CPG DENGUE

3rd Edition 2015

DR LIANA AZLYN BINTI AZMI
PEGAWAI PERUBATAN
HOSPITAL ALOR GAJAH
EPIDEMIOLOGY
• arthropod borne viral disease
• caused: dengue virus ( mosquito-
borne flavivirus)
• transmission: Aedes aegypti and
Aedes albopictus
• serotypes: DENV - 1, 2, 3 and 4.
CLINICAL MANIFESTATIONS
• incubation period: 4 - 7 days
• 3 phases
• Febrile phase
• Critical phase
• Recovery phase
• Gambar CPG
 CRITICAL
• Varying: less
FEBRILE
severe to severe
• Rapid drop in RECOVERY
• High grade fever
temperature
• Facial flushing
• ↑ capillary
• Rash
permeability • Reabsorption of
• Myalgia
• Plasma leakage extravascular fluid
• Vomiting
• Compensated/ • Generally improves
• Headache
decompensated • Clinally improves
• URTI
shock
• Mild haemorrhagic
• Warning signs
• Organ
dysfunction
 FEBRILE CRITICAL RECOVERY/
REABSORPTION
Differentiation from other • Plasma leakage • Cessation of plasma
illnesses • Clinical deterioration leakage
• Haemoconcentration • Reabsorption of fluid
• Hypovolaemia/ shock from extravascular
• Respiratory distress compartment
• Bleeding • Haemodilution
• Organ dysfunction • Fluid overload dan
• May mimic acute pulmonary oedema if IV
abdomen from other fluid continue
causes
• Maybe confused with
septic shock or other
forms of shock
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
CLASSIFICATION
• 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 tolerae 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
Principles for Fluid Resuscitation
 YES NO

• IVD crystalloid 5-7ml/kg/hr for 1-2hrs • If Hct ↑, administer 2nd bolus of fluid ( colloid )
• ↓ 3-5ml/kg/hr for 2-4hrs 10-20ml/kg/hr
• ↓ 2-3ml/kg/hr for 2-4hrs • If Hct ↓, consider significant occult/ ovet bleed.
Initiate transfusion
• If improving, further reduced.
• Monitor Hct 4-6hourly

• 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, comsider other
causes of shock.
• septic shock
• bleeding and leaking at the same time
• cardiac dysfunction
• severe met acidosis with hyperlactataemia (multiorgan failure )
• cytokine storm
Complications in Dengue Infection
• Bleeding/ Haemostasis
• Hepatitis
• ↑ AST/ ↑ ALT
• decreasing to normal within 3 weeks
• Cardiac complication
• Neurological complication
• Renal complication
• Haemophagocytic Syndrome
• Mild bleeding do not require blood transfusion
• If significant bleeding, transfuse with packed cells and/or blood
component

• Suspect significant occult bleeding:

• Hct not as high as expected for the degree of shock
• Hct drop without clinical improvement despite fluid replacement (40-
60ml/kg)
• Severe metabolic acidosis and end-organ dysfunction despite adequate fluid
replacement
THANK YOU