History Date of onset of fever/illness Oral intake Assess for warning signs Diarrhoea Bleeding Change in mental state/seizure/dizziness Urine output (frequenc, volume and time of last voiding) Pregnanc or other comorbidities

2. Physical examinationRefer to clinical parameters for disease monitoring (Table 3)

3. Inestigationsi. FBC and dengue serolog should be taken (as soon as possible)ii. If no facilit for HCT, refer patient to the nearest hospital

Step 2 : Diagnosis, disease staging and seerity assessment

Based on the above the clinician should be able to determine:

1. Dengue diagnosis (provisional)

2. The phase of dengue illness if dengue is suspected (febrile/critical/recover)

3. The hdration and haemodnamic status of patient (in shock or not)

4. Whether the patient requires admission

Step 3 : Plan of management1. Notication is required2. If admission is indicated refer to prerequisites for transfer3. If admission is not indicated:

Dail or more frequent follow up is necessar especiall fromda 3 onwards until the patient becomes afebrile for at least

24-48 hours without antipretics Serial FBC/HCT must be monitored as disease progresses

(Table 3)

Table 1:STEPWISE APPROACH IN OUT PATIENT MANAGEMENT


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1. Symptoms: Warning signs

Bleeding manifestations

Inabilit to tolerate oral uids

Reduced urine output

Seizure

2. Signs: Dehdration

Shock

Bleeding

An organ failure

3. Special Situations: Patients with co-morbidit e.g. diabetes, hpertension,

ischaemic heart disease, morbid obesit, renal failure,chronic liver disease

Elderl (>65 ears old)

Pregnanc

Social factors that limit follow-up e.g. living far from healthfacilit, patient living alone

4. Laboratory Criteria:

Rising HCT accompanied b reducing platelet count

Prerequisites for transfer to hospital1. All efforts must be taken to optimise the patients condition

before and during transfer.

2. The Emergenc & Trauma Department and/or MedicalDepartment of the receiving hospital must be informedprior to transfer.

3. Adequate and essential information must be sent together withthe patient and this includes the uid chart, monitoring chartand investigation results.

Table 2:

WHEN TO REFER FORADMISSION


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Table 3:DISEASE MONITORING FOR DIFFERENT PHASES OFDENGUE ILLNESS

Parameter for monitoringFrequenc of monitoring

Febrilephase Critical phase

Recoverphase

CLINICAL PARAMETERS

General well beingAppetite/oral intakeWarning signs

Smptoms of bleedingNeurological/mental state

Dail or morefrequentltowards latefebrile phase

At least twice a daand more frequentl

as indicated

Dailor morefrequentlas indicated

Haemodnamic status Pink/canosis Extremities (cold/warm) Capillar rell time Pulse volume Pulse rate

Blood pressure Pulse pressureRespirator status Respirator rate SpO

2

4-6 hourldepending

on clinicalstatus

2-4 hourldepending onclinical status

In shock-Ever 15-30 minutestill stable then 1-2hourl

4-6 hourl

Signs of bleeding,abdominal tenderness,

ascites and pleural effusion

Dail or morefrequentltowards late

febrile phase

At least twice a daand more frequentl

as indicated

Dailor morefrequentl

as indicated

Urine output 4 hourl2-4 hourlIn shock-Hourl

4-6 hourl

LABORATORy PARAMETERS

FBCDail or morefrequentl ifindicated

4-12 hourldepending on

clinical statusIn shock-Repeat before andafter each attemptof uid resuscitationand as indicated

Dail

BUSE/Creatinine

Liver function testRandom blood sugarCoagulation proleHCO

3/TCO

2/Lactate

As indicated

At least dail or morefrequentl as indicated

In shock-Crucial to monitoracid-base balance/ABG closel

Asindicated


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FLUID MANAGEMENT

Non-shock patient

Encourage adequate oral intake Intravenous uids are indicated in patients who are vomiting, unable to

tolerate oral uids or an increasing HCT despite increasing oral intake.

Crstalloid is the uid of choice.

Normal maintenance uid per hour can be calculated based on the

following formula (Equivalent to Hallida-Segar formula) : 4 ml/kg/h for rst 10kg bod weight

+ 2 ml/kg/h for next 10kg bod weight

+ 1 ml/kg/h for subsequent kg bod weight

-- For overweight/obese patients calculate normal maintenance uid

based on ideal bod weightDengue Shock Syndrome

Refer to algorithm for uid management for DSS (back cover)

WHEN TO SUSPECT SIGNIFICANT OCCULT BLEEDING?

HCT not as high as expected for degree of shock to be explained b

plasma leakage alone. A drop in HCT without clinical improvement despite adequate uid

replacement (40-60 ml/kg).

Severe metabolic acidosis and end organ dsfunction despiteadequate uid replacement.

MANAGEMENT OF BLEEDING

Patients with mild bleeding from the gums, per vagina, epistaxis orpetechiae do not require blood transfusion.

Blood transfusion with whole blood or packed cell (as fresh as isavailable, preferabl less than 1 week old).

If bleeding continues then consider the use of blood components.

INvASIvE PROCEDURES Endoscop in upper GIT haemorrhage should be avoided. Intercostal drainage for pleural effusion is not indicated.


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qr management of dengue infection in adults (2nd edition)

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