Dengue CPG 2015 – Keypoints

Monitoring the disease:

  • Platelet count predicts the severity of disease, but is NOT predictive of bleeding.
  • WCC normally normalizes followed by platelets.
  • Norml Hct in man in Malaysia is ~45, in woman is ~40.
  • Other important lab tests are coagulation profile (PT/PTT), LFT, renal profile, lactate and blood gases, CK

Diagnostic processes:

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  • Dengue IgM negative before day 5-7 cannot be used to exclude dengue infection.
  • If dengue IgM is negative before day 7, repeat sample must be taken during recovery phase
  • If dengue IgM is negative EVEN after day 7, need to take IgG.

Warning signs of dengue

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  • Diarrhea is now recognized as one of the warning signs.

Frequency of monitoring:

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  • Vital signs: 4-6 hourly; if critical 2-4 hourly
  • Lab tests:FBC 4-12 hourly depending on clinical status, others at least daily
  • Hct should be measured BEFORE and AFTER fluid resus

Common pitfalls in fluid management of dengue

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Choice of fluid is crystalloid

  • How to calculate IV fluid maintenance requirement?
    – Non obese = 1.2-1.5 ml/kg/hour
    – Obese = use ABW
    ABW = IBW + 0.4(actual weight – IBW)

Role of colloid

  • No role of HES –> increases incidence of renal failure and need for hemodialysis, contraindicated in liver and renal failure and with fluid overload state
  • Albumin maybe okay
    – Used in decompesated shock and if 2 rounds of crystalloids infusion does not improve condition

Dengue shock syndrome

  • Pulse pressure < 20 and SBP < 90 are late signs, we want to prevent dengue to progress to decompesated shock.
  • GXM early, ANTICIPATE BLOOD TRANSFUSION !

General idea of dengue shock resus

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Compensated shock

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Decompensated shock

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Metabolic acidosis in dengue

  • Due to lactate acidosis due to tissue hypoperfusion
  • Giving fluid will reverse acidosis, NaHCO3 is NOT recommended
  • Persistent acidosis = CONSIDER BLEEDING !
  • Lactate clearance >20% in 2 hours improve survival

ABG

  • Due to met.acidosis, resp.alkalosis is predicted.
  • IF resp.acidosis, consider PLEURAL EFFUSION or FLUID OVERLOAD !

Electrolytes

  • Hyponatremia is common and is a marker of disease severity.

When to consider occult bleeding?

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  • Transfuse whole blood 10-20 ml/kg or 10 ml/kg of PRBC
  • Oxygen delivery at tissue level is deemed optimal only with fresh packed red cells or whole blood because of higher levels of 2, 3 diphosphoglycerate (2,3 DPG).
    – However, recently published studies done in non-dengue critically ill patients and patients undergoing cardiac surgery have not shown any difference in patient outcomes when transfused fresh blood < 8 days old compared to blood stored longer (> 21 days).

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Dengue in pregnancy?

  • Diagnosis is hard because
    – Hct is lower/near normal due to hemodilution.
    – DBP is lower in 2nd trimester with wider PP.
    – Due to presence of gravid uterus, detection of third space fluid accumulation is harder.
  • Dengue in pregnancy is associated with bad maternal and fetal outcome
    – Mother: more likely to develop DSS
    – Fetal: abortion preterm birth, IUGR etc
    – Complications are more likely if the infection happens in 1st and 3rd trimester.
  • Vertical transmission is possible, BUT ONLY IN SYMPTOMATIC PATIENTS.
    – Asymptomatic mother has lower level of viraemia so vertical transmission is less likely.
  • Vaginal delivery is still the method of choice.
    – If premature labour happens, it is advisable to use tocolytics to delay the delivery until acute infection resolves.
  • During labour, IM INJECTION should be avoided (eg IM oxytocin for PPH)
  • Routine platelet transfusion is NOT indicated.
  • For the baby, serological test should be performed to confirm congenital infection. No long term fetal abns are noted with congenital dengue.

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Marker of severity in dengue

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Reference: CLINICAL PRACTICE GUIDELINES. MANAGEMENT OF DENGUE INFECTION IN ADULTS (THIRD EDITION). Published by: Malaysia Health Technology Assessment Section (MaHTAS)

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