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DISEASE MONITORING Dr Mahiran Mustafa Chairman of CPG Development Committee. CONTENTS. Brief review on different phases in dengue infection Issues at different phases Clinical monitoring for each phase Laboratory monitoring for each phase. INTRODUCTION.
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DISEASE MONITORING Dr Mahiran Mustafa Chairman of CPG Development Committee
CONTENTS • Brief review on different phases in dengue infection • Issues at different phases • Clinical monitoring for each phase • Laboratory monitoring for each phase
INTRODUCTION • Monitoring dengue cases require the understanding that dengue infection is a systemic and dynamic disease. • Its clinical, haematological and serological profiles changing from day to day and accelerate by the hour during the critical phase, particularly in those with plasma leakage • Failure in recognising and interpreting the clinical and laboratory manifestations can lead to delay in appropriate management thus cause intractable shock and death
OUTPATIENT MONITORING Symptoms: • Warning signals • Bleeding manifestations • Inability to tolerate oral fluids • Reduced urine output • Seizure Signs: • Dehydration • Shock • Bleeding • Any organ failure Laboratory: • HCT • Hb • Platelet
DISEASE MONITORING CARD DENGUE DISEASE PROGRESSION CARD Patient’s name: ________________________________ I/C No. : _______________________________ Date of onset of fever : __________________________
Clinical deterioration often occurs during the critical phase because of marked plasma leakage • Evidence of plasma leakage includes: raised HCT haemodynamic instability fluid accumulation in extravascular space
Pathophysiology • Inadequate perfusion of the tissue leads to increased anaerobic glycolysis and resultant lactic acidosis • Shock that leads to DIC and bleeding • Vascular permeability leads to leakage • Haemoconcentration • Hypovolaemia leads to reflex tachycardia and vasoconstriction
WARNING SIGNALS • Vomiting • Abdominal pain • Restlessness or altered mental state • Mucosal Bleed • Sudden change of temperature to subnormal • Raising HCT with rapid drop in platelet
SEVERE MANIFESTATIONS • Acute abdomen • Hepatitis and hepatic failure • CNS manifestations • Carditis or cardiomyopathy
Pathophysiological changes from normal circulation to compensated and decompensated shock
Fluid Therapy: Non Shock Recommendation • Encourage adequate oral fluid intake. (Grade C) • IV fluid is indicated in patients who are vomiting or unable to tolerate oral fluids. (Grade C) • IV fluid is also indicated in patients with increasing HCT (indicating on-going plasma leakage) despite increased oral intake. (Grade C) • Crystalloid is the fluid of choice for non shock patients. (Grade C)
Indications for referral to Intensive • Recurrent or persistent shock • Requirement of respiratory support (non-invasive and invasive ventilation) • Significant bleeding • Encephalopathy or encephalitis
DISCHARGE CRITERIA • Afebrile for 48 hours • Improved general condition • Improved appetite • Stable haematocrit • Rising platelet count • No dyspnoea or respiratory distress from pleural effusion or ascites • Resolved bleeding episodes • Resolution/recovery of organ dysfunction
Summary:Principles of disease monitoring 1.Dengue is a systemic and dynamic disease. Therefore disease monitoring is governed by different phases of the disease. 2. The critical phase (plasma leakage) may last for 24-48 hours. Monitoring needs to be intensified and frequent adjustments in the fluid regime may be required. 3. Recognition of onset of reabsorption phase is also important because intravenous fluid regime needs to be progressively reduced/ discontinued