4. Case Histories

1. 4. Case Histories Dengue Expert Advisory Group

2. Case history 1 24 yr old male came to the OPD with H/O fever for 1 day. Had myalgia, and severe headache. No vomiting. O/E Flushed skin, good hydration, pulse 80/min, BP 110/80. No abnormality was detected on examination. He was sent home by the OPD doctor advising him to drink - the amount, type of fluid to take paracetamol in correct dose to have rest.

3. He was also advised to come back on the 4th day of the illness with CBC. He came back on 4th day, still febrile, had nausea. Pulse 80/min, BP 110/80. CBC on D-3 WBC – 3800 Hct – 38.8 Plt – 120,000

4. In patient management • FBC and Haematocrit monitored • Fluid intake and output monitored IV fluids – 1500 ml with 1000 ml orally per day given. Total – 2500 ml/d Domperidone and PCM sos • Vital signs monitored

5. Case history 1 contd. 3 4 5 6 6 7 8 9 WBC 3.8 2.8 4.1 10 9.9 10 8.3 5.5 HCT 38.8 40.5 44.5 48.5 43.9 42.8 39.7 40 PLT 120 80 21 6 9 9 19 57

6. Management contd. Symptomatic management continued Monitoring continued. Fluid increased with rise of PCV No clinical deterioration. Had small right sided pleural effusion. No specific management done. Patient improved i.e.. General condition, appetite. Fever settled. Patient was discharged home once the plt count was >50,000 & Afebrile for 48 hrs

7. Lessons learned: Doing a CBC from 3rd day is better. Often only symptomatic management is adequate. If there is no active bleeding, there is no place for platelet transfusion even if the platelet count is low. No place for steroids or FFP.

8. CASE – 2: The shocked LADY A 33 yr old lady, a mother of a 5 month old baby, was admitted with a H/O fever for 5 days. On admission – pulse 100/min, BP 100/90, CRFT- 3 secs, R/pleural effusion +

9. Fluid Allocation for shocked Patient 10 ml/kg 1 2 3 7-5 ml/kg 5-3 ml/kg 3-1 ml/kg M + 5% 24-36 hrs KVO

10. Fluid given during 1st 24 hrs Total volume given for first 24 hrs – 3600 ml

11. IV calcium gluconate given 6 hrly. Amount of fluid reduced to 75ml/hr and then 50ml/hr and then stopped. PCV remained stable Blood pressure, pulse, CRFT and UOP maintained. No further interventions were necessary.

12. Lessons learned: Treat both • impending shock (prolonged CRFT, narrow pulse pressure, severe postural drop of BP, hypotension) • Full blown shock (BP un-recordable) AGRESSIVELY and PPOMPTLY. With crystalloid bolus and gradual reduction of fluid. If PCV is low, give blood. May need dextran later.

13. Case 3: Over-loading is easy ! A 30 yr old male with DHF was referred (at a private hospital) on 14th Sep. Admitted on 12th at 5 pm & transferred to ICU on 13th at 6 pm.

14. Over-loading is easy ! • Fluid given for 24 hrs = 4150 ml. • Now the patient has got B/L pleural effusions and ascites.

15. Overloaded patient: PCV increased to 52 Pulse pressure narrowed to 20 with a postural drop of 30 in SBP. Dextran 500 ml given over one hour with 10 mg of frusemide Pulse pressure improved. Good UOP. Patient recovered without any further intervention

16. Lessons learned: Fluid overload can occur un-intentionally. Patients should be told how much and what to drink Dextran is useful in fluid overloaded patients Frusemide in small doses is very effective

17. Dextran 40 Preferred colloid in DHF Mechanism of Action - Produces plasma volume expansion by virtue of its highly colloidal starch structure, similar to albumin Given as a bolus in DHF– 250 ml over 30 mins or 500 ml over 1 hr. Not as a slow infusion. Recommended maximum – 1500 ml for 24 hrs. Should not be used in a dehydrated patients who present with shock and high HCT until the hydration is corrected with crystalloids.

18. Case history: delay costs ! • Mrs. R • 53 year old female • Diabetic and hypertensive • Admitted on 08/06/2011 11.05 pm • D3 of fever • On admission Pulse 88/min, BP 120/80,(110/80) CRFT < 2 sec, Liver 2 cm, tender. WBC – 1600 N – 43% Hb – 13.7 PCV – 42 platelet – 40,000

19. SHO seen 09/06/2011 at 4 am. • Patient C/O dizziness • No bleeding manifestations • CVS - PR – 104 BP – 130/90 supine 100/80 sitting • CRFT - < 2sec • Tender hepatomegaly • R/S pleural effusion • PCV - 46

20. Critical period 4.00am 09/06/2011 to 4.00 am 11/09/2011 • From 4.00 am to 9.00 am 100ml/hr • Bolus of N. saline 500ml at9.00am • After that 150ml/hr x 3hrs 100ml/hr x 39 hrs

21. PCV 46 49.7 48 46 46 47 32? 40 40 39 Pul p 40 20 30 30 30 30 30 30 30 25 30 40 CRFT <2 <2 <2 <2 <2 <2 <2 >2

22. Critical period over at 4 am on 11.06.11. • By end of critical period 5350ml fluid given • Blood ordered at 6.30 am • Admitted to ICU 9.25 am • On admission to ICU PR- 120/min BP 110/90 mmhg Pt dyspnoec, with oxygen SPO2- 96% RR - 38 • Blood 2 pints received at 10.40am!! After 4 hrs

23. 1st 24 hours after critical period PCV 33 32 28 26 39 39 38 35 31 39 42 45 46

24. Patient developed shock on 11/06/2011 evening with impalpable peripheral pulses and cold extremities Femoral CVP catheter inserted. Patient developed respiratory distress and was intubated on 12/06/2011 at 6.30am

25. 2nd 24 hours after critical period 12/06/11 PCV 41 35 32 35 41 31 33 37 37 37 36 35 37 37 37 37

26. 2nd 24 hours after critical period 12/06/11 Inspite of blood and fluid boluses, patient was going into shock repeatedly. Decided to aspirate the R pleural effusion Activated factor VII two vials given Pleural effusion aspirated.

29. 1600 ml of blood aspirated. Peripheral circulation returned in the midway of aspiration.

30. 3rd 24 hours after critical phase 13/06/11 PCV 37 37 37 37 38 40 39 38 40 39 39 38 38 39 34 35 37 40 43 41 41 40 40 39

31. R/S pleural aspiration repeated 14/06/2011 1300ml blood aspirated • Patient extubated on 16/06/2011 • R/S Intercostal tube inserted due to persistant haemothorax on 17/06/2011 1070ml drained.

33. Throughout clotting profile – normal Slight elevation of liver enzymes Renal functions – low K+ Low Serum calcium – i.v calcium gluconate given Good glycaemic control on insulin CRP – 67- 225 – 162 -16 Patient respiratory secretions culture - MRSA Pleural fluid culture and blood cultures – sterile Treated with antibiotics + chest physiotherapy

34. CASE PROFOUND SHOCK A 10 year old boy presented at E/S C/O • Fever ---05 days high grade, continuous with body aches • Melina ---01 day two episodes and one episode of hematochezia • Altered conscious level --1 hour

35. O/E Unwell looking GCS 12/15 A febrile Pulse Feeble BP un recordable Cold clammy skin CRT>2sec Abdomen tender, Liver 3cm blcm and tender TT + ve USG abdomen pericholic fluid Pelvic ascites

36. Management • Fluid resuscitation with crystalloid • Push with N/saline 20ml /kg • Repeat with 10 ml/kg • Dextran 40 10ml/kg over 1 hour • Pulses palpable but tachycardia • Crystalloids continued

37. Blood Transfusion Crystalloids 18 hours later developed tachycardia Narrowed pulse pressure Amount of fluids increased

38. Packed Cells Transfusion • Crystalloids gradually tapered

39. CASE • A six year old girl presented in emergency with C/O: • Fever ---04 days high grade continuous with body aches • Epistaxis ---01 day 3 episodes • Vomiting --- 01 day 2-3 episodes • Fit-----half hour 1 episode, Generalized tonic / colonic

40. ON EXAMIANTION • Lethargic , but arouse able child SOMI -Ve • PR- 80/min, BP- 100/80mmHg, Temp- 100F, • Abdomen mildly tender • Liver palpable 2 cm below costal margin • TT +VE • No clinical and radiological evidence of pleural effusion • Ultrasound abdomen showed no free fluid • TLC 3,500 Plts 80,000 Hct 36% BSR 20mg/dl

41. INITIAL MANAGEMENT • BSR corrected • Maintenance fluid (Oral + I/V) • Vitals’ Monitoring 4 Hourly

42. ON DAY 5 • Pulse rate 95/min • Blood pressure 100/75 • Liver palpable 3 cm BCM and tender • Ultrasound abdomen showed gall bladder wall edema and mild pelvis ascites

43. Crystalloids continued

44. ON DAY 6 (After noon) • Crystalloid bolus with 10 ml / kg • Tapered gradually Pulse rate 120/min Blood pressure 100/85