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DENGUE HAEMORRAGIC FEVER AND DENGUE SHOCK SYNDROME MANAGEMENT

DENGUE HAEMORRAGIC FEVER AND DENGUE SHOCK SYNDROME MANAGEMENT. Dr. Rakhi M R. Dengue fever is an infection caused by dengue virus resulting in a self limiting febrile illness…. Suspicion index: Erythematous flush Dengue facies Suffused face Injected eyes Purplish lips

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DENGUE HAEMORRAGIC FEVER AND DENGUE SHOCK SYNDROME MANAGEMENT

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  1. DENGUE HAEMORRAGIC FEVER AND DENGUE SHOCK SYNDROME MANAGEMENT Dr. Rakhi M R

  2. Dengue fever is an infection caused by dengue virus resulting in a self limiting febrile illness…. • Suspicion index: • Erythematous flush • Dengue facies • Suffused face • Injected eyes • Purplish lips • Redden malar regions and ear lobules

  3. Classical Dengue Fever • A/c febrile illness of 2-7 days of duration with more than two of the following manifestations: • Headache • Retro orbital pain • Leucopenia • Tourniquet test positive • Hemorrhagic manifestations • Arthralgia or myalgia • Rash • Erythematous flush

  4. Dengue Hemorrhagic Fever • More seen in children • Infants – primary infection • Older children – secondary infection, this can occur even many years later. • Hemorrhage in DHF is due to • Vasculopathy • Prothrombin complex deficiency • Platelet dysfunction • Thrombocytopenia

  5. Diagnostic Features • Fever of a/c onset • Hemorrhagic tendencies • Positive tourniquet test • Petechiae, Ecchymosis, purpura • Hematemesis or malena • Thrombocytopenia – less than 1 lakh • Evidence of plasma leakage • Increased hematocrit by 20% • Decreased Hct by 20% after volume replacement • Pleural effusion and ascitis • hypoproteinemia

  6. Dengue Shock Syndrome • All the signs of DHF + signs of circulatory failure • Rapid and weak pulse • Narrow pulse pressure • Hypotension • Cold extremities • Restlessness

  7. Symptomatology of mild capillary leak • Weakness, irritability, anxiety, restlessness • Symptomatology of severe capillary leak • Oliguria, rt hypochondriac pain, BP fall • Symptomatology of congestive phase • Bounding pulse • Wide pulse pressure • CCF • Increased urine output

  8. Disease course

  9. DHF III and IV are considered as DSS

  10. Investigations • Hb, Hct, PLC • Limitations of Hct are pre existing anemia, severe bleeding, early volume replacement • TC, DC for leucopenia with relative lymphocytosis • CXR and USG Abdomen for serous effusions • Electrolytes – hyponatremia • Proteins – decreased • Mild elevation in SGOT, SGPT • PT, APTT – prolonged in DIC

  11. ABG – metabolic acidosis • ECG changes • Serology – Ig G and Ig M if possible (after 5-7 days of fever)

  12. Interpretations of dengue serology

  13. Differential diagnosis • Chicken guinea fever • Leptospirosis • Measles • Septicemia • Kawasaki disease

  14. MANAGEMENT • OP MANAGEMENT • Collect BRE, PCV, PLC. • Asses vital signs – PR, BP, CRT and watch for bleeding • Do tourniquet test • If vitals are stable, advice rest, Pmol, No aspirin/ brufen • Plenty of oral fluids/ ORS • Food acc to appetite • Monitor urine output • Keep body temp below 39°C • Give large amt of fluids

  15. Indication for admission • Restlessness/ Lethargy • Shock • Bleeding tendencies • Tachycardia • CRT>2 sec • Cool extremities and mottled skin • Oliguria • a/c abdominal pain • Positive tourniquet test • Hematocrit>35% or rising hct>20% • PLC<1 lakh

  16. Initial Rx in the ward or ICU • If increase in hct is more than 20%, initiate iv therapy (NS/ 5% dextrose) 6ml/kg/hr and in case of improvement 3ml/kg/hr for 3 hrs and discontinue over 6-12hrs. • If no improvement, change to 10ml/kg/hr and after improvement taper iv fluids gradually to 6-3ml/kg/hr

  17. No imp, unstable vitals Hct rise Hct falls Dextran or plasma 10ml/kg/hr Blood 10ml/kg/hr Improvement Reduce the IV from 10-6-3hrly and discontinue by 24-48 hrs

  18. DSS Mx • Initiate IV therapy 10-20ml/kg/hr and then continue the same protocol as above in tapering fluids • In case of no improvement give blood/ dextran as the case scenario dictates…..

  19. Indications for blood products • Blood transfusion • Significant blood loss • Persistent shock with falling Hct • FFP/ Cryoprecipitate – DIC • Platelets • Less than 50,000 with significant mucosal bleeding • Less than 20,000 with no significant mucosal bleeding.

  20. Criteria for D/S • Patient should be afebrile for atleast 24hrs • Passing urine normally • Having improved appetite • No respiratory disease • Stable Hematocrit • PLC>50,000

  21. THANK YOU

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