CASE

PRESENTATION:
DENGUE
ALVAREZ. AVINANTE. GARDE. LOPEZ
JUNIOR INTERNS NOVEMBER ROTATORS
 GENERAL DATA

v GENERAL DATA: J.S, 3 years old, male, child,

unemployed, Filipino, Roman Catholic, born on
September 15, 2016 in Quezon City, currently residing
at Violage homes, Quezon City, and was admitted for
the second time at Veterans Memorial Medical
Center on November 9, 2019.

vCHIEF COMPLAINT: ON AND OFF FEVER

HISTORY
J I GA RD E
 HISTORY OF PRESENT ILLNESS
v 7 days PTA:

ü(+) INTERMITTENT FEVER

üTmax = 38 degrees Celsius
ü(-) cough, (-) colds, (-) fever, (-) abdominal pain, (-) bleeding, (-)
nausea and vomiting
üRushed to a private clinic and managed as a case of Tonsillitis
üInitially treated w/ Cefaclor 3ml TID, Mefenamic Acid (unrecalled
dose), Paracetamol 250mg/5ml
 HISTORY OF PRESENT ILLNESS
v 6 days PTA:

ü(+) INTERMITTENT FEVER

ü(+) 1 episode of minimal nose bleeding
ü(-) cough, (-) colds, (-) fever, (-) abdominal pain, (-) bleeding, (-)
nausea and vomiting
üNo consult done
 HISTORY OF PRESENT ILLNESS
v 3 days PTA:

ü(+) INTERMITTENT FEVER

ü(+) Abdominal pain, Pain Scale of 7 out of 10, localized,
characterized as crampy
ü(-) cough, (-) colds, (-) fever, (-) bleeding, (-) nausea and
vomiting, (-) loose stools
üNo consult done
 HISTORY OF PRESENT ILLNESS
v Few hours PTA:

ü(+) INTERMITTENT FEVER

ü(+) Rashes all over his body
ü(-) cough, (-) colds, (-) fever, (-) abdominal pain, (-) bleeding, (-)
nausea and vomiting, (-) loose stools
üConsulted in our institution (VMMC)
GROWTH AND DEVELOPMENT
v1. Nutrition
üUndernutrition

a) Feeding
ü Formula (Pediasure)
b) Vitamin Supplement:
ü Cherifer

c) Present diet type and age started:

ü Fruit and Vegetables: 8 months
ü Meat: 1 year old
ü Table food: 1 year old
 GROWTH AND DEVELOPMENT
v1. Psycho-motor Landmark:

Regard 3 months Put 3 words 1 year old

together
Social Smile 3 months
Bowel 3 years old
Turned over 4 months
Bladder control 3 years old
Crept 4 months
Clothes self 3 years old
Sat Aided 6 months
Sat Alone 7-8 months
Walked 1 year old
1st words 1 year old
Developmental Level

General Behavior Active, Playful

Habits Playing games with his brothers,

playing games in cellphone

Sleep Pattern Sleep at 9 pm and wakes up at 8:30

am
 IMMUNIZATION
1ST 2ND 3RD
DPT
OPV
HEP B

DATE
BCG At birth
Chicken pox 9 months
Rubeola 9 months
Rubella 9 months
Mumps 9 months
Previous Illness
v No know Allergies
vNo Childhood Diseases
vPrevious Hospitalization:
ü2016- VMMC: Pneumonia
 REVIEW OF SYSTEMS
v General: (-) fever; (-) chills, (-) malaise, (-) easy fatigability, (-) weight loss Integumentary: (+) Rashes all over his body, (-) pruritus, (-)
hyperpigmentation

vHead and Neck: (-) headache, (-) dizziness, (-) syncope, (-) blurring of vision, (-) diplopia, (-) photophobia, (-) eye pain, (-) hearing loss, (-)
ear discharge, (-) ear pain, (-) tinnitus, (-) vertigo, (-) nasal obstruction, (-) epistaxis, (-) hoarseness, (-) sore throat,
(-) disturbance of taste

vRespiratory: (-) dyspnea; (-) chest pain , (-) hemoptysis, (-) cough , (-) back pain, (-) orthopnea, trepopnea

vCardiovascular: (-) palpitation, (-) PND, (-) orthopnea, (-) shortness of breath

vGastrointestinal: (-) poor appetite, (-) dysphagia, (-) odynophagia, (-) nausea, (-) vomiting, (-) hematemesis, (-) abdominal enlargement,
(-) diarrhea- watery, (-) constipation, (+) abdominal pain, (-) flatulence, (-) steatorrhea, (-) melena, (-) hematochezia

vGenitourinary: (-) dysuria; (-) anuria, (-) polyuria, (-) oliguria, (-) hematuria, (-) incontinence, (-) dribbling, (-) urinary frequency, (-)
flank/suprapubic pain, (-) passage of stone, (-) discharge

v Musculoskeletal: (-) muscle pain, (-) joint pain & stiffness, (-) swelling of right lower leg , (-) bone deformity, (-) weakness, (-) atrophy,
(-) contracture, (-) restriction of motion

vNervous: (-) syncope, (-) seizures, (-) weakness or paralysis, (-) headache; (-) tremors, (-) loss of memory, (-) depression, (-) delirium,
(-) hallucination, (-) peripheral neuropathy

vEndocrine: (-) heat or cold intolerance, (-) polyuria, (-) polyphagia, (-) abnormal growth

vHematologic: (-) easy bruisability, (-) pallor

Past Medical History
(+) Asthma
(+) Pneumonia
Family Medical History
vMaternal Grandmother: (+) Asthma
vSiblings: J.S and L.S (+) Asthma
PHYSICAL EXAM
J I GA RD E
 GENERAL SURVEY
v Alert, conscious, coherent, well-groomed, and nourished. cooperative with normal speech and
volume. Not in cardiorespiratory distress.
vB. VITAL SIGNS:
üBP: 90/60 mmHg
üPR: 104 bpm
üRR: 30 cpm
üTemperature: 36.8 C
vANTHROPOMETRIC: Ht: 95.5 cm, Wt: 11.4 kg, BMI: 12.5 kg/m2 (Underweight)
v Z SCORES:
üHeight for Age: Z= 0.06 (Normal Stature)
üWeight for Age: Z= -2.25
üWeight for Height: Z= -3.65
vINTEGUMENTARY Skin is brown, smooth, no active lesion, with good mobility, elasticity and
turgor, (+) Herman Sign. The hair is black, smooth, abundant, well distributed, no parasites, no
signs of alopecia. The nails are pinkish, smooth, no cyanosis, no clubbing with good
capillary refill.
HEENT
HEAD
Normocephalic head, symmetrical and has no deformities. No hematomas noted. Temporal arteries are not
visible but bilaterally palpable with weak pulsations. Face is symmetrical, no lesion, edema, or any deformities.

EYES
Eyebrows are black in color, well distributed, symmetrically aligned and moves with equal movement. Eyelids
have no lesion, edema, discharge or discoloration. Eyelids close symmetrically and blinks bilaterally. Eyelashes
are black, short and are present in both upper and lower eyelids with no matting. Bulbar conjunctiva is
transparent with no lesions, discharge, hemorrhage and engorged vessels. Sclera is white in color with no
lesions and congested vascularities. Palpebral conjunctiva is shiny, smooth and pink with no lesions or edema.
Cornea is transparent and clear with no opacities, ulcerations, no foreign body and no scars. Iris is brown in
color with no lesions noted. The pupils are 3 mm, round and black. Both pupils are reactive to both direct and
consensual stimuli. No nystagmus and lid lag. Negative red-orange reflex.

EARS

Ears are symmetrical, no deformities, and no lesions. No tenderness and masses noted on the pinna and
mastoid area upon palpation. External auditory canal is patent, walls are pinkish in color, no discharges, no
foreign bodies, with a lot of cerumen. Tympanic membrane is pearly white in color with good cone of light, no
bulging, no retraction, and no perforation. Patient can hear soft spoken voice clearly on both ears.
HEENT
NOSE
Nose is symmetrical, no flaring of ala nasi. Nasal vestibule is patent, pink in color, no lesions and no
bleeding. Nasal septum is straight, at the midline and no perforation. Turbinates are pink, no edema, no
swelling, no secretions. No tenderness in paranasal sinuses upon palpation and no clouding upon
transillumination.

MOUTH AND THROAT

Lips are brown in color, symmetrical, (+) dry Lips, with no lesion. Buccal mucosa is pinkish and moist, no
lesions and no swelling. Tongue is pale in color, no lesion, no hypertrophy and atrophy. Tongue is in the
midline position upon protrusion and retraction, can move freely without difficulty. Patient has
incomplete set of teeth with dental caries. Gingiva is moist, no bleeding, no gingival recession, no
hypertrophy or atrophy. Palate is pinkish with no lesions has symmetrical elevations, uvula is in the
midline. Tonsils are not enlarged. NECK Neck is brown in color with no gross deformities, no lesions and
no scars. Neck is symmetrical; trapezius and sternocleidomastoid are well developed. Trachea and hyoid
bone are in the midline. Thyroid gland is palpable, moves up with deglutition, no tenderness and no bruit.
Submandibular lymph nodes are palpable bilaterally, other lymph nodes such as preauricular,
postauricular, occipital, tonsillar, submental, superficial cervical, posterior cervical, deep cervical and
supraclavicular lymph nodes are not palpable.
CHEST AND LUNGS EXAMINATION
Chest is symmetrical, no gross deformities, no lesions, no subcutaneous blood
vessels noted and has normal muscle movement. Equal chest expansion, no
lagging, no widening or narrowing of intercostal spaces (ICS); no retractions on the
chest wall. With normal respiratory rate of 30 cpm. Upon palpation, no tenderness
and masses noted; equal tactile fremitus on both lungs; all lung fields resonant on
percussion; vesicular breath sounds noted upon auscultation of lung fields. No
adventitious breath sounds heard. Negative bronchophony, egophony, and
whispered pectoriloquy.
CARDIOVASCULAR
Adynamic precordium, no bulging, no depression, no visible pulsations.
Normal Rate and Regular Rhythm, no murmurs.
ABDOMEN
Flat, no discolorations, no lesions, no striae, no masses, no superficial
veins. Normoactive bowel sound, tympanitic in all quadrants, soft,
and non tender.
SPINE & EXTREMITIES
Grossly normal extremities, no lesions, no masses, no cyanosis, no edema
NEUROLOGICAL EXAMINATION
CEREBRAL
conscious, coherent, alert. Speech is normal as to tone, volume. Oriented to
person, time and place. Patient can follow simple commands.
A. CRANIAL NERVES
I – Patient’s olfactory nerve is intact, with alert response to milk
II- Intact Optic Nerve.
II & III – Both pupils are 2-3 mm, reactive to direct and consensual light stimuli.
III, IV, VI –Intact Extra Ocular Muscles
V – Trigeminal nerve is intact facial sensations
VII- Facial nerve is intact. No facial asymmetry.
VIII- Patient’s vestibulocochlear nerve is intact. Intact gross hearing
IX, X –Patient has intact glossopharyngeal and vagus nerves. Uvula is in the midline
and there is symmetric elevation of the pharyngeal wall. Patient has a positive gag
reflex.
X- No hoarseness of voice
XI – Patient’s accessory nerve is intact. Patient is able to shrug his shoulders against
resistance and laterally rotate his head against resistance.
XII – Patient’s hypoglossal nerve is intact. No noted atrophy or fasciculation of the
tongue. Patient’s tongue is in the midline upon protrusion and is able to move
tongue in all directions
MOTOR Muscle tone is normal and normal muscle strength grade is 5/5 both in
upper and lower extremities. No atrophy/hypertrophy, no involuntary movements
and fasciculations noted. D. CEREBELLAR Patient can do finger to nose test (slower
right arm), heel to shin test and alternate pronation and supination of the arms. E.
DEEP TENDON REFLEX Biceps, triceps, knee and ankle jerk reflex is 2+. Pathologic:
Patient is negative for Babinski reflex. F. SENSORY Sensation for pain, crude touch
and position sensation on upper and lower extremities both sides are all intact.
Patient cannot identify writing on skin, patient has agraphesthesia . Negative
Romberg's test. G. MENINGEAL SIGNS No nuchal rigidity. Patient negative for
Kernig’s and Brudzinski’s sign.
DIFFERENTIAL
DIAGNOSIS
J I A LVA REZ
SALIENT FEATURES
vAge : 3 years old
vIntermittent fever for 1 week (TMAX 38C)
vRashes
vAbdominal pain
v Dry Lips
vTachycardia
vRecent history of dengue of sibling
vDiagnosed as a case of Tonsilitis (7days PTA)
vPMH: Pneumonia (2016)
Differentials
v Typhoid Fever
vUrinary Tract Infection
v Systemic Viral Infection
v Upper Respiratory Tract Infection
v Dengue
TYPHOID FEVER
RULE IN RULE OUT

Fever (-) constipation

Abdominal pain (-) diarrhea

Rashes (-) headache

(-) anorexia

(-) vomiting
 URINARY TRACT INFECTION
RULE IN RULE OUT Diagnostics to be requested

Fever (-) Dysuria Urinalysis

Uncircumcised boys at higher risk (-) Urinary Frequency

Tachycardia (-) Back pain

Abdominal Pain
UPPER RESPIRATORY TRACT INFECTION
RULE IN RULE OUT

Fever Rash

Abdominal Pain (-) cough

PMH: Pneumonia (2016) (-) colds

Tonsilitis (-) tachypnea

Decreased Appetite (-) decreased breath sounds

(-) crackles / rhonchi

SYSTEMIC VIRAL INFECTION
RULE IN RULE OUT

Fever Cannot totally rule out

Abdominal pain

Rashes
 DENGUE
RULE IN RULE OUT Diagnostics to be requested

Fever Cannot totally rule out CBC with PC

Rash Dengue NS1

Abdominal pain Dengue IgG

Recent history of dengue of Dengue IgM

sibling

Minimal nose bleeding

COURSE IN THE WARD
J I A LVA REZ
 1ST HOSPITAL DAY – NOVEMBER 9, 2019
8th day of illness
S o A P
(-) Fever Awake, Alert, not in cardiorespiratory Patient was • Please admit patient to pedia-ward under
(+) Macular rashes distress admitted to the service of Dr. Dulay See.
on Upper Skin: Medium-fair, (+) macular rashes on the ward • Secure consent for admission and
Extremities, upper extremities, bilateral, non-pruritic, due to on management
bilateral, non no lesions, no masses and off • TPR q4 and record please
pruritic Anicteric Sclera, pink palpebral fever. • Diet: DAT
(-) Abdominal pain conjunctiva, (-) NAD, (-) CLAD • IVF: PLR 270 cc x 8hrs, 33-34 ugtts/ min
(-) Dyspnea Symmetric chest expansion, no retractions, • Labs requested: CBC PC, Dengue IGM IGG,
(-) Nausea no lagging, clear breath sounds • Medications:
(-) Vomiting Adynamic precordium, NRRR (-) murmur • Monitor Input and Output q shift and
Flat abdomen, Normoactive bowel sounds, record please
Last febrile Grossly normal extremities, no cyanosis, no • Complete database c/o SIIC
episode: 11/08/19 pallor, full equal pulses, CRT <2 secs • Should have 1 responsible watcher at all
12 NN **LIVER SPAN times
Vitals: BP: 100/60 HR: 109 RR: 22 • Refer
Temp: 36.5 O2Sat: 97.4 % Paracetamol 250 mg / 5 ml, 2.5 ml q4 for fever
>37.8c
Fluid Balance: 280
 Hematology report (November 9,2019)
Results Normal values
Hgb 119 140-180 g/L
Hct 0.36 0.40-0.50
WBC count 4.3 5-10 x 10/L
Stab 0.04 0.01-0.05
Segmenters 0.35 0.60-0.70
Lymphocyte 0.48 0.20-0.40
Monocyte 0.013 0.01-0.06
Eosinophil 0.01-0.05
Platelet count 168 150-450 x 10/L
Immunology
Results
Dengue IgG negative
Dengue IgM Positive
Dengue NS1
 2nd HOSPITAL DAY – NOVEMBER 10, 2019
9th day of illness
S o A P
(-) Fever Awake, Alert, not in cardiorespiratory distress Dengue Fever Diet: DAT
(-) Vomiting Skin: Medium-fair, (+) macular rashes on upper without warning
(-) Abdominal pain extremities, bilateral, non-pruritic, no lesions, signs IVF: 180 cc x 8hrs, 22-23
(-) Dyspnea no masses ugtts/ min
(-) Nausea Anicteric Sclera, pink palpebral conjunctiva, (-)
(-) Headache NAD, (-) CLAD, dry lips, moist buccal mucosa Labs requested: For Repeat
Good appetite Symmetric chest expansion, no retractions, no CBC PC
Good Activity lagging, clear breath sounds
Adynamic precordium, slightly tachcardic, NRRR Medications:
Last febrile (-) murmur Paracetamol 250 mg / 5 ml,
episode: 11/08/19 Flat abdomen, Normoactive bowel sounds, 2.5 ml q4 for fever >37.8c
12 NN Grossly normal extremities, no cyanosis, no
pallor, full equal pulses, CRT <2 secs

Vitals: BP: 100/60 HR: 109 RR: 22

Temp: 36.8 O2Sat: 98 %
Fluid Balance: 1160
 3rd HOSPITAL DAY – NOVEMBER 11, 2019
10th day of illness
S o A P
(-) Fever Awake, Alert, not in cardiorespiratory distress Dengue Fever Diet: DAT
(-) Vomiting Skin: Medium-fair, (+) macular rashes on upper without warning
(-) Abdominal pain extremities, bilateral, non-pruritic, no lesions, signs IVF: 180 cc x 8hrs, 22-23
(-) Dyspnea no masses ugtts/ min
(-) Nausea Anicteric Sclera, pink palpebral conjunctiva, (-)
(-) Headache NAD, (-) CLAD Labs requested: Still for
Good appetite Symmetric chest expansion, no retractions, no Repeat CBC PC
Good Activity lagging, clear breath sounds
Adynamic precordium, NRRR (-) murmur 1:10 PM :
Last febrile Flat abdomen, Normoactive bowel sounds, May go home
episode: 11/08/19 Grossly normal extremities, no cyanosis, no Discontinue IVF
12 NN pallor, full equal pulses, CRT <2 secs Advise increased oral fluid
and daily proper hygiene
Vitals: BP: 100/60 HR: 100 RR: 22 Avoid Strenous activity for 2
Temp: 36.9 O2Sat: 98 % weeks
FF up at Pedia OPD on
November 18, 2019
 Hematology report (November 11,2019)
Results Normal values
Hgb 112 140-180 g/L
Hct 0.36 0.40-0.50
WBC count 5.2 5-10 x 10/L
Stab 0.01-0.05
Segmenters 0.28 0.60-0.70
Lymphocyte 0.68 0.20-0.40
Monocyte 0.02 0.01-0.06
Eosinophil 0.02 0.01-0.05
Platelet count 341 150-450 x 10/L
Course in the ward
Day 1 Day 2 Day 3
• Last Febrile episode: •Afebrile • Afebrile
11/8/19 •(-) dehydration • HCT: 112
• HCT: 119 •(+) rash Sent Home
• (+) possible dehydration
• (+) rash

Management

IVF: PLR 270 cc x

8hrs, 33-34 ugtts/
min
180 cc x 8hrs, 180 cc x 8hrs, Sent Home
Paracetamol 250 mg 22-20 ugtts/ min
22-20 ugtts/ min
/ 5 ml, 2.5 ml q4 for
fever >37.8c
CASE DISCUSSION
J I LOPEZ
 Definition
Dengue fever is a benign syndrome caused by several
arthropod-borne viruses and is characterized by biphasic
fever, myalgia or arthralgia, rash, leukopenia, and
lymphadenopathy.

Nelson’s Pediatrics, 21st Edition

 Definition
Dengue (breakbone fever) is a mosquito-borne
infection caused by a flavivirus that is characterized by
fever, severe headache, muscle and joint pain, nausea
and vomiting, eye pain, and rash.

Jawetz, Melnick & Adelber’g Medical Microbiology, 26th Edition

 Epidemiology

Dengue is the most rapidly spreading

mosquito-borne viral disease in the world.

WHO DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL, 2009

Epidemiology

A total of 271,480
Dengue cases were
reported from
January 1 to August
31. This is 95%
higher compared to
the same period last
year (85,981).

DOH, 2019 Dengue Monthly Report No. 8

Etiology
DENGUE VIRUS
oSmall single stranded RNA virus
o4 distinct serotypes (DEN 1, DEN 2, DEN 3, DEN 4)
oBelong to the genus Flavivirus, family Flaviviridae

WHO DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL, 2009

 Etiology
VECTOR
◦Aedes mosquitoes, principally Aedes aegypti
◦ a daytime biting mosquito
◦ virus is passed on to humans through bites of an infective female Aedes
mosquito, which mainly acquires the virus while feeding on the blood of an
infected person

WHO DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL, 2009

 Course of Disease

Three phases of Dengue:

1. Febrile phase
2. Critical phase
3. Recovery phase

WHO DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL, 2009

 Course of Disease

WHO DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL, 2009

 Course of Disease

WHO DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL, 2009

 Course of Disease

WHO DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL, 2009

Febrile Phase Critical Phase Recovery Phase
Fever lasts 2-7 days Plasma leak lasts 24-48 hours Reabsorption lasts 2 to 4 days
Hallmark features: High grade fever Hallmark features: Varying degrees of Hallmark features: Resolution of plasma
hemorrhage and plasma leak leakage and hemorrhage, stabilization
of vital signs, reabsorption of
accumulated fluids, improved appetite
and sense of wellbeing
Other signs and symptoms: severe Development of warning signs: Development of HERMANN’S RASH
headache, retro-orbital pain, muscle (LICPALM)
joint and bone pain, facial flushing, skin 1. Lethargy
erythema 2. Increased hematocrit
3. Clinical fluid accumulation
Anorexia, nausea, vomiting are 4. Persistent vomiting
common 5. Abdominal pain
6. Liver enlargement
7. Mucosal bleed
Laboratory finding: decreased WBC Laboratory warning signs: Hematocrit stabilizes, WBC starts to rise
count 1. Rapid decrease in platelet count, Later recovery of platelet count
2. Increasing hematocrit,
3. Leukopenia
Potential complications: Dehydration Potential complications: Potential complications:
Shock from plasma leakage Intravascular fluid overload
Coagulopathy
Organ impairment
 Management

WHO DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL, 2009

 Management

DOH, Revised Dengue Clinical Case Management Guidelines 2011

 Management

DOH, Revised Dengue Clinical Case Management Guidelines 2011

DOH, Revised Dengue Clinical Case Management Guidelines 2011
 Management

DOH, Revised Dengue Clinical Case Management Guidelines 2011

 Treatment

DOH, Revised Dengue Clinical Case

Management Guidelines 2011
 Group A: May be sent home
Action Plan
• Oral rehydration solution (ORS)
should be given based on weight,
using currently recommended
ORS:

DOH, Revised Dengue Clinical Case

Management Guidelines 2011

• Reduce osmolarity of ORS containing

sodium 45 to 60 mmol/liter.
• Sports drinks should NOT be given due to its
high osmolarity which may cause more
danger to the patient.
 Group A: May be sent home

DOH, Revised Dengue Clinical Case

Management Guidelines 2011
Group B: Referred to in-
hospital Management
Action Plan
a. Dengue without Warning Signs
Encourage oral fluids. If not tolerated, start intravenous
fluid therapy of 0.9% NaCl (saline) or Ringer’s Lactate
with or without dextrose at maintenance rate

Fluid management for patients who are admitted,

without shock (Dengue without Warning Signs):
• Isotonic solutions (D5 LRS, D5 Acetated Ringers D5
NSS/D5 0.9 NaCl) are appropriate for Dengue patients
without warning signs who are admitted without shock.
• Maintenance IVF is computed using the caloric
expenditure method (Holliday-Segar Method) or
calculation Based on Weight (Ludan Method).

DOH, Revised Dengue Clinical Case

Management Guidelines 2011
 Group B: Referred to in-hospital Management

If the patient shows signs of mild dehydration but is NOT in shock, the volume needed for mild
dehydration is added to the maintenance fluids to determine the total fluid requirement (TFR).

DOH, Revised Dengue Clinical Case

Management Guidelines 2011
 Group B: Referred to in-hospital Management

Monitoring by health care providers:

• Temperature pattern
• Volume of fluid intake and losses
• Urine output – volume and frequency
• Warning signs
• Hematocrit, white blood cell and platelet counts

DOH, Revised Dengue Clinical Case

Management Guidelines 2011
 Group B: Referred to in-hospital Management
b. Dengue with Warning Signs
1. Obtain a reference hematocrit before fluid therapy
2. Give only isotonic solutions such as 0.9% NaCl (saline), Ringer’s Lactate,
Hartmann’s solution.
Start with 5-7 mL/kg/hour for 1-2 hours, then reduce to 3-5 mL/kg/hr for 2-4
hours, and then reduce to 2-3 mL/kg/hr or less according to clinical response
3. Reassess the clinical status and repeat the hematocrit
4. If the hematocrit remains the same or rises only minimally, continue with
the same rate (2-3 mL/kg/hr) for another 2-4 hours.

DOH, Revised Dengue Clinical Case

Management Guidelines 2011
 Group B: Referred to in-hospital Management
5. If there are worsening of vital signs and rapidly rising hematocrit,
increase the rate to 5-10 mL/kg/hour for 1-2 hours
6. Reassess the clinical status, repeat hematocrit and review fluid infusion
rates accordingly
7. Give the minimum intravenous fluid volume required to maintain good
perfusion and urine output of about 0.5 mL/kg/hr. Intravenous fluids are
usually needed for only 24 to 48 hours.
8. Reduce intravenous fluids gradually when the rate of plasma leakage
decreases towards the end of the critical phase. This is indicated by:
• Urine output and/or oral fluid intake is/are adequate, or
• Hematocrit decreases below the baseline value in
a stable patient
DOH, Revised Dengue Clinical Case
Management Guidelines 2011
 Group B: Referred to in-hospital Management
Monitoring by health care providers:
Patients with warning signs should be monitored until the “at-risk” period is
over. A detailed fluid balance should be maintained. Parameters that should
be monitored include:
• Vital signs and peripheral perfusion (1-4 hourly until the patient is
out of critical phase)
• Urine output (4-6 hourly)
• Hematocrit (before and after fluid replacement, then 6-12 hourly)
• Blood glucose
• Other organ functions (such as renal profile, liver profile,
coagulation profile, as indicated)

DOH, Revised Dengue Clinical Case

Management Guidelines 2011
Group C:
Require
Emergency
Treatment and
Urgent Referral
JOURNAL
J I AVINA NT E
Restrictive versus Liberal Fluid Resuscitation in
Children with Dengue Shock Syndrome: the
differences in Clinical Outcomes
and Hemodynamic Parameters
SA PTA D I YULIA RTO1, KURNIAWA N TA UFIQ KA D A FI1, D ESSY
A NITA SA RI21
 Introduction
Dengue Shock Syndrome (DSS) is one of dangerous
clinical manifestations of dengue infection characterized by
severe plasma leakage due to increased vascular
permeability leading to rapid and progressive intravascular
volume reduction.

Current guideline recommends fluid resuscitation as a

mainstay therapy, based on clinical sign and hematocrit
level.
 Study design and population
Øretrospective observational study.
Ø All pediatric patients who presented with clinical criteria
for dengue hemorrhagic fever grade III and IV based on
WHO classification of dengue fever in 2011
Methods
Restrictive fluid resuscitation group was defined as patients
who received bolus infusion ≤ 40 ml/kg BW,

Liberal group received bolus infusion > 40 ml/kg BW

Patients were resuscitated with either crystalloid or

colloid solutions.
Hemodynamic parameters were measured by
ultrasonic cardiac output monitor.
 Scope and limitations
children with age from 1 month to 18 years old who were admitted
to pediatric intensive care unit (PICU), pediatric wards, and
emergency room at a Saiful Anwar General Hospital
from January 2016 to December 2016.

Exclusion criteria:
children with congenital heart diseases, immunodeficiency disorders,
autoimmune diseases, pulmonary diseases, hematology diseases,
and renal diseases.
 Statistical Analysis
The two independent groups were compared using
Mann-Whitney test. Categorical variables were
expressed as frequencies and percentages and
analyzed with Chi-square tests or Fisher’s exact tests,
as appropriate. Level of statistical significance was
declared at p- value < 0.05 levels.
 Results
There was no statistically difference was found in clinical outcomes
in both groups
The median (range) length of stay in PICU was similar in the two
groups: (2-18) days in restrictive group versus (2-19) days in liberal
groups.

The median duration of mechanical ventilation in restrictive group

was (1-18) days, while in liberal group was (2-18) days.
Regarding the hemodynamic parameters of the study
patients no significant difference was observed among two
groups
 Conclusion
This study showed that there is no difference in
clinical outcomes (length of mechanical ventilation
and length of PICU stay), and hemodynamic
parameters (preload, inotropy, afterload, and
cardiac index) in Dengue Shock Syndrome patients
who receive restrictive or liberal fluid resuscitation.