25/06/55

PICU 1

2-7 . Decrease fever

- Dehydration
- Convulsion
- Observer signs& symptom
Leakage - 24-48 .. Shock
- Monitor Vital signs
- Signs shock Hct. timing
- Bleeding
72 ...... Fluid overload
- Vital signs normal, wide pulse pressure
- Void, Hct Hemodilution Redistribution of Fluid
- Convalescent Rash
- Sense of well being

25/06/55

 (2-7
~ 39- 40C .




3-5 4-7
CBC: Hct 32- 42%
WBC > 5,000
Platelet ~ 180,000
100,000
admit
*** CBC

25/06/55


Flow /

38.5 c

1-3

3- 5

Tourniquest test

(5- 7 )

TT+

NEGATIVE

POSITIVE

25/06/55

CBC/ Dengue titer+

-V/S stable , pulse pressure

admit

- Bradycardia
-

- /

- f/u ()

-Nsaids

- TT CBC

- ORS ( )

-/

Flow

- 50 %

CBC

- convalescent rash
-

-CBCDengue titer(NS1)( )
3

-Hct ( dilutional effect)

- 6 8

wbc 5,000 platelet 100,000

wbc 5,000 platelet 100,000

wbc 5,000 platelet 100,000

admit /

**

**

/ Flow

**

**

f/u 12 24

f/u 24
CBC

CBC

- Bradycardia
* IV Fluid

4
D/C

 OPD/ ER 3

C > 3
Tourniquet test +ve ve
Vital signs
25/06/55

Shock
Shock

Grade III
Hct, DTX
D/NSS, 5%DAR
Admit ICU

-
-
- Capillary refil > 2 Sec
-
- Pulse PP
mmHg

- CBC
-
- admit
- TT + admit
F/U

DLR 10 cc/Kg./hr ( IBW, max 50 Kg.)

Grade IV

Hct, DTX.

NSS AR LR IV drip -
rate IV cc/Kg/hr(IBW, max50Kg)
Admit ICU
** (High Risk Patients) 1

admit**
-

/
/

(High Risk Patients)

1
-


Flow Refer DHF gr I / II / III / IV
Flow Refer
25/06/55

.219/1 .219/2

DHF gr I III

DHF gr IV volume overload Intubation

- DHF gr II ,III * *

- * *

- DHF gr II Active bleeding or DHF gr III admit ICU

- ICU admit ER ER

- DHF gr I, gr II

-admit 3/ 4 ()

-Bradycardia ,arrhythmia , arrest ,desaturated

- Tube complication , pneumothorax

-admit 1, 1 (MED)
**
-

- IV . .....
- HCTIV / HCT
- IV fluid /
- Vital sign / HCT refer


OPD

Lab CBC

Ward

Lab

25/06/55

GO

 OPD

25/06/55

Day

Lab CBC: Hct, WBC, Plt, Lympho
(WBC<5,000)
( day 3,4)

paracetamal ( )

 /
25/06/55

< 38.0 c ( 4 )
24 48
Lab CBC: WBC < 5,000
24
Day 3,4,5


9

 :
25/06/55

1. Plt.>100,000 day 1.2.3

2. - Plt< 100,000
- Plasma
Shock
3.Shock - Plt Prolong shock
4. Bleed - Plt Hct Massive
bleeding
5. Fluid over load Referral
: Plt. 150,000 50,000 70,000
Plt.
Vital sings , Hct rising

10

Thrombocytopenia

25/06/55

Vascular

TT Positive
Plasma leakage

Plasma leakage - Protein

Platelet Bleeding Factor I,II.III,IV

Hepato-megaly

NH3 Urea - Urine

Cell Macrophage in Kuffer cell

Coagulogram

INR Prolong
Bleeding
DIC

11

 ( 24-48 HRS.)
25/06/55

Plasma
Shock Hypovolemic shock
- Hemodynamics change
- Volume decreased
- (viscosity) Hct rising
- Viscosity
- Red blood cell
- Plasma
Decreased cardiac output
Vasodilation
12

IV TYPE FOR DENGUE TREATMENT

25/06/55

Crystalloids :- Sodium chloride 0.9%, 5%D/NSS. 5%DAR

- RL ( Hartmanns solution)
- Isotonic solution Value Sodium
- Osmotic P.= Plasma - Osmolarity

Colloidal solution:- Plasma expander :

- Osmotic Pressure > Plasma 2-3 times,
e.g. 10% Dextran-40 , Hespan, Gelofusine
- Plasma substitute: Osmotic pressure = plasma,
- e.g. plasma, Hemaccel

13


Volume replacement 24 -48 hrs.(Plasma)
Effective circulating volume
Follow -Hct adjust Rate IV infusion
FWB,PRC
- > 10% BTW

25/06/55

- Hct drop
- Crystalloid not improved
- Hypotension

DHF : Dynamic disease Plasma 24 -48

Absorb Intravascular
14

BW : IV Fluid

IV Fluid
25/06/55

BW < 40 Kg.

Maintenance+5% Def.

BW > 40 Kg.

2 x maintenance

IBW

IBW =
< 7 ( *x2 ) + 8
> 7 =x3

. > 50 ..
50 .

15

CALCULATION OF M + 5% DEFICIT
50 kgs
M = (10 X 100 ml) +
(10 X 50 ml) +
(30 X 20 ml)
= 1,000 + 500 + 600

25/06/55

Maintenance:
10 kg.
= 100 ml/ kg
10 kg = 50 ml/kg
= 20 ml/kg
5% Deficit
= 50 ml/kg

= 2,100/day = 87 ml/hr

2M BW > 40kg
2M =2,100x2

= 4,200 ml/day
=175 ml/hr=3.5 ml/kg/hr

5% Def. = 50 X 50 ml
= 2,500
M+5%D = 2,100 + 2,500
= 4,600/day
= 4,600/24 hr = 191.67 ml/hr
= 191.67/50 kg = 3.83 ml/kg/hr
Professor Siripen Kalayanarooj

16

RATE IV FLUID : COMPARE

ADULT AND CHILDREN

Adult
(ml/hr)
40

80

M +5%D

100-120

M +7%D

150

M + 10%D

10

300 - 500

25/06/55

M/2

Child
(ml/kg/hr)
1.5

17

IV Adjust Non shock gr. I,II

(grcc/hr)
IV Adjust Non shock
I,II

10

Name..............................................BW.Kg

M.CC/Day =..cc/hr,M+5%....................CC/Day=..cc/hr

7ml/kg/hr

(cc/hr)
(cc/hr)

6
(cc/hr)

1.5ml/kg/hr

3 ml/kg/hr

5 ml/kg/hr

(cc/hr)

5 ml/kg/hr

25/06/55

(cc/hr)

Rate of IV
(ml/hr)

DHF 2

(cc/hr)

3 ml/kg/hr
(cc/hr)

1.5

ml/kg/hr

KVO

2
0
Shock time
1 2

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
Hct.
Hct.
Hct.
Plt..
Plt.
Plt.
Time...

Type
total
Hct (%)
Urine (ml.)

18

IV Adjust OnIV AdjustShock

Gr III, IV
On Shock Gr III, IV

DHF 3

6 hrs=.CC
M=CC/Day=cc/hr M+5%=.CC/Day=cc/hr

Name.........................BW..................kg.

10
9

25/06/55

10-5 ml/kg/hr

12 hrs =CC

7
6

4
3

5-3 ml/kg/hr

IV Transfusion
(ml/kg/hr)

18 hrs =..CC

3-1.5 ml/kg/hr

24 hrs..CC

1.5ml/hr -KVO
ml/kg/hr

2
1
0
1

10

11

shock
Hour

12

13

14

15

16

17

18

19

20

21

hour

10

11

12

13

14

15

16

17

18

19

20

21

22

Time
Type IV
Intake

Urine (ml.)
Hct (%)

22

19

23

 shock Adult
600

shock Adult

500

...................................................
300-500 ml/hr
500-300-150
ml/hr

............................................................

...................................................... ............. ..........

25/06/55

(ml/hr)

DHF 4

400

300

120-100 ml/hr

200

100-80 ml/hr

80-40 ml/hr

100

0
1

10

11

12

13

14

15

16

13

14

15

17

18

19

20

21

22

shock

10

11

12

16

17

18

19

20

21

(ml.)

Urine (ml.)
Hct (%)

20

22

decrease perfusion and subsequent hypoxia

Perfusion Hypoxia

Hypotension, No BP

inadequate circulatory volume

A rapid, weak, thread pulse

decrease blood flow combined with Tachycardia

Cool, Clammy skin

vasoconstriction

Rapid and shallow respiratory

sympathetic nerves system stimulation and acidosis

Hypothermia

decrease perfusion and evaporation of sweat

Thirst and dry mouth

fluid depletion

Fatigue

inadequate oxygenation

Cold and mottled skin

Especially extremities

insufficiency perfusion of skin

Look eye staring in to space

Often with pupil dilated

25/06/55

Anxiety, restlessness
Altered mental state EMV

21

 Shock

Pulse
pressure

CBC:

25/06/55

100/80, 110/90,100/100

Hct > 10-20%

WBC <5,000, Platelet
<100,000

22

25/06/55

1-2

Shoc
k

23

 Shock:

25/06/55

BP, Pulse rate 3,4

CP =3 sec.

On IV type ,rate IV
IV line IV Load Hct. Stat, DTX stat.
Lab
stat

Lab
Lab

BP Pulse 15 -30 1-2

IV 1 Load
24


Monitor Vital signs 1- 2 hrs BP, PR ,RR
25/06/55

, Full, Moderate, Rapid, No

palpable
Systolic Diastolic ( pulse pressure)

Signs & Symptoms

Pulse PP CP delay > 2 sec , , ,

Care IV Fluid:
Isotonic : 5% D/NSS, Ringer
Record

Urine output : 0.5 cc/kg/hr,

25


25/06/55

10 % TBV

Lab

26

 ()
25/06/55

/


8 < 0.5 ml/kg/hr >
1-2 ml/kg/hr
10-20%
Plt < 100000, Hct > 45%

/
27


25/06/55

28


Shock
25/06/55

- IV 2-6
IV
- BP, PR stable (pulse )
- Hct Load IV
- Hold volume
Colloid (Dextran-40)

29


25/06/55

Bleeding Leakage

BP drop Pulse Hct

Leakage Bleeding
O2 Sat <95%
Volume

Hypotension

Hypoxia

30


25/06/55

Internal bleeding

Load

IV load 10cc/kg/hr 3
6 Leakage
Pulse BP
Pt
CR delay> 2 sec
O2 Sat < 95%
Hct
Leakage

31


25/06/55

External bleeding

- ?
Hct Lab Order
Pulse BP drop
Shock Hypoxia
Conscious change -restless
CR > 2 sec
O2 Sat <95%

32



BP Pulse O2 Sat drop


gas
Hypoxia
Pulmonary edema- Respiratory failure

25/06/55

Leakage

33

SIGNS

34

25/06/55

:
-Rapid pulse: Age ,Rhythm
-Narrowing of pulse pressure
2.Respiratory distress:
-Rapid HR,RR ,Dyspnea, Tachypnea
-Poor tissue perfusion
-Oxygen Sat drop>95%
1.Vital signs

SYMPTOMS
25/06/55

(Puffy eyelid)
(Ascites)
(edema)
(restless)
(distress)
35

MONITORING:
25/06/55

1.Vital signs :
-Check BP Pulse q 30-1 hr, 1-2 hrs/record
-Notify Dr. recently/ if abnormal signs
-Pt restless
2.Respiratory distress:
-Give oxygen via facemask or nasal catheter
-Observe tissue perfusion
-Check Oxygen Sat drop>95% if <95%/ Notify Dr.
-If rate RR,HR increase notify and prepare
36
emergency care

 BRAIN EDEMA VOLUME LOAD

25/06/55

- BP HR
- Conscious change
- Neuro-signs GCS
- Urine BUN/Cr
- Hypertension Notify
- CT Brain

37

 BRAIN EDEMA BLEEDING

25/06/55

- BP drop HR
- Conscious change
- Neuro-signs GCS
- O2 Sat drop < 95%
- Bleeding show- Coffee ground, Melena
- CT

38

O2 Sat < 95 %
Lab : Blood gas , Blood
electrolyte

25/06/55

39

 :
25/06/55

A:

Appetite

B:

Bradycardia- Pulse normal

C: Convalescent Rash-iching
D: Diuresis more frequency
40

25/06/55

41


25/06/55

24 ..
2
>50,000 /..
42

25/06/55

1.
2.
3.
4.

43

25/06/55

1. ( Refer)
2. DHF 1
3. DHF 2 DHF 3
DHF 4

44

THANK YOU
25/06/55

45