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(2011) DOH Guidelines Dengue PDF
(2011) DOH Guidelines Dengue PDF
Department of Health
National Dengue Prevention and Control Program
National Center for Disease Prevention and Control (DOH-NCDPC)
San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila
Telephone No.: 651-78-00 local 2353
Dengue Fever
Republic of the Philippines
Department of Health
National Dengue Prevention and Control Program
National Center for Disease Prevention and Control (DOH-NCDPC)
San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila
Telephone No.: 651-78-00 local 2353
According to WHO, dengue is the most rapidly spreading mosquito-borne viral disease in the world. In the last
50 years, incidence has increased 30-fold with increasing geographic expansion to new countries and, in the
present decade, from urban to rural settings. Between 2001 and 2008, more than a million cases were reported in
Cambodia, Malaysia, Philippines, and Vietnam – the four countries in the Western Pacific Region with the highest
numbers of cases and deaths. Official reports from these countries revealed a combined death toll of 4,798.
Dengue is an all-year round disease in the Philippines. In 2008, the Philippines was reported as one of the countries with the
highest number of dengue cases and deaths in the Western Pacific Region. In 2010, all regions reported cases of dengue
and several outbreaks were reported in provinces and municipalities. The cases totaled to 135, 355, which is 135% higher
compared to 57,636 cases in 2009.
The elimination of dengue is the responsibility of everyone. The Department of Health continuously seeks the participation
of communities in eliminating mosquitoes as well as their breeding sites. Responding to dengue cases, on the other hand,
requires the delivery of competent clinical services and management decisions among all lebels of health care. Dengue mis-
sions were conducted to selected regions where increases in the numbers of dengue cases and outbreaks were observed.
Visits to hospital wards and rural health units found varying clinical skills and degrees of capacity to diagnose, classify, and
manage dengue cases.
To address this, the DOW with support from WHO conducted on 29 October 2010 a National Dengue Workshop on Clinical
Management to serve as a forum for the local adaptation of the recently updated WHO Dengue Guidelines for Diagnosis,
Prevention and Control. The results of the discussions paved the way to the development of a standard source of information
and guidelines for dengue case management.
II. OBJECTIVE
This document aims to establish a standard in the diagnosis and treatment of dengue for all public and private health facilities
and other stakeholders.
III. COVERAGE
This administrative order shall apply to all public and private health workers, LGUs, NGOs, academe and other stakeholders
involved in the diagnosis and treatment of dengue cases.
The following sections and annexes contain updated information on the course of dengue illness, revised dengue case
classification, and treatment guidelines specifically for health practitioners, laboratory personnel, those involved in vector
control, and other public health officials and staff.
In the event that any rule, section, paragraph, sentence, clause or word of this administrative order is declared null and void
for valid reason(s), the validity of the other provisions shall not be affected.
V. REPEALING CLAUSE
All orders and other issuances inconsistent with this administrative order are hereby revised, modified or rescinded accordingly.
All other provisions of existing issuances which are not affected by this order shall remain valid and in effect.
VI. EFFECTIVITY
This Order takes effect immediately upon posting and publication in the DOH intranet, or fifteen days upon filing with the
University of the Philippines Law Center.
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Dengue Fever
ANNEX A Changes in dengue epidemiology in recent years led
to difficulties and inconsistencies in the use of the
REVISED DENGUE CASE CLASSIFICATION previous dengue case definition and classification. The
adoption of this new classification is deemed a solution
In the new case classification, patients with dengue are in determining more standard, practical and appro
classified according to the levels of severity as having priate management of dengue cases in the country.
dengue without Warning Signs, Dengue with Warning Likewise, this improvement is seen to improve consist-
Signs, and Severe Dengue based on clinical manifesta- ency in reporting across various levels of health care
tions with or without laboratory parameters. facilities.
The Old Case Definition and Classification vis-a-vis the New Case Definition and Classification for Dengue
OLD NEW
Case Definition and Levels of Severity Case Classification and Levels of Severity
Case Definition for Dengue Fever Case Definition for Dengue without Warning
Signs
Probable dengue:
An acute febrile illness with 2 or more of the follow- Probable dengue:
ing: Lives in or travels to dengue-endemic area, with fever,
• Headache plus any two of the following:
• Retro-orbital pain • Headache
• Arthralgia • Body malaise
• Rash • Myalgia
• Hemorrhagic manifestations • Arthralgia
• Leukopenia; • Retro-orbital pain
AND • Anorexia
• Supportive serology (a reciprocal HI antibody titer • Nausea
>1280, a comparable IgG assay ELISA titer or (+) • Vomiting
IgM antibody test on a late or acute convalescent • Diarrhea
phase serum specimen • Flushed skin
• Rash (petechial, Hermann’s sign)
Confirmed: AND
A case confirmed by laboratory criteria • Laboratory test, at least CBC (leucopenia with or
without thrombocytopenia) and/or dengue NS1 antigen
Case Definition for Dengue Hemorrhagic Fever test or dengue IgM antibody test (optional)
(DHF)
Confirmed dengue:
The following must all be present: • Viral culture isolation
1. Fever, or history of fever, lasting for 2-7 days, • PCR
occasionally biphasic
2. Hemorrhagic tendencies evidenced by at least one Case Definition for Dengue with Warning Signs
of the following:
a. (+) tourniquet test Lives in or travels to dengue-endemic area, with fever
b. Petechia, ecchymosis, purpura lasting for 2-7 days, plus any of the following:
c. Bleeding from the mucosa, GIT, injection sites • Abdominal pain or tenderness
or other locations • Persistent vomiting
d. Hematemesis or melena • Clinical signs of fluid accumulation
3. Thrombocytopenia (100,000 cells/mm3 or less) • Mucosal bleeding
4. Evidence of plasma leakage due to increased • Lethargy, restlessness
vascular permeability, manifested by at least one • Liver enlargement
of the following: • Laboratory: increase in Hct and/or decreasing platelet
a. A rise in the hematocrit equal to or greater than count
20% above average for age, sex, and popula-
tion Confirmed dengue:
b. A drop in the hematocrit following volume re- • Viral culture isolation
placement treatment equal to or greater than • PCR
20% of baseline
c. Signs of plasma leakage such as pleural effu- Case Definition for Severe Dengue
sion, ascites and hypoproteinemia
Lives in or travels to a dengue-endemic area with fever
Case Definition for Dengue Shock Syndrome (DSS) of 2-7 days and any of the above clinical manifestations
for dengue with or without warning signs, plus any of
All of the four criteria for DHF must be present plus the following:
evidence of circulatory failure manifested by: • Severe plasma leakage, leading to:
• Rapid and weak pulse, AND - Shock
• Narrow pulse pressure (<20 mmHg [2.7kPa]) - Fluid accumulation with respiratory distress
OR
66
Dengue Fever
OLD NEW
Case Definition and Levels of Severity Case Classification and Levels of Severity
Critical Phase
A. ASSESSMENT
WARNING SIGNS
• Abdominal pain or tenderness Step 1 – Overall Assessment
• Persistent vomiting
• Clinical signs of fluid accumulation 1.1 History
• Mucosal bleeding • Date of onset of fever/illness
• Lethargy; restlessness • Quantity of oral intake
• Liver enlargement • Assess for warning signs
• Laboratory: Increase in hematocrit and/or • Diarrhea
decreasing platelet count • Seizures, impaired consciousness, behavioral
changes
• Urine output (frequency, volume and time of last
Some patients may deteriorate to Severe Dengue, voiding)
defined by one or more of the following: (i) plasma • Other important relevant histories:
leakage that may lead to shock (dengue shock) and/or o Family members or neighbors with dengue, or
fluid accumulation, with or without respiratory distress, travel to dengue-endemic areas
and/or (ii) severe bleeding, and/or (iii) severe organ o Co-existing conditions such as infancy, pregnancy,
impairment. obesity, diabetes mellitus, hypertension, etc.
o Jungle trekking and swimming in waterfall (con-
Shock occurs when a critical volume of plasma is lost sider leptospirosis, typhus malaria)
through leakage. It is often preceded by warning signs. o Recent unprotected sexual or drug use behavior
The body temperature may be subnormal when shock (consider acute HIV seroconversion illness)
occurs. With prolonged shock, the consequent organ
hypoperfusion results in progressive organ impairment, 1.2 Physical Examination
metabolic acidosis and disseminated intravascular • Assess mental state and Glasglow Coma scale
coagulation. This in turn leads to severe hemorrhage (GCS) score
causing the hematocrit to decrease in severe shock. • Assess hydration status
Instead of the leucopenia usually seen during this • Assess hemodynamic status (refer to Table 1)
phase of dengue, the total white cell count may • Look out for tachypnea/acidotic breathing/pleural
increase in patients with severe bleeding. In addition, effusion
severe organ impairment such as severe hepatitis, • Check for abdominal tenderness/hepatomegaly/as-
encephalitis or myocarditis and/or severe bleeding cites
may also develop without obvious plasma leakage • Examine for rash and bleeding manifestations
or shock. • Tourniquet test (repeat if previously negative or if
there is no bleeding manifestation)
Recovery Phase
1.3 Investigation
A gradual re-absorption of extravasated fluid from the • Full blood count (FBC)
intravascular to the extravascular space (e.g., pleural o A full blood count should be done at the first visit
effusion, ascites) by way of the lymphatics will take • Dengue diagnostic tests
place in the next 48-72 hours. Patients’ general well- o Laboratory tests should be performed to confirm
being improves, hemodynamic status stabilizes and the diagnosis – viral culture isolation or PCR.
diuresis ensues. Some patients may have a classical However, it is not necessary for the acute man-
rash of “isles of white in the sea of red.” The hematocrit agement of patients except in cases with unusual
stabilizes or may be lower due to the dilution effect manifestations
of reabsorbed fluid. White Blood Count usually starts
to rise soon after defervesence but the normalization Step 2 – Diagnosis, Assessment of Disease Phase
of the platelet count is typically later than that of and Severity
WBC count.
Determine:
Clinical problems encountered during the different phases • Is it dengue?
of dengue are: • Which phase of dengue? (febrile/critical/recovery)
• Are there warning signs?
• Febrile phase – dehydration; high fever may cause • What is the hydration and hemodynamic status?
febrile seizures in young children; neurological distur- • Does the patient require admission?
bances
• Critical phase – shock from the plasma leakage; severe Step 3 – Management
hemorrhage; organ impairment
• Recovery phase – hypervolemia (only if intravenous a. Disease notification
fluid therapy has been excessive and/or extended into b. Management decisions – depending on the clinical
this period) manifestations and other circumstances, patients
68
Dengue Fever
may: What should be avoided?
• Be sent home (GROUP A); or may • Do not take NSAIDS, e.g. acetylsalicyclic acid
• Be referred for in-hospital management (aspirin)/ mefenamic acid or steroids. If you are
(GROUP B); or may already taking these medications, please consult
• Require emergency treatment and urgent your doctor.
referral (GROUP C) • Antibiotics are not necessary
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Dengue Fever
Calculation of Oral Rehydration Fluids Using b. Dengue with Warning Signs
Weight (Ludan Method) 1. Obtain a reference hematocrit before fluid therapy
2. Give only isotonic solutions such as 0.9% NaCl
Body weight (kg) ORS to be given (saline), Ringer’s Lactate, Hartmann’s solution.
Start with 5-7 mL/kg/hour for 1-2 hours, then
>3-10 100 mL/kg/day reduce to 3-5 mL/kg/hr for 2-4 hours, and then
>10-20 75 mL/kg/day reduce to 2-3 mL/kg/hr or less according to clinical
>20-30 50-60 mL/kg/day response (see Table 3)
>30-60 40-50 mL/kg/day 3. Reassess the clinical status and repeat the hematocrit
4. If the hematocrit remains the same or rises only mini-
Source: Ludan A. Chapter 41: Pediatric fluid and Electrolyte mally, continue with the same rate (2-3 mL/kg/hr) for
Therapy. Textbook of Pediatrics and Child Health. del Mundo F, another 2-4 hours.
Estrada FA, Santos-Pcampo PD, Navarro XR, editors. Manila: 5. If there are worsening of vital signs and rapidly rising
JMC Press. Fourth Edition. 2000:1485-1499 hematocrit, increase the rate to 5-10 mL/kg/hour for
1-2 hours
• If the patient shows signs of mild dehydration but is 6. Reassess the clinical status, repeat hematocrit and
NOT in shock, the volume needed for mild dehydration review fluid infusion rates accordingly
is added to the maintenance fluids to determine the total 7. Give the minimum intravenous fluid volume required
fluid requirement (TFR). to maintain good perfusion and urine output of about
• The following formula may be used to calculate the 0.5 mL/kg/hr. Intravenous fluids are usually needed
required volume of intravenous fluid to infuse: for only 24 to 48 hours.
8. Reduce intravenous fluids gradually when the rate
TFR = Maintenance IVF + Fluids as for Mild dehydration* of plasma leakage decreases towards the end of the
critical phase. This is indicated by:
*where the volume of fluids for mild dehydration is • Urine output and/or oral fluid intake is/are adequate,
computed as follows: or
Infant 50 mL/kg • Hematocrit decreases below the baseline value in
Other Child or Adult 30 mL/kg a stable patient
• One-half of the computed TFR is given in 8 hours and Monitoring by health care providers:
the remaining one-half is given in the next 16 hours Patients with warning signs should be monitored until the
• Sample computation for a 10 kg patient with dengue “at-risk” period is over. A detailed fluid balance should
and mild dehydration: be maintained. Parameters that should be monitored
include:
Step 1 : Compute for Total Fluid Requirement: • Vital signs and peripheral perfusion (1-4 hourly until
TFR = Maintenance Fluids + Fluids for Mild the patient is out of critical phase)
dehydration • Urine output (4-6 hourly)
= (100 x 10 kg) + (50 x 10 kg) • Hematocrit (before and after fluid replacement, then
= 1000 + 500 6-12 hourly)
= 1500 mL • Blood glucose
• Other organ functions (such as renal profile, liver profile,
Step 2 : Compute one-half of TFR: coagulation profile, as indicated)
TFR/2 = 1500 mL/2 = 750 mL
Step 3 : Volume to be given in the first 8 hours: GROUP C – Patients with Severe Dengue Requiring
= 750 mL in 8 hours Emergency Treatment and Urgent Referral
= 93 mL/hour for 8 hours
a. Management for patients admitted to the hospital
Step 4 : Volume to be given in the next 16 hours: with Compensated Shock
= 750 mL in 16 hours
= 46 mL per hour for 16 hours 1. Start intravenous fluid resuscitation with isotonic
crystalloid solutions at 5-10 mL/kg/hr over 1 hour, then
• Periodic assessment is needed so that fluid may be reassess the patients condition (vital signs, capillary
adjusted accordingly refill time, hematocrit, urine output) and decide depend-
• Clinical parameters should be monitored closely and ing on the situation:
correlated with the hematocrit. This will ensure adequate 2. If the patients condition improves, intravenous fluids
rehydration, avoiding under and over hydration. should be gradually reduced to
• The IVF rate may be decreased anytime as neces- • 5-7 mL/kg/hr for 1-2 hours, then
sary based on clinical assessment. • To 3-5 mL/kg/hr for 2-4 hours, then
• If the patient shows signs of deterioration see Manage- • To 2-3 mL/kg/hr and then
ment for Compensated or Hypotensive Shock, which- • To reduce further depending on hemodynamic
ever is applicable. status, which can be maintained for up to 24 to 48
hours
Monitoring by health care providers: (Note: Please refer to Tables 2 and 3 for a more appro-
• Temperature pattern priate estimation of normal maintenance requirement
• Volume of fluid intake and losses based on ideal body weight.)
• Urine output – volume and frequency 3. If vital signs are still unstable (shock persists), check
• Warning signs the hematocrit after the first bolus:
• Hematocrit, white blood cell and platelet counts • If hematocrit increases or is still high (>50%),
70
Dengue Fever
Algorithm for the Treatment of Compensated Shock
BOX A. Obtain baseline CBC (a). Fluid resuscitation with plain isotonic crystalloid 10 mL/
kg/hour over 1 hour. Give oxygen support.
Is there
improvement? (b)
(See Table 1)
Yes No
BOX B.
• Fluids should not exceed 3 liters per day HCT or High HCT
to avoid fluid overload (g) and (h).
• If feasible, monitor HCT every 6 hours or
as necessary (a). BOX C. BOX D.
• Reassess hemodynamic status frequently
(see Table 1) including urine output (f) Administer 2nd bolus of fluid, If there are signs of occult/
• Monitor for signs of bleeding colloid/crystalloid (c) 10 mL/kg overt bleeding initiate transfu-
in 1 hour sion with fresh whole blood 20
mL/kg or PRBC 10 mL/kg
1. If improved go to Box B.
BOX A. Obtain baseline CBC (a). Fluid resuscitation with 10 mL/kg plain isotonic crystalloid
or colloid over 15 minutes (c). Give oxygen support.
Is there
improvement? (b)
(See Table 1)
Yes No
BOX B.
If patient remains
stable, go to BOX B
If patient improves, go BOX E
to BOX B
If patient does not improve,
consider inotropes (d) and
refer to tertiary care center
72
Dengue Fever
repeat a second bolus of crystalloid solution at 10- output, do not require extra intravenous fluid. Continue
20 mL/kg/hr for 1 hour. After this second bolus, if to monitor closely and it is likely that the hematocrit
there is improvement, then reduce the rate to 7-10 will start to fall within the next 24 hours as the plasma
mL/kg/hr for 1-2 hours, and then continue to reduce leakage stops
as above _>For example: A decrease in hematocrit:
• If hematocrit decreases compared to the initial • Together with unstable vital signs (particularly narrowing
reference hematocrit (<40% in children and adult of the pulse pressure, tachycardia, metabolic acidosis,
females, <45% in adult males), this indicates poor urine output) indicates major hemorrhage and the
bleeding and the need to cross-match and transfuse need for urgent blood transfusion
blood as soon as possible (see Treatment for • Together with stable hemodynamic status and ad-
Hemorrhagic Complications) equate urine output indicates hemodilution and/or
4. Further boluses of crystalloid or colloidal solutions may re-absorption of extravasated fluids; intravenous fluids
need to be given during the next 24 to 48 hours must be discontinued immediately to avoid pulmonary
edema
b. Management for patients admitted to the hospital
with Hypotensive Shock
C. TREATMENT OF HEMORRHAGIC COMPLICATIONS
Patients with hypotensive shock should be managed
more vigorously Mucosal bleeding may occur in any patient with dengue
but if the patient remains stable with fluid resuscitation/
1. Initiate intravenous fluid resuscitation with crystalloid replacement, it should be considered as minor. This
or colloid solution (if available) at 20 mL/kg as a bolus usually improves rapidly during the recovery phase.
given over 15 minutes to bring the patient out of shock
as quickly as possible. In patients with profound thrombocytopenia, ensure strict
2. If the patient’s condition improves, give a crystalloid/ bed rest and protection from trauma to reduce the risk
colloid infusion of 10 mL/kg/hr for 1 hour, then continue of bleeding.
with crystalloid infusion and gradually reduce
• To 5-7 mL/kg/hr for 1-2 hours, then Do not give intramuscular injections to avoid hematoma.
• To 3-5 mL/kg/hr for 2-4 hours and then
• To 2-3 mL/kg/hr or less, which can be maintained for Note: Prophylactic platelet transfusions for severe
up to 24 to 48 hours (refer to Table 2) thrombocytopenia in otherwise hemodynamically stable
3. If vital signs are still unstable (shock persists), check patients are not necessary.
hematocrit after the first bolus:
• If hematocrit increases compared to the previous If major bleeding occurs, it is usually from the gastroin-
value or remains very high (>50%), change intra- testinal tract and/or per vagina in adult females. Internal
venous fluids to colloid solutions at 10-20 mL/kg as bleeding may not become apparent for many hours until
a second bolus over ½ to 1 hour. After this dose, the first black stool is passed
reduce the rate to 7-10 mL/kg/hr for 1-2 hours, then
change back to crystalloid solution and reduce rate Who are at risk of major bleeding?
of infusion as mentioned above when the patient’s • Patients with prolonged/refractory shock
condition improves • Patients with hypotensive shock and renal or liver
• If hematocrit decreases compared to the previous failure and/or severe and persistent metabolic
value (<40% in children and adult females, <45% in acidosis
adult males), this indicates bleeding and the need to • Patients given non-steroidal anti-inflammatory agents
cross-match and transfuse blood as soon as possible (NSAIDs)
(see treatment for hemorrhagic complications) • Patients with pre-existing peptic ulcer disease
4. Further boluses of fluid may need to be given during • Patients on anticoagulant therapy
the next 24 hours. The rate and volume of each bolus • Patients with any form of trauma, including intra-
infusion should be titrated to the clinical response. muscular injection
Patients with severe dengue should be admitted to
the high dependency or intensive care areas. Note: Patients with hemolytic conditions will be at-risk
for acute hemolysis with hemoglobinuria and will require
c. Monitoring blood transfusion
Patients with dengue shock should be frequently moni- How to recognize severe bleeding
tored, until the danger period is over. A detailed fluid • Persistent and/or severe overt bleeding in the presence
balance of all input and output should be maintained. of unstable hemodynamic status, regardless of the
hematocrit level
Notes: • A decrease in hematocrit after fluid resuscitation
Interpretation of hematocrit: Changes in the hematocrit together with unstable hemodynamic status
are a useful guide to treatment. However, it must be inter- • Refractory shock that fail to respond to consecutive fluid
preted in parallel to the hemodynamic status, the clinical resuscitation of 40-60 mL/kg.
response to fluid therapy and the acid-base balance. • Hypotensive shock with low/normal hematocrit before
_>For example: A rising or persistently high hematocrit: fluid resuscitation
• Together with unstable vital signs (particularly narrowing • Persistent or worsening metabolic acidosis ± a
of the pulse pressure) indicates active plasma leakage well-maintained systolic blood pressure, espe-
and the need for a further bolus of fluid replacement. cially in those with severe abdominal tenderness and
• With stable hemodynamic status and adequate urine distension
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Dengue Fever
Table 1. Hemodynamic Assessment: Continuum of Hemodynamic Changes
Sensorium Clear and lucid Clear and lucid (shock can be Change of mental status
missed if you do not touch the (restless and combative)
patient)
Capillary refill time Brisk (<2 sec) Prolonged (>sec) Very prolonged, mottled skin
Blood pressure Normal for age Normal systolic pressure but Narrowed pulse pressure
Normal pulse rising diastolic pressure (<20 mmHg)
pressure for age Narrowing pulse pressure Hypotension (see definition below)
Postural hypotension Unrecordable BP, Metabolic
acidosis
Source: WHO and Special Programme for Research and Training in Tropical Diseases. Dengue Guidelines for Diagnosis, Treatment,
Prevention and Control 2009.2
Normal maintenance fluid per hour can be calculated based on the following formula* (Equivalent to Holliday-
Segar formula):
4 mL/kg/h for first 10 kg body weight
+ 2 mL/kg/h for next 10 kg body weight
+ 1 mL/kg/h for subsequent kg body weight
*For overweight/obese patients calculate normal maintenance fluid based on ideal body weight (IBW)
(Adapted from WHO 1997)
IBW for overweight/obese adults can be estimated based on the following formula
Female: 45.5 kg + 0.91 (height – 152.4) cm
Male: 50.0 kg + 0.91(height – 152.4) cm
(Gilbert DN, et al 2007)
Estimated body weight, Normal maintenance Fluid regimen based Regimen based on
or IBW (kg) fluid [mL/hour] based on on 2-3 mL/kg/hour 1.5-2 mL/hour
Holiday-Segar formula (mL/hour) (mL/hour)
5 10 10 - 15
10 20 20 - 30
15 30 30 - 45
20 60 40 - 60
25 65 50 - 75
30 70 60 - 90
35 75 70 - 105
40 80 80 - 120
50 90 100 - 150
60 100 90-120
70 110 105-140
80 120 120-150
Notes:
For adults with IBW >50 kg, 1.5-2 mL/kg can be used for quick calculation of hourly maintenance fluid regime. For adults with IBW>
50 kg, 2-3 mL can be used for quick calculation of hourly maintenance fluid regime
74
Dengue Fever
Action Plan Crystalloids
• Give 5-10 mL/kg of fresh packed red blood cells or 10-20 0.9% saline [“normal” saline]/NSS
mL/kg of fresh whole blood at an appropriate rate and • Normal plasma chloride ranges from 95 to 105
observe the clinical response mmol/L. 0.9% saline is a suitable option for initial
• A good clinical response includes improving hemo fluid resuscitation, but repeated large volumes of
dynamic status and acid-base balance. 0.9% saline mat lead to hyperchloremic acidosis.
• Consider repeating the blood transfusion if there is Hyperchloremic acidosis may aggravate or be
further blood loss or no appropriate rise in hematocrit confused with lacticacidosis from prolonged shock.
after blood transfusion Monitoring the chloride and lactate levels will help
• Although there is little evidence to support the practice to identify this problem. When serum chloride level
of platelet concentrates and/or fresh frozen plasma exceeds the normal range, it is advisable to change
transfusion for severe bleeding, they may be given to other alternatives such as Ringer’s lactate.
judiciously. Ringer’s Lactate
• Ringer’s Lactate has lower sodium (131 mmol/L) and
chloride (115 mmol/L) contents and osmolality of 273
D. DISCHARGE CRITERIA mOsm/L. It may not be suitable for resuscitation of
patients with severe hyponatremia. However, it is
ALL of the following conditions must be present a suitable solution after 0.9 Saline has been given
1. No fever for 48 hours and the serum chloride level has exceeded the
2. Improvement in clinical status (general well-being, normal range. Ringer’s Lactate should probably
appetite, hemodynamic status, urine output, no res- be avoided in liver failure and patients taking
piratory distress) metformin where lactate metabolism may be
3. Increasing trend of platelet count impaired.
4. Stable hematocrit without intravenous fluids Colloids
• The types of colloids are gelatin-based, dextran-
based and starch-based solutions. One of the
Table 4. Estimated Ideal Body Weight for Overweight
biggest concerns regarding their use is their impact
or Obese Adults
on coagulation.
• Dextrans may bind to von Willebrand factor/Factor
Height Estimated, IBW (kg) Estimated IBW (kg)
VIII complex and impair coagulation the most.
(cm) for adult males for adult females
However, this was not observed to have clinical
150 50 45.5 significance in fluid resuscitation in dengue shock.
160 57 52 Dextran 40 can potentially cause an osmotic renal
170 66 61.5 injury in hypovolemic patients.
180 75 70 • Gelatin has the least effect on coagulation among all
the colloids but the highest risk of allergic reactions.
Allergic reactions such as fever, chills and rigors have
ANNEX D also been observed in Dextran 70.
ANNOTATIONS d. Inotropes
The use of inotropes should be decided on carefully and
a. If Hct is not readily available, assess hemodynamic it should be started after adequate fluid volume has been
status of patient using parameters in Table 1. administered.
76
Dengue Fever
ANNEX F
Probable dengue:
Lives in or travels to dengue-endemic area, with fever,
plus any two of the following:
• Headache
• Body malaise
• Myalgia Warning Signs
• Arthralgia • Abdominal pain or tenderness
Assessment
Negative Positive
Positive
Co-existing conditions?
Classification
Social circumstances?
Negative
GROUP C
GROUP A GROUP B
Require Emergency
May be Sent Home Referred for In-hospital Management
Treatment
Full Blood Count (FBC) Full Blood Count (FBC) Full Blood Count (FBC)
Hematocrit (HCT) Hematocrit (HCT) Hematocrit (HCT)
Other organ function tests
as indicated
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Dengue Fever
Treatment Treatment Treatment Treatment of Compensated
Advice for • Encourage oral fluid intake 1. Obtain a reference hemato Shock
• Adequate bed rest • Give oral rehydration solution crit before fluid therapy
• Adequate fluid intake based on weight 2. Give only isotonic solu- 1. Start intravenous fluid re-
• Paracetamol, 4 grams max • If oral fluids are not tolera tions such as 0.9% NaCl suscitation with isotonic
per day in adults and accord- ted, start intravenous fluid (saline), Ringer’s Lactate, crystalloid solutions at 5-10
ingly in children therapy, 0.9% NaCl (saline) Hartmann’s solution. mL/kg/hr over 1 hour, then
or Ringer’s Lactate at main- Start with 5-7 mL/kg/hour reassess the patients con-
Patients with stable Hemat- tenance rate for 1-2 hours, then reduce dition (vital signs, capillary
ocrit can be sent home to 3-5 mL/kg/hr for 2-4 refill time, hematocrit, urine
Fluid management for patients hours, and then reduce to output) and decide depend-
who are admitted, without 2-3 mL/kg/hr or less accord- ing on the situation.
shock ing to clinical response 2. If the patients condition
• Isotonic solutions (D5 LRS, 3. Reassess the clinical status improves, intravenous flu-
D5 Acetated Ringers, D5 and repeat the HCT ids should be gradually
NSS/D5 0.9 NaCl) are appro 4. If the HCT remains the reduced to
priate same or rises only mini- o 5-7 mL/kg/hr for 1-2
• Compute maintenance IVF mally, continue with the hours, then
using the caloric-expendi- same rate (2-3 mL/kg/hr) o 1 pt To 3-5 mL/kg/hr for
ture method (Holliday-Segar for another 2-4 hours. 2-4 hours, then
Method) or calculation Based 5. If there are worsening of o To 2-3 mL/kg/hr and
on Weight vital signs and rapidly rising then to reduce further
• If the patient shows signs of HCT, increase the rate to depending on hemody-
mild dehydration but is NOT 5-10 mL/kg/hour for 1-2 namic status, which can
in shock, the volume needed hours be maintained for up to
for mild dehydration is added 6. Reassess the clinical sta- 24 to 48 hours
to the maintenance fluids tus, repeat hematocrit and 3. If shock persists check the
to determine the total fluid review fluid infusion rates hematocrit after the first
requirement (TFR). accordingly bolus:
• The following formula may be 7. Give the minimum intrave- • If hematocrit increases or
used to calculate the required nous fluid volume required is still high (>50%), repeat
volume of intravenous fluid to to maintain good perfusion a second bolus of crystal-
infuse: and urine output of about loid solution at 10-20 mL/
TFR – Maintenance IVF + 0.5 mL/kg/hr. Intravenous kg/hr for 1 hour. After this
Fluids as for Mild dehydra- fluids are usually needed second bolus, if there is
tion* for only 24 to 48 hours. improvement, then reduce
8. Reduce intravenous fluids
Management
78
Dengue Fever
Monitoring Monitoring Monitoring 3. If shock persists, check
• Daily review for disease • Temperature pattern • Vital signs and peripheral hematocrit after the first
progression • Volume of fluid intake and perfusion (1-4 hourly until bolus:
- Decreasing WBC losses patient is out of critical • If hematocrit increases
- Defervescence • Urine output (volume and phase) compared to the previ-
- Warning signs (until out of frequency) • Urine output (4-6 hourly) ous value or remains very
critical period) • Warning signs • Hct (before and after fluid high (>50%), change in-
• Advice for immediate return • Hct, WBC and platelet counts replacement, then 6-12 travenous fluids to colloid
to hospital if with develop- hourly) solutions at 10-20 mL/kg
ment of any warning signs • Blood glucose as a second bolus over ½
• Written advice of manage- • Other organ functions (renal to 1 hour. After this dose,
ment (e.g. Home Care Card profile, liver profile, coagula- reduce the rate to 7-10 mL/
for Dengue) tion profile, as indicated) kg/hr for 1-2 hours, then
change back to crystalloid
solution and reduce rate
of infusion as mentioned
above when the patient’s
condition improves
• If hematocrit decreases
compared to the previous
value (<40% in children
and adult females, <45% in
adult males), this indicates
bleeding and the need to
cross-match and transfuse
blood as soon as possible
(see treatment for hem-
orrhagic complications)
4. Further boluses of fluid may
need to be given during the
next 24 hours. The rate and
volume of each bolus infu-
sion should be titrated to the
clinical response.
Treatment of Hemorrahgic
Complications
• Give 5-10 mL/kg of fresh
packed red blood cells or 10-
20 mL/kg of fresh whole blood
at an appropriate rate
All of the following conditions must be present
Discharge
Fluids/Electrolytes
Dextrose in Water
B. Braun 10% Dextrose in Water
B. Braun 5% Dextrose in Water
LVP D10W
LVP D5W
Maintesol
Marivelle-5
Medisol 10%
Medisol 5%
Lactated Ringer's Solution
B. Braun Lactated Ringer's Solution
Marilact
Medisol Hartmann's
Normal Saline Solution
B. Braun Sodium Chloride 0.9%
Soln for Injection
Oral Rehydration Salts
Glucolyte
Glucost R
Hydrite
Pedialyte 45/75
Sodalite
Plasma Volume Expanders
Voluven 6%
Analgesics/Antipyretics
Para-Aminophenol Derivatives
Paracetamol
Aeknil
Alvedon
Biogesic
Calpol
Cetra
Dolexpel
Kiddilets
Nahalgesic
Naprex
Opigesic
Pynal
Rexidol
Sinomol
Tempra/Tempra Forte
Tylenol
80