D NGUE WORKSHOP 2015

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OPD – CASE 2

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History

33/ Indian /man•Presented with fever •Myalgia and arthralgia•Went to KK on Day 2 of feverFBC : Wbc 9.4 Hb 13.3 Hct 39 Plat 241

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ID HSB 2015

FEVER CLERKING SHEET

When to suspect dengueFever with two or more of the following manifestations:•- headache•- retro-orbital pain•- myalgia•- arthralgia•- rash•- haemorrhagic manifestations•- leukopenia/ Thrombocytopenia

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You are the doctor in charge

What would you do?

•Dengue combo rapid test : NS1: Positive , Dengue Ig M : negative

•Look for warning signs

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Dengue NS1 • The NS1 gene product is a glycoprotein produced by

all flaviviruses

• NS1 antigen appears as early as day 1 after the onset of fever and declines to undetectable levels after day 5–6.

• It is a tool to facilitate early detection of dengue

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Dengue Ig M

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Negative in early febrile phase, a positive result indicates a recent infection, not the acute infection

Becomes positive towards defervescence and increasingly more positive;

Day 7 of illness almost 80% positive; remains detectable for another 2-3 month

Warning signsListen : Mucosal bleed( 4 symptoms) Abd pain Persistent vomiting Restless/lethargy

Examine : Tender enlarged liver( 2 signs) Third space loss

Lab : ( 1 lab) increase in HCT accompanied by rapid decrease in Platelet count

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What would you do next ?

Assess for hydration status/ BP/PR/ Pulse volume/ CRT/ RR/

Physical Exam

Do not for get to : Notify Dengue

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ID HSB 2015

Dengue Clerking Sheet

• No vomiting, no abdominal pain

• BP 120/80mmHg, PR 90 /min• RR 16/min• No rashes , no petechiae

• Lung : clear • PA : soft , no ascites, no tenderness

No warning signs, Vital signs are stableID HSB 2015

Desided to send patient home

-Prescribe symptomatic therapy-Advise patient to return to clinic if :I. fever persists more ≥ 3days or II. develops warning signs orIII. unable to take orally

What is your advice to patient ?

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PNEUMONIC : DENGUE

• D- daily monitoring of patient's status• E- encouraging intake of oral fluids• N- note for any warnings or signals (persistent

vomiting, severe abdominal pain, restlessness, irritability, platelet count, bloated abdomen)

• G- give symptomatic treatment (avoid aspirin/NSAID)• U- use mosquitoe screens, insect sprays, repellant• E- early consultation is advised if you have doubts

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Plan of management

• If admission is not indicated• Daily or more frequent follow up is

necessary especially from day 3 of illness onwards until the patient becomes afebrile for at least 24 - 48 hours without antipyretics

• Refer to Home Care Advice Leaflet for Dengue Patients.

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ID HSB 2015

HOME CARE ADVICE LEAFLET FOR DENGUE PATIENTS

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ID HSB 2015

Day 5 : still febrile

– Still poor appetite but able to drink– No vomiting , no abdominal pain– No other complaints

– T 38 C,BP 108/80mmHg, PR 90/min– Lung : Clear, PA :no tenderness– Day 5: Hb 15.8 Hct 45.9 Platelet 102 Wbc 4.07– Day 2: Hb 13.3 Hct 39 Platelet 241 Wbc 9.4

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What would you do ?

• Day 5 illness , still in febrile phase• No warning signs• VS stable• HCT : increasing, Platelet : dropping• But entering defervescent phase soon!

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ID HSB 2015

Plan of management

• If admission is indicated• Stabilise the patient at primary care

before transfer (refer to intravenous fluid regime)

• Communicate with the receiving hospital: Emergency & Trauma Department AND/Or Medical Department before transfer

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What is your diagnosis

– T 38 C,BP 108/80mmHg, PR 90/min– Lung : Clear, PA :no tenderness

– Day 5: Hb 15.8 Hct 45.9 Platelet 102 Wbc 4.07– Day 2: Hb 13.3 Hct 39 platelet 241 Wbc 9.4

– Day 5 : Alb 32 ALT 79 AST 167

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What is your diagnosis?

Day 5 illness, febrile phasewith warning signs,

vital signs are stable,mild transaminitis

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What are the warning signs?

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How much fluid to give?

• Fluid management in dengue with warning signs– Obtain baseline HCt– IVD 5-7mls/kg/hr for 1 to 2 hours, then– Reduce to 3-5mls/kg/hr for 2 to 4 hours, and then– Reduce to 2-3mls/kg/hr or less according to

clinical response and HCT

• If clinical parameters worsening and Hct is rising, increase the rate of infusion

5,3,2

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B) Dengue with alarm signs + but haemodynamically stable : 5/3/2 regime OR 7/5/3 regime

5mg/kg/H : 1-2hrs 7ml/kg/H

3ml/kg/H: 2-4 hrs 5ml/kg/H

2ml/kg/H : till review ( 2-4H) 3ml/kg/H ID HSB 2015

Weight 60kg

•IVD 5ml/kg : 300ml/Hour for 1 hour review

•IVD 3ml/kg : 180ml/Hour for 2hours review

•IVD 2ml/kg : 120ml/Hour for 2-4hoursreview

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3 hours later , at completion of 5/3 regime….

• BP 110/80mmHg, PR 110/min ( weak ) • T 37 C• Lung :clear

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Dengue Fever , day 5 illness, in critical phase

In compensated shock

What would you do ?

1. Refer to ED and medical team on call 2. Run fluid 10ml/kg over 1 hour, and assess

again

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Dengue CPG :

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• However, if patient is ill, (i.e : in compensated or decompensated), pre-empting a deterioration that may require resuscitation, you should inform BOTH Emergency Department and Medical Department Physician prior to transfer.

• This is to facilitate rapid response to critically ill patient.

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THANK YOU

ID HSB 2015