CPG DENGUE

3rd Edition 2015

DR FADHLY SHARIMAN BIN HJ YAHAYA
PEGAWAI PERUBATAN
HOSPITAL ALOR GAJAH
 Content

• Introduction
• Dengue Classification
• Assessment
• Diagnostic Tools
• Clinical management
• Complication
 Febrile phase
• High grade fever
• Duration: 2-7 days
• Facial flushing
• Skin erythema
• Generalized body ache, myalgia,
arthralgia
• Retro-orbital eye pain,
photophobia
• Rubeliform exanthema
• Headache

• Sore throat, injected pharynx

• Conjunctival injection
• Anorexia, nausea and vomiting
are common.
 Critical phase
• Febrile afebrile
• Warning sign (increase
capillary
permeability/plasma leak)
• No warning sign
• Risk of complications

• Progressive leukopenia
• Rapid decrease in platelet count
• An increasing haematocrit above
the baseline may be one of the
earliest additional signs
• The period of clinically significant
plasma leakage usually lasts 24−48
hours.
 Recovery phase
• 48−72 hours after critical phase.
• Gradual reabsorption of
extravascular compartment fluid
• General well- being improves
– appetite returns
– GI symptoms abate
– haemodynamic status stabilizes
– urine output normalize
• Ix:
– WBC rises
– Hct stabilizes
– followed by platelet rise
• Still possibility of complications
Warning sign
• Evidence of plasma leakage:
– ↑ HCT
– Haemodinamic instability
– Fluid accumulation
– Hypoproteinaemia
 INVESTIGATION
• FBC:
– ↓ TWBC
– ↓PLT
– ↑HCT ( Male ≤ 60yrs 46%, Male ≥ 60yrs 42%,
Female 40%)

• RP
• LFT
• Coagulation profile
• VBG
 DIAGNOSTIC TEST
• Rapid Combo Test (RCT) : NS1 antigen, IgM/ IgG
antibodies
• Dengue Antigen and Serology Test by ELISA
– IgM positive after day 5-7 of illness
– IgG positive after day 7 f illness
• Significant of IgG : secondary infection
• False positive Dengue Serology:
– other flavivirus : JE
– non-flavivirus: malaria, toxoplasmosis, syphillis,
leptospirosis
– CTD: rheumatoid arthritis
CRITERIA FOR OUTPATIENT
TREATMENT
CRITERIA REFERRAL
FLUID MANAGEMENT
• Choice of fluid: crystalloid
• No co-morbidities and can tolerating orally:
– oral fluid intake 2-3L daily
– may not require IVD
• IVD should be instituted:
– vomiting
– unable to tolerate orally
– diarrhoea
– ↑Hct or other signs of plasma leakage
CPG recommendation
 Patophysiology of plasma leakage
• Increase in vascular permeability → plasma leakage into
extravascular compartment → haemoconcentration and
hypovolaemia or shock

• Hypovolaemia → tachycardia and generalised vasoconstriction

• Clinical manifestations of vasoconstriction:

– skin: coolness, pallor, delayed CRT
– CVS: ↑ diastolic blood pressure, narrow pulse pressure
– Renal: ↓ urine output
– GI system: vomiting, diarrhoea, abdominal pain
– CNS: lethargy, restlessness, apprehension, ↓ consciousness
– Respiratory: tachypnoea (RR>20/min)
• Inadequate perfusion of the tissue leads to ↑
anaerobic glycolysis and lactic acidosis →
shock →multiorgan failure and DIC
 YES NO

• IVD crystalloid 5-7ml/kg/hr for 1- • If Hct ↑, administer 2nd bolus of

2hrs
• ↓ 3-5ml/kg/hr for 2-4hrs
• ↓ 2-3ml/kg/hr for 2-4hrs
• If improving, further reduced.
• Monitor Hct 4-6hourly
fluid ( colloid ) 10-20ml/kg/hr
• If Hct ↓, consider significant
occult/ ovet bleed. Initiate
transfusion

• If Hct ↑, consider bolus fluid or

increase fluid
• If Hct ↓, consider packed red cells
and/or blood components
transfusion

• Consider stopIVD 48hrs of

plasma leakage/ defervescence.
 YES

• IVD crystalloid/colloid 10ml/kg/hr for

1hr
• ↓ 5-7ml/kg/hr for 1-2hrs
(crystalliod)
• ↓ 3-5ml/kg/hr for 2-4hrs
• ↓ 2-3ml/kg/hr for 2-4hrs

• If improving, further reduced.

• Monitor Hct 4hourly or more
frequent

• If Hct ↑, consider bolus fluid or

increase fluid
• If Hct ↓, consider packed red cells
and/or blood components
transfusion

• Consider stopIVD 48hrs of

plasma leakage/ defervescence.
• If Hct remain unchanged after 1st fluid
resuscitation, consider other causes of shock.
– septic shock
– bleeding and leaking at the same time
– cardiac dysfunction
– severe met acidosis with hyperlactataemia
(multiorgan failure )
– cytokine storm
 When to stop IV fluid therapy
Recognize signs below:
• No plasma leakage
• Stable vitals
• Hct decrease with good pulse volume
• Apyrexia (without the use of antipyretics) > 24–48 hours
• Resolving GI symptoms
• Improving urine output

Continuing intravenous fluid therapy > 48 hours of the critical

phase put patient at risk of
•pulmonary oedema
• other complications – ie. thrombophlebitis
 Complications and intensive care
management
Causes of complications in dengue include:
• Missed diagnosis
• Inadequate monitoring and misinterpretation of vital signs
• Inadequate monitoring of fluid intake and urine output
• Late recognition of shock and severe bleeding
• Too much or inadequate IV fluids i.e. poor knowledge
• Careless attitude towards aseptic techniques.
Cont. Complications and intensive care
management
Complications:
1. Prolonged and/or profound shock
2. Severe bleeding with severe disseminated intravascular
coagulopathy
3. Fluid overload
4. Respiratory distress and failure
5. Multi-organ dysfunction of liver, kidneys and neurological
system
6. Irreversible shock and death.

***This group of patients should be referred to a hospital with

intensive care facilities!
 Acute respiratory distress and failure

Causes of acute respiratory distress and failure

are:
1. Severe metabolic acidosis from severe shock
2. Fluid overload – large pleural effusions and
ascites
3. Acute pulmonary oedema (APO)
4. Acute respiratory distress syndrome (ARDS)
Severe metabolic acidosis from severe
shock
• Kussmaul’s breathing
• Should be treated as for hypotension shock
i.e. prompt resuscitation with fluid boluses
• After fluid resuscitation, ensure that the
respiratory effort has subsided and adequate
circulation are present. Otherwise severe
bleeding needs to be considered.
 2. Fluid overload
Causes of excessive fluid overload are: Early clinical features of fluid overload are:
• Excessive/ rapid fluid resuscitation • Tachypnoea
• Incorrect use of hypotonic crystalloid solutions e.g. • Suprasternal in-drawing and intercostal
0.45% NACL solutions or usage of large volumes of
IV fluids. recession (in children)
• Inappropriate transfusion • Respiratory distress, SOB, wheezing,
• prolonged IV fluids therapy, i.e., continuation of IV crepitations
fluids after plasma leakage has resolved (> 48 hours • Large pleural effusions
from the start of plasma leakage)
• co-morbid conditions
• Tense ascites, persistent abdominal
discomfort/pain/tenderness
• Increased JVP.

Late clinical features are:
• pulmonary oedema
• irreversible shock (heart failure, often in
combination with ongoing hypovolaemia).
Action plan:
• Oxygen therapy
• Further action plan depens on the patient’s
haemodynamic stability, intravascular volume status and
the timing of this event with respect to critical phase.
 Pulmonary oedema and acute
respiratory distress syndrome (ARDS)
1. Aggravated by rapid infusion of large volumes of fluid
during the critical phase.
2. The goals of therapy is to optimize oxygenation and
ventilation. Apart from increasing the FiO2, PEEP
should be delivered through NIV such as CPAP/BiPAP
and mechanical ventilation.

Non-invasive ventilation (NIV) Mechanical ventilation

• Alert, cooperative and
haemodynamically stable with no, or
mild, metabolic acidosis
• In shock and are restless, combative or
confused;
• Respiratory failure from acute
pulmonary oedema/ARDS ± shock;
• Fail to respond to non-invasive
ventilation.