Management of Dengue in Adults Part II fluid management - Ker

Management of

Dengue in Adults

Part II : Fluid

Management

Dr Ker Hong Bee

Hospital Raja Permaisuri

Bainun

Ipoh

1Perak Dengue TOT 2012

Causes of death in DHF patients

1. Prolonged shock

� Delayed diagnosis/ delayed resuscitation

� Untreated prolonged shock > 4 hours will lead to organ

failure and prognosis is very grave

2. Fluid overload2. Fluid overload

� excess fluids or fluid given beyond the time of leakage

3. Massive bleeding

4. Unusual manifestations

� Encephalopathy

� Fulminant hepatitis


Clinical Course of DHF


Increased capillary

permeability

Systemic vascular

leakage becomes

apparent around the

time of defervescence

Warning signs If

Immunopathogenesis of Severe

Dengue

Simmons. Current concepts: Dengue. NEJM

2012;366:1423-32

Warning signs If

clinically significant

leakage develops

Compensated shock

Decompensated shock


Warning signs :

Patients who may deteriorate into

Severe Dengue

Perak Dengue TOT 2012 5

Assessment in Dengue

• Warning signs

• Evidence of plasma leakage

• Look for defervescence

• Hours since onset of leakage Identify

phase of illness

Symptoms & signs

• BP, pulse pressure, PR

• Capillary filling

• Respiratory rate

• Most useful HCT & WBC count trend

Assess peripheral circulation

Lab parameters


DIAGNOSIS

• Day of illness

• Dengue fever / severe dengue

• ± warning signs

• Febrile phase / Defervescence by hours

• Haemodynamic stable / in shock• Haemodynamic stable / in shock

D4 , Severe dengue with DHF

with warning signs

defervesence phase 6 hours

in compensated shock


Fluid Management in Dengue

Maintenance

fluid

Resuscitation

fluidfluid fluid

1. With warning signs

2. Compensated shock

3. Decompensated shock

1. Non shock patients

unable to tolerate orally

2. Patients in shock


Fluid in Non shock Dengue patients

• IV fluid (0.9% saline) is indicated in those with

o increasing HCT (indicating on-going plasma leakage)

despite increased oral intake

owho are vomiting and not tolerating orally

• 1.2 - 1.5 X Maintenance in critical phase• 1.2 - 1.5 X Maintenance in critical phase

• 4-6 hourly fluid adjustment during critical phase

• Fluid resuscitation if warning signs or deterioration to shock

• Reduce and consider discontinuation of IV fluid after 24-48

hours of defervescence in stable patients


Fluid management - maintenance

• Calculations for normal maintenance of intravenous fluid infusion per hour:

(Equivalent to Halliday-Segar formula)

4 mL/kg/h for first 10kg body weight

+ 2 mL/kg/h for next 10kg body weight

+ 1 mL/kg/h for subsequent kg body weight

*For overweight/obese patients calculate normal maintenance fluid based on ideal body weight

Ideal bodyweight can be estimated based on the following formula

Female: 45.5 kg + 0.91(height -152.4) cm

Male: 50.0 kg + 0.91(height -152.4) cm


If patient weighs 60kg ……..

4 mL/kg/h for first 10kg body weight

+ 2 mL/kg/h for next 10kg body weight

+ 1 mL/kg/h for subsequent kg body weight for 1x maintainance

4ml/kg/hr x 10 = 40 ml/hr4ml/kg/hr x 10 = 40 ml/hr

2ml/kg/hr x 10 = 20 ml/hr

1ml/kg/hr x 40 = 40 ml/hr

total = 100 ml/hr = 1 pint over 5 hrs

( 2400 ml/day )


Dengue with warning signs : should be monitored in

hospitals


5-7

3-5ml/kg/hr

Fluid for Dengue with Warning Signs

2-3

1 2 3 4 5 6 7 8

Hours

ml/kg/hr

1.2 – 1.5 x maintenance pending clinical parameters and

HCT


Dengue Shock Syndrome – DHF Grade 3 and 4

• Dengue shock syndrome is a medical emergency

• Recognition of shock in its early stage (compensated

shock) and prompt fluid resuscitation will give a good

clinical outcomeclinical outcome

• Pulse pressure of < 20 mmHg and systolic pressure < 90

mmHg are late signs of shock in adults


120

110

10090

80

Blood pressure, pulse pressure, heart rate in

hypovolemic shockPULSE PULSE

PRESSURE

( SBP-DBP )

RESPIRATORY

RATE• Narrowing pulse

HR

80

70

60

Time

LCS Lum

Compensated shock Decompensated shock

RATE

Perak Dengue TOT 2012

• Narrowing pulse

pressure

• Tachycardia

• SBP maintains

• Tachypnoeic

15


Dengue Shock Syndrome

• All patients with dengue shock should be managed in

HDU/ICU

• Fluid resuscitation must be initiated promptly and should

not be delayed while waiting for admission to ICU or high

dependency unitdependency unit

• The volume of initial and subsequent fluid resuscitation

depends on the degree of shock

• Following initial resuscitation there maybe recurrent

episodes of shock because capillary leakage can continue

for 24-48 hours


IV fluid in Dengue Shock Syndrome

• IV fluid therapy is the mainstay of treatment for dengue

shock

• Studies# showed no clear advantage of using any of the

colloids over crystalloids in terms of the overall outcome

• Colloids may be preferable as the fluid of choice in • Colloids may be preferable as the fluid of choice in

patients with intractable shock in the initial resuscitation

• The choice of colloids includes gelatin solution (e.g.

Gelafusine) and starch solution (e.g. Voluven)

# Dung NM, Day NP, Tam DT, et al. Fluid replacement in dengue shock syndrome: a randomized, double-blind comparison of four intravenous-fluid

regimens. Clin Infect Dis. 1999 Oct;29:787-94.

Ngo NT, Cao XT ,Kneen R, et al. Acute management of dengue shock syndrome : a randomized double-blind comparison of 4 intravenous fluid regiments in

the first hour. Clin Infect Dis. 2001. 32:(2) 204-13.

Wills BA, Nguyen MD, Ha TL, et al. Comparison of three fluid solutions for resuscitation in dengue shock syndrome. N Engl J Med. 2005 Sep 1;353(9):877-89.


Assessment after each bolus of fluid

resuscitation

Clinical parameters

1.Improvement of general

well being / mental state

2.Warm peripheries

Laboratory parameters

1.Decrease in HCT

2.Improvement in

metabolic acidosis2.Warm peripheries

3.CRT < 2sec

4.BP stable

5.Improving pulse pressure

6.Less tachycardic and less

tachypnoiec

7.Increase in urine output (≥

0.5ml/kg/hr)

metabolic acidosis


Dengue Shock Syndrome

• Fluid therapy has to be judiciously controlled

to avoid fluid overload, result in massive pleural

effusion, pulmonary oedema or ascites





Fluid for DHF with Compensated Shock

5-

10

5-7

ml/

kg

/hr

3-5

2-3

1.2-1.5x maintenanceTo further reduce fluid if patient continues to improve

Aim

to

stop

1 2 3 4 5 6 7 8 9 10 1

1

12 1

3

14 15 1

6

1

7

1

8

1

9

2

0

2

1

2

2

2

3

2

4

24-48

ml/

kg

/hr

Hours


Assessment after each bolus of fluid

resuscitation

Clinical parameters

1.Improvement of general

well being / mental state

2.Warm peripheries

Laboratory parameters

1.Decrease in HCT

2.Improvement in

metabolic acidosis2.Warm peripheries

3.CRT < 2sec

4.BP stable

5.Improving pulse pressure

6.Less tachycardic and less

tachypnoiec

7.Increase in urine output (≥

0.5ml/kg/hr)

metabolic acidosis


If still unstable after fluid resuscitation ?

Patient remains in shock after the first 2 cycles

of fluid resuscitation with crystalloids

(about 40 ml/kg)

Repeat HCT remains high Repeat HCT dropsRepeat HCT remains high

Colloids should be

considered for the 3rd

cycle

Repeat HCT drops

Suspect significant bleed

(often occult) and blood

transfusion should be

instituted ASAP


Persistent shock despite 60 ml/kg IV fluid

resuscitation

Consider :

• Significant occult bleeds

• Cardiogenic shock (due to myocarditis or ischaemic

heart disease)

• Sepsis


28


Fluid for DHF with Decompensated Shock

2

0

1

0

5-7

ml/

kg

/hr

3-5

2-3

1.2-1.5x maintenanceTo further reduce fluid if patient continues to improve

Aim to

stop

1 2 3 4 5 6 7 8 9 1

0

1

1

1

2

1

3

1

4

1

5

1

6

1

7

1

8

1

9

2

0

2

1

2

2

2

3

2

4 24-48

ml/

kg

/hr

Hours 30Perak Dengue TOT 2012

Remember

• The chart on the rate of fluid administration is only a guide

• Individual patient's rate of fluid requirement will depend on

the rate of leakage in that patient

• The rate of IV fluid administration has to be adjusted all the

time with FREQUENT MONITORING of

�vital signs ( BP, pulse pressure, periperal perfusion and urine

output ) and

�laboratory parameters ( HCT / HCO3 ± Se lactate )


Dengue hepatitis and liver failure

• Hepatitis is common in patients with DF/DHF

• Maybe mild or severe regardless of the degree of plasma

leakage

• Fulminant hepatitis with liver failure may occur

�higher propensity to bleed, especially gastrointestinal

bleeding

�Supportive therapy

�Not to fluid overload patient

� IV N-acetylcysteine (NAC) therapy may be beneficial – need further

clinical trials


Clinical Course of DHF


Recovery Phase

• After 24-48 hours of defervescence, plasma leakage stops and

is followed by reabsorption of extravascular fluid

• HCT level stabilises or drops further due to haemodilution

following reabsorption of extravascular fluidfollowing reabsorption of extravascular fluid

• The recovery of white cell count (WCC) is followed by the

recovery of platelet count

• Discontinue IVD during reabsorption phase to avoid fluid

overload


Common pitfalls in fluid therapy

1. Treating patient with unnecessary fluid bolus based on

raised HCT as the sole parameter without considering

other clinical parameters

2. Excessive and prolonged fixed fluid regime in stable 2. Excessive and prolonged fixed fluid regime in stable

patients

3. Infrequent monitoring and adjustment of infusion rate

4. Continuation of intravenous fluid during the recovery

phase


The role of blood and blood

productsproducts


How to Recognize Significant Occult

Bleeding?

Significant bleeding or DIVC usually occurs following

prolonged shock and acidosis


Management of bleeding in dengue


Role of prophylactic transfusions in

dengue ?

NO !


Thank You


Documents

Management of Dengue in Adults Part II fluid management - Ker