GENERAL SERVICE CONFERENCE

MARCH 2022

Maria Godesa F. Refuerzo

First Year Resident
Objectives
• To discuss a case of a patient with dengue fever
• To discuss an approach to patients presenting with
fever and rash
• To discuss the epidemiology, pathogenesis, clinical
manifestations, diagnosis and management of dengue
fever
General Data
RF
7/M
Filipino
Roman Catholic
Quezon City

Informant: Mother (good reliability)

Chief Complaint

generalized weakness
History of Present Illness
Fever (Tmax 38°C)
Paracetamol (10 mkdose)
→ temporary lysis
(+)good appetite and activity
(+)good UO and BM
(-)cough, colds, diarrhea
5 days PTA
Fever (Tmax 38.9°C)
(+)nausea, headache, dizziness,
retroorbital pain
(+) decrease appetite and activity
(-)abdominal pain, (-) vomiting
Paracetamol (10 mkdose) → no relief
4 days PTA
 History of Present Illness
Urinalysis
Complete Blood Count
Color Yellow
Hemoglobin 132
Transparency Slightly
hazy
Hematocrit 39 A> Urinary Tract
Infection
pH 6.0
WBC 7.4
THM:
Specific Gravity 1.020 Clarithromycin BID
Segmenters 59 Paracetamol (10) PRN
Glucose Negative
Lymphocytes 40
Protein Trace
Monocytes 1
RBC 8-10/hpf
Persistence of fever, nausea,
headache, decrease appetite Platelet Count 271
WBC 1-2/hpf
and activity (+) ↑ urinary
frequency, urgency (-) dysuria,
hematuria
2 days PTA
History of Present Illness

Fever (Tmax 37.9°C) (+) generalized weakness

(+)anorexia (+) nausea, poor oral intake
(-)vomiting, abdominal pain (+) maculopapular rash
(-)mucocutaneous bleeding
1 day PTA Day of Consult
Review of Systems
General No weight gain/loss

Skin No jaundice, cyanosis, hair loss

HEENT No blurring of vision, eye discharge, diplopia, hearing loss, ear discharge, tinnitus, nasal
discharge, epistaxis, sore throat, no dysphagia

Respiratory No cough, colds, difficulty of breathing

Cardiovascular No chest pain, palpitations, orthopnea, PND

Gastroenterology No abdominal pain, vomiting, diarrhea, constipation

Genito-urinary No dysuria, hematuria, urinary incontinence, frequency, intermittency, decrease in urine

output

Musculoskeletal No arthralgia, joint swelling, limitation of movement

Hematologic No mucocutaneous bleeding, easy bruisability

Endocrinologic No polyuria, polydipsia, polyphagia, heat or cold intolerance

Neurologic No seizure, change in behavior, sensorium

Ancillary History
Birth and Maternal
42 years old G5P5 (5005) nonsmoker, nonalcoholic drinker
Cognizant of pregnancy at 1 month AOG
Started PNCU at 1month AOG at Culiat Local Health Center
Prenatal labs: HIV, syphilis and Hep B were nonreactive
UTI at 6 months AOG, treated with antibiotic x 7days
No other maternal illnesses
UTZ done 2x normal. No CAS done.
No exposure to tobacco, radiation and viral exanthem

Patient was born term at 39-40wks AOG via NSD at LIC

attended by a OB with good cry and good activity. BW ~ 3.0
kg. No cord coil. No MSAF. No fever. No seizure. No jaundice. No
cyanosis. No fetomaternal distress during labor and delivery.
BCG, Hepa B, Vit K, and erythromycin ointment were
given. NBS and HS done w/c normal results. With noted UO and
BM within 24H of life. Discharged after 2 days.
Family History
Father 56yo, +Stroke
Mother 49yo, healthy
Eldest sister, 30yo, healthy
Elder sister, 28yo, healthy
3rd sister, 24yo, healthy
Eldest brother, 22yo, healthy
Sister, 21yo, healthy
No hypertension, Diabetes mellitus, Bronchial
asthma, thyroid, neurologic, hematologic,
oncologic diseases
No other heredofamilial disease
Immunization History
Done at Local Health Center Complete Immunization Status
until 1 year old BCG x 1
BCG x 1 Hep B x 1
Hepa B x 1 DTwP-Hib-HepB x 3; Booster x 2
DTwP-Hib-HepB x 3 OPV x 3
OPV x 3 PCV x 3; Booster x 1
Measles x 1 Rotavirus x 2
MMR x 1 Influenza yearly
PCV x 3 Measles x 1
Flu vaccine x 1 (2021) MMR x 2
No boosters Varicella x 2
JEV x 1; Booster x 1
Hepatitis A x 1
Past Medical Nutritional
History History
Non-picky eater
No previous hospitalization Usual diet: rice, fish and chicken
or surgeries
24 hour diet recall

No allergies to food or Breakfast 1 cup of rice, 1 pc fried egg and

medication hotdog (485)

Lunch 1 cup of rice, 1 pc fried chicken,

½ cup vegetables (473)

Snack 1 pack biscuit, 1 cup milk (233)

Dinner 1 cup rice, 1 pc chicken (450)

Total Calories: 1,641 kcal

Developmental Socioeconomic
History History
At par with age Lives with 5 other family members
Currently at Gr 1 attending 2 storey cemented well-lit, well-ventilated
modular class (+) exposure to tobacco from brother
With good standing & Drinking water is mineral water
harmonious relationship with Garbage is collected every other day, not
friends/peers segregated
(+) Exposure to mosquito from
playing outside the house
No exposure to known
COVID 19 cases or with
COVID 19 symptoms
No pertinent recent
history of travel
 Physical Examination
General Awake, weak-looking, not in cardiorespiratory distress

Vital Signs BP palpatory 80 → 80/50 (faint) HR 77 RR 22 T 36.6C O2 sat 100% at RA

Anthropometrics Wt: 39.7kg (z >3)/ Ht: 132 cm (z>1 )/ BMI 22.8 (z >3)
IBW: 22 Average Wt: 30kg
HEENT Anicteric sclerae, pink palpebral conjunctivae, non-sunken eyes, (-) alar flaring, (-) nasoaural
discharge, dry lips and moist mucosa, (-) CLADS

Chest Symmetric chest expansion, (-) subcostal retractions, clear breath sounds, adynamic precordium,
normal rate regular rhythm, no murmurs, PMI at 5th ICS MCL

Abdomen Flabby abdomen, normoactive BS, soft, direct tenderness on RUQ, no palpable masses, no
organomegaly
Genitourinary Grossly male

Extremities Fair pulses, cold extremities, CRT 2 seconds

Skin (+) maculopapular rash on trunk and extremities, no jaundice, no pallor

Neurological Examination
With spontaneous eye opening,
Oriented to 3 spheres
Spontaneous movement of all extremities

Cranial Nerves
2-3 mm BERTL
Midline gaze, EOM intact
No sensory deficit on V1-V3
Intact gross hearing
Uvula and tongue in the midline
Symmetrical shoulders

(-) Babinski (-) Clonus

(-) Nuchal rigidity
(-) Tremors
(-) Dysmetria, (-) Dysdiadochokinesia
Salient Features
7/M
6 day history of Fever (Tmax 38.9C)
(+)nausea, headache
(+)decrease appetite, poor oral intake,
generalized weakness
(+)maculopapular rash
(+) weight and BMI z>3
(+) BP palpatory 80 mmHg
(+) dry lips
(+) RUQ tenderness
(+) poor peripheral perfusion
Last UO 4/11 11pm 100ml; Last fever 4/7 11pm 37.9c
Primary Impression

Hypovolemic shock secondary to poor oral intake

r/o Dengue Severe, Day 6 of Illness Day 0-1
afebrile
Presumptive UTI
Obese for age
 Course at the Triage 1st hospital day
Day 6 of Illness
Day 0 afebrile

2:35am 3:00 am

BP palpatory 80mmHg → Reassessment s/p

80/50 (faint), HR 77bpm, RR PIES 20cc/kg bolus
24cpm, T 36.6C O2 99%
weak-looking, awake, with non- BP 110/80 mmHg
sunken eyes, dry lips, clear HR 98 bpm
breath sounds, fair pulses, Awake, coherent
CRT 2 secs and cold better pulses and
extremities warmer extremities
CRT 2 secs
A>Hypovolemic shock sec to
poor oral intake O2 at 15 LPM

One bolus of PIES at 20cc/kg

1st hospital day Admit to ER

 Course at the Emergency Room
1st hospital day
3:17 am Hooked to PIES mild with frequent
reassessment
Awake, conscious, not in distress
BP 110/70, HR 108, RR 24, T Diagnostics:
36.5C, O2 100% CBC, Electrolytes
Nonsunken eyes, anicteric sclera, BUN/Crea
no alar flaring, nonhyperemic Blood CS, CRP
tonsils, no CLADS, moist lips Urinalysis, Urine CS
SCE, no retractions, CBS, AST/ALT
AP, NRRR, no murmur Dengue IgG/IgM
Soft nontender abdomen, no COVID RT PCR
organomegaly Chest Xray APLat
Warm extremities, CRT <2s
Cefuroxime (100) q8h
Paracetamol (10) PRN
A> Hypovolemic shock sec to Omeprazole (1) OD
poor oral intake, Presumptive
UTI, r/o Dengue Fever Sips of liquid

Received at ER
Course at the Emergency Room
7:30 am 1st hospital day

Complete Blood Count ALT 312 U/L(6.2x) Sodium 126 mmol/L PT 16.7

Potassium 3.7 mmol/L INR 1.29

Hemoglobin 169
AST 791 U/L (13.4x)
Chloride 93 mmol/L
Hematocrit 51 PTT 44.3
BUN 4.2 mmolL Calcium 2.07 mmol/L
WBC 6
Crea 46 umol/L (EGFR)
Segmenters 60
A> Dengue Severe D6 of Illness,
Lymphocytes 34 Dengue IgG Positive D0 Afebrile
Monocytes 6 Dengue IgM Positive Increase IVF to TFR 10 for 1 hour
then reassess
Platelet Count 44
CRP 15.8 (1.58x) Start N-acetylcysteine (50) IV
q12h
NPO
Course at the Emergency Room
1st hospital day
8:30 am
Reassessment s/p TFR 10 x 1 hour

Awake, comfortable, Not in distress

BP 110/70 HR 112 RR 20 T 36.9C O2 99%
AS, PPC, no alar flaring
Moist lips and buccal mucosa
SCE, no retractions, CBS
AP, NRRR, no murmur
Soft abdomen, (+) RUQ tenderness, NABS
Warm extremities, pulses full and equal, > Refer to PICU for co-
CRT <2s management of Dengue
Severe
 Course at the Emergency Room
1st hospital day
10:00 am PICU
Urinalysis
Maintain PIES at TFR 10,
Color Yellow reassess after 1 hour
Transparency Clear Cefuroxime discontinued
IFC inserted
pH 6.5

Specific Gravity 1.010

Awake, oriented to time, place and person
BP 110/70 HR 118 RR 24 T 36.5 O2 99%
Glucose Negative
AS, PPC, slightly dry lips, pink mucosa, no
bleeding, no alar flaring, SCE, CBS, AP, slightly Protein +1
tachycardic, regular rhythm, flabby abdomen,
(+)direct tenderness at RUQ, no RBC 1/hpf
organomegaly, warm ext, full pulses
UO 3 ckh post IFC insertion WBC 2/hpf
 Course at the Emergency Room
1st hospital day
11:00 am 12:00pm 1:30pm 3:00pm

s/p TFR 10 x 1 hour s/p TFR 7 x 2 hour s/p TFR 5 x 1 hour s/p TFR 5 x 2 hours

Awake, oriented, not in Awake, oriented, not in Awake, oriented, not in BP 90/50 HR 106 RR
distress distress distress 25 T 36.5C O2 99%
BP 100/70 HR 126 RR BP 110/70 HR 110 RR BP 100/60 HR 115 RR Slightly dry lips, pink
28 T 36.5C O2 99% 28 T 36.5C O2 99% 25 T 36.5C O2 99% mucosa
Slightly dry lips, pink Slightly dry lips, pink Slightly dry lips, pink SCE, CBS, tachycardic,
mucosa mucosa mucosa regular rhythm
SCE, CBS, tachycardic, SCE, CBS, normal rate, SCE, CBS, slightly Warm extremities, full
regular rhythm regular rhythm tachycardic, regular pulses
Minimally distended Minimally distended rhythm
abdomen abdomen Warm extremities, full CFI: 2153 CFO: 934
Warm extremities, full Warm extremities, full pulses CFB: +1219
pulses pulses UO: 1.93 ckh
FO: 3.0%
Course at the Emergency Room
1st hospital day
3:30 pm
4:30 pm 5:45pm

inc to TFR 7 x 1 hour s/p TFR 7 x 2 hours

Awake, oriented, not in Awake, oriented, not in

distress distress
BP 100/60 HR 115 RR BP 110/70 HR 107 RR
30 T 36.5C O2 99% 28 T 36.6C O2 99%
Slightly dry lips, pink Slightly dry lips, pink
mucosa mucosa
SCE, CBS, tachycardic, SCE, CBS, tachycardic,
regular rhythm regular rhythm
Nondistended abdomen Nondistended abdomen
Warm extremities, full Warm extremities, full
pulses, CRT 3 pulses, CRT 2

>Increase IVF rate to TFR 7 for >Decrease IVF rate at TFR 5 for now
now then reassess
Admit to COVID Ward
 Course in the COVID Ward
1st hospital day
9:00 pm Complete Blood Count CFI: 4403
CO: 1395
Reassessment s/p TFR 5 Hemoglobin 169 154
CFB: +3008
Conscious, coherent, NICRD %FO: 7.5%
Hematocrit 51 46
BP 110/80 HR 102 RR 21 UO: 2.7 ckh x 1 hr
T 36.8C O2 98% WBC 6 8.9
Anicteric sclera, pink palpebral
> Decrease IVF rate to
conjunctiva, no alar flaring Segmenters 60 54
TFR 3 then reassess
SCE, no retractions, CBS
Lymphocytes 34 43 after 1 hour
AP, DHS, no murmur
Soft nondistended abdomen
Monocytes 6 3
(+)direct tenderness on RUQ
Full and equal pulses Platelet Count 44 46
CRT <2 seconds, warm extremities

Received at COVID ward

 Course in the COVID Ward
10:00 pm 12:20 am
1:00 am
Sodium 126 127
s/p TFR 3 x 1 hour s/p TFR 3 x 2 hours
Complete Blood Count
Potassium 3.7 3.6
Asleep, comfortable, Asleep, easily arousable,
NID Hemoglobin 154 138
NICRD Chloride 93 99
BP 100/70 HR 108 RR 20 BP 100/70 HR 94 RR 22
T 36.7C O2 99% T 36.5C O2 99% Hematocrit 46 42
Calcium 2.07 1.82
AS, PPC, no alar flaring,
AP, PPC, no alar flaring,
moist lips and mucosa, SCE, WBC 8.9 7.4
moist lips no retractions, CBS, AP,
SCE, no retractions, CBS, NRRR, no murmur, non- Segmenters 54 55 >Shift IVF to
AP, NRRR, soft abdomen, distended abdomen, soft PNSS at TFR 3
FEP, CRT <2s non-tender, FEP, CRT 2, Lymphocytes 43 36
CFI: 4583 warm extremities
CFO: 1585 CFI: 4673 CFO: 1675
CFB: +2998 CFB: +2998 Monocytes 3 9
FO: 3.0% FO: 9.9%
UO: 2ckh x 1h UO: 3.0 ckh x 1h Platelet 46 53
Count

2nd hospital day

Day 7 of illness,
Day 1-2 afebrile
 Course in the COVID Ward 2nd hospital day
2:30am 6:10am

s/p TFR 3 x 4 hours s/p TFR 3x 6 hours

8:00 am

Asleep, easily arousable, Asleep, easily arousable, Complete Blood Count

NID NID
BP 90/60 HR 100 RR 24 BP 100/70 HR 108 RR 20 Hemoglobin 138 129
T 36.8C O2 99% T 36.8C O2 99%
AS, PPC, no alar flaring, AS, PPC, no alar flaring, Hematocrit 42 39
moist lips and mucosa, moist lips and mucosa,
SCE, no retractions, CBS, SCE, no retractions, CBS, WBC 7.4 7.0
AP, NRRR, no murmur, AP, NRRR, no murmur,
non-distended abdomen, non-distended abdomen, Segmenters 55 57
soft non-tender, FEP, CRT soft non-tender, FEP, CRT Sodium 127 130
2, warm extremities 2, warm extremities Lymphocytes 36 29
CFI: 4853 CFO: 1830 Potassium 3.6 3.7
CFB: +3028 Monocytes 9 13
FO: 10% Chloride 99 100
UO: 2.6 ckh x 1h Platelet Count 53 59
Calcium 1.82 1.77

Albumin 14.5
 Course in the COVID Ward 2nd hospital day

11:50 am

PICU Notes
Awake, comfortable, NID Shift IVF to Plain LR at TFR 2
BP 110/70 HR 84 RR 36 Encourage increase in oral fluid intake
T36.4C O2 98% Diet for age
AS, PPC, no alar flaring, slightly dry
lips, SCE, no retractions, CBS, good
air entry, AP, NRRR, no murmur, soft
abdomen (+)RUQ tenderness, FEP, CFI: 6239 CFO: 3001
CFB: +3238
warm extremities, CRT <2 FO: 10%
(+)petechiae on extremities UO: 4.56 ckh x 8hrs
Course in the COVID Ward
8:30 pm 4:50 am

Complete Blood Count

Albumin 14.5 Sodium 130 132 Shift to heplock
Hemoglobin 129 124
Room Air
Potassiu 3.7 3
Blood CS NG X 36 hrs m
Transfuse 1 vial
Hematocrit 39 38 20% albumin
Chloride 100 85 Started oral KCl
WBC 7.0 7 correction
Calcium 1.77 2
Segmenters 57 44
Feeding progressed

ALT 312 (6.2x) 208 (4x)

Lymphocytes 29 45

AST 791 (13.4x) 331 (5.6x)

Monocytes 13 10

Platelet Count 59 105

3rd hospital day
Day 8 of illness
Day 2-3 afebrile
 Course in the COVID Ward
10:30am
Conscious, coherent, NID
BP 100/70 HR 92 RR 19 T
36.5 O2 99%
AS, PPC, nonsunken eyes,
no alar flaring
Dry lips, moist mucosa
SCE, no retractions, CBS
AP, no murmur, NRRR
FEP, CRT <2 sec, warm
extremities
PICU Notes
For upright CXR APL w/
lateral decubitus
Critical issues resolved
Admit to Regular Ward
3rd hospital day
7:30pm
Awake, comfortable, NID
BP 100/60 HR 90 RR 25 T
37.0 C O2 99%
AS, PPC, no alar flaring,
moist lips
SCE, no retractions, CBS,
AP, NRRR, no murmur
soft abdomen, FEP, CRT
<2s, warm extremities
CFI: 9501 CFO: 10,001
CFB: -500
 Course in the GS Ward
6:30 am
Complete Blood Count
Albumin 14.5 35
Hemoglobin 124 125

Hematocrit 38 38
Sodium 132 137
WBC 7 6.6
Potassium 3 4.3
Segmenters 44 43

Lymphocytes 45 41 Chloride 85 103

Monocytes 10 13
Calcium 2 2.25
Platelet 105 167

4th hospital day

Day 9 of illness
Day 3-4 afebrile
 Course in the GS Ward 4th hospital day

5:00 pm

(+) Good oral intake and UO May go home

No DOB/cough
No fever recurrence Take home medications:
Multivitamins syrup OD
Comfortable not in distress
BP 110/70 HR 89 RR 20 T 36.5C O2 Close follow-up after a week
99%
SCE, no retractions, CBS, AP, no murmur
Soft abdomen, nontender, full equal
pulses, warm ext CRT <2

I/O 1170/2270 (-1100)

UO 2.4ckh x24 hrs

Discharge
Final Diagnosis

Dengue Severe (Hypotensive Shock) resolved

Obese for age
 Approach to a
child with
Fever and Rash

Rosa Magenta Camaclang, MD

Essential Elements
History Physical Exam
❑ Demographic data ❑ Vital signs
❑ Features of rash ❑ Characteristics of rash
❑ Associated symptoms ❑ Distribution and localization of
❑ Prior health status rash
❑ Family history ❑ Associated enanthem
❑ Associated organ findings
Salient Features
✔ Fever of 6 days
✔ Retro-orbital pain
✔ Headache
✔ Nausea
✔ Generalized body aches
✔ Anorexia
✔ Maculopapular rashes
Characteristics of rash
⮚ Maculopapular
⮚ Diffuse erythoderma
⮚ Urticarial
⮚ Vesicular, bullous, pustular
⮚ Petechial-purpuric
⮚ Erythema nodosum
⮚ Other distinctive rashes
Main differentials
Measles Meningococcemia Covid 19 Dengue Fever
o High grade fever o High grade fever o Fever o High grade fever
o Cough o Headache o Cough, Coryza o Headache / retroorbital
o Coryza o Irritability / lethargy o Myalgia pain
o Conjunctivitis o Respiratory symptoms o Sore throat o Myalgia / arthralgia
o Lymphadenopathy o Myalgia o Shortness of breath, o Anorexia
o Maculopapular rashes o Vomiting dyspnea o Abdominal pain, vomiting
o Koplik spots o Petechial or purpuric rash o Abdominal pain, vomiting o Lethargy / restlessness
o Shock o Rashes o Mucosal bleeding
o Asymptomatic o Maculopapular rashes
o Shock

o Thrombocytopenia, o Cultures positive for N. o Positive covid rt-pcr or o Leukopenia,

leukopenia, serum igm, igg meningitidis antigen test thrombocytopenia, elevated
hct
o Dengue ns1, igg or igm
Dengue Fever
⮚ benign syndrome caused by arthropod-borne
viruses characterized by biphasic fever, myalgia or
arthralgia, rash, leukopenia, and
lymphadenopathy (Nelson’s 21st Ed)
⮚ Severe cases were previously classified as Dengue
Hemorrhagic fever or Dengue Shock Syndrome
⮚ Revised case definition by WHO in 2009 now
includes Severe dengue
Epidemiology
⮚ Estimated 50 million dengue infections occur annually and
approximately 2.5 billion people live in dengue endemic
countries
⮚ 1.3 billion live in 10 countries of the SEA region which are
endemic areas
Epidemiology
In the Philippines…
⮚ From Jan. 1 to Dec. 31, 2021, there was a total of 79,872 dengue
cases with 285 deaths (CFR 0.4%) reported. This compares to the
90,135 cases and 324 deaths reported in the same period in 2020

⮚ Because of quarantine restrictions and absence of face to face

classes, there was very little exposure of people, thus transmission
of dengue virus was contained

http://outbreaknewstoday.com/philippines-dengue-fever-2021-nearly-80k-cases-lower-than-2020/
Dengue virus transmission
⮚genus Flavivirus and family Flaviviridae
⮚Four virus serotypes (DENV-1 to DENV-4)
⮚Infection with any one serotype confers lifelong
immunity to that virus serotype
⮚Secondary infection with another serotype or
multiple infections with different serotypes leads
to severe form of dengue
⮚Human as main reservoir; Mosquitoes as vector
(Aedes aegypti, Aedes albopictus)
Pathogenesis

https://www.uptodate.com/contents/dengue-virus-infection-pathogenesis
Clinical Manifestations
Course of Dengue Illness
High-risk patients
Laboratory Diagnosis
Probable Dengue Other laboratory tests
✔ Dengue NS1 Antigen ✔ Complete blood count
✔ Dengue IgM, IgG ▪ WBC
▪ Platelet
Confirmed Dengue ▪ Hematocrit
✔ Isolation of virus from serum ✔ End organ labs
via PCR, immunofluorescence, ▪ AST, ALT, BUN, Creatinine,
or ELISA TPAG, CKMB
✔ NAAT-LAMP
In our patient
✔ Day 6 of Illness, Day 0-1
Afebrile
✔ Hypotensive shock
✔ Poor peripheral perfusion
✔ RUQ tenderness
✔ Elevated Hct, Decreased Plt
✔ Elevated liver enzymes
✔ Dengue IgM, IgG confirmed
In our patient
✔ Day 6 of Illness, Day 0-1
Afebrile
✔ Hypotensive shock
✔ Poor peripheral perfusion
✔ RUQ tenderness
✔ Elevated Hct, Decreased Plt
✔ Elevated liver enzymes
✔ Dengue IgM, IgG confirmed
MANAGEMENT OF DENGUE IN
CHILDREN
References
Hemodynamic Assesment of dengue
1. Management is
based on what
type of dengue
2. General principle:
minimal amount to
maintain effective
circulatory volume
3. Use ideal body
weight
4. IV fluids is given
only on critical
phase
Choice of fluids
No preferential fluids between crystalloid and coloids
Isotonic solutions is used (275-295 mosm)
Advantages and Disadvantages
of Crystalloid
Advantages Disadvantages
1. Fills intravascular 1. May leave
volume rapidly intravascular space
2. Cheap due to small
molecules (edema)
Comparison of different isotonic
fluids
Advantages and Disadvantages
of Colloids
Advantages Disadvantages
1. Stays in 1. Expensive
intravascular 2. Adverse effects
volume longer ( allergic, renal
failure,bleeding,
fluid overload)
Indication for colloid transfusion
1. Overt signs of fluid overload (puffy eyelids,
tachypnea,dyspnea, distended abdomen, respiratory
distress)
2. Persistently elevated Hct despite IV fluid
administration
3. History of hypotonic solutions administration prior to
shock
Colloids available
Tetraspan 6 % ( HES 110) - Maximum 50 cc/kg/day

Voluvent ( HES 130)- Maximum 30 cc/kg/day

Management of dengue with warning
signs (stable)
Start with
estimated deficit
to run hourly
then decrease
fluid

Total duration of
fluids:
60-72 hours
Management of compensated shock
1. Start with TFR
10-15 crystaloid
over 1 hour
with gradual
decrease +
oxygen support
2. Colloids may be
given after
reassessment
3. Overt bleeding-
prbc transfusion
 Management of hypotensive shock
1. Crystaloid 20
cc/kg over 15
minutes + oxygen
support
2. Bolus may be
given until 3rd
time
3. Inotropes after
3rd bolus
4. Signs of bleeding
warrants prbc
transfusion
Role of blood products
FFP and cryoprecipitate are indicated only in DIC (induced by
bleeding, shock)

Platelet transfusions remain controversial

Indication: < 10.000 with massive bleeding
Not to be given as prophylaxis

Prbc and whole blood indication: persistence and severe/overt

bleeding in presence of unstable hemodynamic status ( > 10 %
TBV, Fall in Hct, refractory shock)
Monitoring
Dengue without warning signs:
Temperature, appetite, intake and output, vomiting,abdominal pain, bleeding

Dengue with warning signs

Vital signs every 4 hours, Hct q4-6, urine output q6-8 for 24-48 h

Dengue severe
Hourly urine output, Vital signs q15 till stable , then q1-2 for 4 hours, then q2-3 h

Temperature is recorded q6 in all dengue

Special Investigation
In the presence of refractory or recurrent shock:
A- acidosis
B- leeding
C- alcium and electrolyte
S-ugar (hypoglycemia)
Discharge Criteria
1. No fever for at least 48 hours without antipyretics
2. Platelet count at least 50.000 or at least 2
consecutive increase in platelet count
3. Improvement in general wellbeing, appetite, UO,
hemodynamic status
4. Minimum of three days post recovery from shock
Discussion
1. Patient was admitted on day 6 of illness, discharged on
day 10 of illness
2. Total duration of IV fluids - 36 hours
3. Choice of IV fluids - PIES
4. No colloids given
5. Notice fall in Ht of more than 10 % ( 51 to 45 to 46 to 42
to 39 to 38) → responsive to IV fluids
6. Correction of hypoalbuminemia and electrolyte ( hypo K
was done
7. Discharge Ht and plt ( 38 and 167) from baseline ( 51 and
44)
8. Noted pleural effusion on convalescence phase, repeat
CXR was done prior to discharge
THANK YOU