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Journal Report

A Prognostic Model for the


Development of Profound Shock
among Children Presenting with
Dengue Shock Syndrome
Study Done by :
Phung, Khanh Lam et.al.
May 2015

Presented by :
Christina Quinones Marquez MD
Mary Mediatrixs Medical Center
Article

Title : A Prognostic Model for Development of


Profound Shock among Children Presenting
with Dengue Shock Syndrome
by Phung Khank Lam, Dong Thi Hoai Tam,
Nguyen Minh Dung, Nguyen Thi Han Tien
et al.
Pediatric Intensive Care Unit of the Hospitak
for Tropical Disease in Ho Chi Minh City,
Vietnam last May 2015
Objectives

To identify risk factors for the development of


profound and recurrent amongst children
with Dengue Shock Syndrome
To Development of a prediction model for
the development of profound and recurrent
amongst children with Dengue Shock
Syndrome
Study Design

Prospective Cohort Study of patients


diagnosed as Dengue Shock Syndrome in
the Pediatric ICU of the Hospital for the
Tropical Diseases, Ho Chi Minh City,
Vietnam
Study Procedures

Children less than 15 yrs old admitted at


PICU and diagnosed as Dengue Shock
Syndrome eligible for enrolment
After the consent, demographic information,
history and Physical examination were taken
within 2 hrs of onset of shock.
Detailed recording of fluid usage and clinical
outcomes
Study Procedures

Specimens for Dengue diagnostics were also


collected both at enrolment and discharge
( Dengue IGM Dengue IGG
Capture ELISA/ RT PCR)
All Patients were managed using the Hospital of
Tropical Disease protocol-driven guidelines for
pediatric Dengue Shock Syndrome by the same
team
Dengue Shock Syndrome Protocol

In Patients compensated shock (Pulse


Pressure narrowing < 20 mmHg but systolic
Pressure is normal for age and with signs of
impaired perfusion)
25ml/kg Lactated Ringers solution over 2 hours,
Standby colloid solution (if develop
decompensated/hypotensive shock or without
detectable output
Dengue Shock Syndrome Protocol

In Patients compensated shock (Pulse


Pressure narrowing < 20 mmHg but systolic
Pressure is normal for age and with signs of
impaired perfusion)
25ml/kg Lactated Ringers solution over 2 hours,
Standby colloid solution (if develop
decompensated/hypotensive shock or without
detectable output
Dengue Shock Syndrome Protocol

In Patients compensated shock (Pulse


Pressure narrowing < 20 mmHg but systolic
Pressure is normal for age and with signs of
impaired perfusion)
After initial 2 hour infusion, all patients receives a
standardized schedule of LRS, reducing the rate
of fluid perfusion at fixed time intervals
to 3 ml/kg/hr over 8 hours
Dengue Shock Syndrome Protocol

In Patients with Recurrent shock (recurrence


of Pulse Pressure narrowing <20mmHg, in
association with tachycardia, cool
extremities, rising hematocrit)
10-15 ml /kg infusion of colloids over 30-60
minutes
Dengue Shock Syndrome Protocol

Inotrophic support was given


only to patients with unstable hemodynamic
indices despite volume resuscitation,
Potential for adverse effects of colloid therapy
(severe coagulopathy, early evidence of fluid overload,
renal compromise)
Dengue Shock Syndrome Protocol

Blood Products Usage : Conservative


Whole Blood reserved with frank hemorrhage
causing circulatory compromise
Whole blood for rescue therapy in patients with
prolonged unresponsive shock
Definition of Terms

Dengue Shock Syndrome


With Pulse Pressure narrowing to less than or
equal to 20 mmHG but systolic pressure is
maintained with signs of impaired perfusion
Recurrent Shock
At least one episode of shock after initial fluid
resuscitation
Definition of Terms

Profound DSS
Either a) requirement for two or more colloid
boluses ( either for crystalloid resuscitation for
compensated shock at presentation plus two or
more episodes of recurrent shock or colloid
resuscitation for decompensateds shock plus one
or more episodes of recurrent shock
B) requirement of inotropes in addition to colloid
therapy to maintain cardiovascular stability
Hemodynamic Status
(1) when PP greater than or equal 10
mmHg and SBP is maintained above the lower
limit of normal age
(2) when PP less than or equal 10
mmHg and SBP is below the lower limit of
normal age
(3) if blood pressure is unmeasurable
Research methodology

Discuss the authors methodology, sampling


procedures, study design etc.
Results

Analysis of 1207 children with Dengue Shock


Syndrome
222 (18%) developed profound DSS
433 ( 36% ) developed recurrent shock
Table 1. Baseline characteristics and outcomes of study participants (N = 1207).

Lam PK, Hoai Tam DT, Dung NM, Hanh Tien NT, Thanh Kieu NT, et al. (2015) A Prognostic Model for Development of Profound
Shock among Children Presenting with Dengue Shock Syndrome. PLOS ONE 10(5): e0126134.
https://doi.org/10.1371/journal.pone.0126134
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0126134
Table 1. Baseline characteristics and outcomes of study participants (N = 1207) continuation.

Lam PK, Hoai Tam DT, Dung NM, Hanh Tien NT, Thanh Kieu NT, et al. (2015) A Prognostic Model for Development of Profound
Shock among Children Presenting with Dengue Shock Syndrome. PLOS ONE 10(5): e0126134.
https://doi.org/10.1371/journal.pone.0126134
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0126134
Results
Independent Risk Factors identified
ASSOCIATED for both the development of
Profound Dengue Shock and Recurrent
Shock are the following
A) Younger Age
B) Earlier Day of Presentation
C) Higher Pulse Rate
D) Higher temperature
E) For Females, worse hemodynamic status
at presentation
Results

Female fender has been previously identified


by previous studies to be an independent
predictor of mortality in children DSS
and was analyzed separately for
hemodynamic status
Results
Other Risk Factors identified NO
SIGNIFICANT ASSOCIATION for both the
development of Profound Dengue Shock
and Recurrent Shock are the following
A) Platelet Count
B) Bleeding
C) Abdominal Tenderness
D) Liver Size
Score System

Used a simplified Logistic Model to create a


score system
easier to understand rather than
regression formula / normogram
Fig 3. Score-chart for prediction of profound shock.

Lam PK, Hoai Tam DT, Dung NM, Hanh Tien NT, Thanh Kieu NT, et al. (2015) A Prognostic Model for Development of Profound
Shock among Children Presenting with Dengue Shock Syndrome. PLOS ONE 10(5): e0126134.
https://doi.org/10.1371/journal.pone.0126134
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0126134
Example

A 10 year old female who presents on day 6


of illness with a pulse of 100 beats/min
temperature 37.5 C, hematocrit of 44% and
BP of 80/60
Score
11 = {5} + {2} + {1} + {2} + {1} + {0}
Limitations of the study

Single institution
Definition of clinical outcomes
Could vary from one institution, and country
Critical appraisal

Objectives
To identify risk factors for the development of
profound and recurrent shock among children
with dengue shock syndrome
Develop a prediction model for the development
of profound and recurrent shock amongst children
with dengue shock syndrome
Critical appraisal

Objectives
To identify risk factors for the development of
profound and recurrent shock among children
with dengue shock syndrome
Develop a prediction model for the development
of profound and recurrent shock amongst children
with dengue shock syndrome
Critical appraisal

Was There an Adequate Sample of Subjects for


the Study?
Yes
Critical appraisal

Will the reproducibility of the test result and


interpretation be satisfactory in my clinical
setting?
Yes.
Critical appraisal

Are the results applicable to the patients in my


practice?

YES
Critical appraisal

Will the results change my management


strategy ?

YES
Conclusion

Several risk factors for the development of


profound or recurrent shock among children
presenting with DSS identified
The score chart derived from the prognostic
models should improve triage and
management of children presenting with
DSS in dengue endemic areas
Group discussion

Open up the topic for wider discussion within


the group