DENGUE FEVER Severe Dengue

Online Lecture • Lives in or travels to dengue-endemic area with fever

Lecturer: Dr. Austria-Cantimbuhan of 2-7 days and any of the above clinical
Transcribed by: Don Edward Dela Rosa manifestations for dengue with or without warning
signs, plus any of the following:
2009 New Dengue Classification o Severe plasma leakage, leading to:
Dengue Case Classification by Severity ➢ Shock
➢ Fluid accumulation with respiratory
distress
o Severe organ impairment:
➢ Liver: AST or ALT ≥1000
➢ CNS: seizures, impaired consciousness
➢ Heart: myocarditis
➢ Kidneys: renal failure
Dengue WITHOUT warning sign o Severe bleeding
❖ Probable Dengue
• Lives in or travels to dengue-endemic area, plus Clinical and Laboratory Diagnosis of Dengue
patient has fever and 2 of the following clinical • Incubation period: 3-14 days (usually 4-7 days)
features: • Three phases:
o Headache o Febrile phase
o Body malaise o Critical phase
o Myalgia o Recovery phase
o Arthralgia
o Retro-orbital pain Febrile Phase
o Nausea and vomiting
o Anorexia
o Diarrhoea
o Flushed skin
o Rash (petechial rash, Herman’s sign)
o Tourniquet test positive
AND
• Laboratory test: CBC
o Leukopenia
o WITH or WITHOUT thrombocytopenia • Fever from 0-7 days
AND/OR • Biphasic fever pattern possible
• Dengue NS1 antigen test or Dengue IgM antigen test • Monitor defervescence and warning signs to recognize
(optional tests) start of critical phase
❖ Confirmed Dengue • Clinical manifestations:
• Viral culture isolation o Sudden onset of high fever PLUS any of the
• PCR following:
➢ Severe headache
Dengue WITH warning sign ➢ Retro-orbital pain
• Lives in or travels to dengue-endemic area, with ➢ Myalgia
fever lasting 2-7 days, plus any one of the following: ➢ Rash: transient, macular, maculopapular
o Abdominal pain or tenderness ➢ Minor haemorrhagic manifestations:
o Mucosal bleeding petechiae, purpura, epistaxis, haematuria
o Clinical signs of fluid accumulation ➢ Positive tourniquet test
o Persistent vomiting ➢ Facial flushing
o Lethargy, restlessness ➢ Anorexia
o Liver enlargement ➢ Injected oropharynx
o Decreased or no urine output within 6 hours
AND
• Laboratory test: CBC
o Increase in haematocrit
o AND/OR decreasing platelet count
 • Laboratory Findings
o Increase in haematocrit (hemoconcentration)
o Moderate to severe thrombocytopenia
o Leukopenia
o Transient increase in APTT with decrease in
fibrinogen

Recovery Phase

• Laboratory Findings
o CBC with decrease in WBC, mild to moderate
thrombocytopenia
o Elevated AST/ALT
o Hyponatremia
• Follows critical phase
Critical Phase • Gradual reabsorption of extravascular compartment
fluid in 48-72 hours
• Clinical manifestations
o Rash (isles of white in a sea of red)
o General well-being with improving appetite
o GIT symptoms start to subside
o Hemodynamic status stabilizes, and diuresis
improves
o Generalized pruritus
• As early as 3rd day after onset of fever to time of o Bradycardia and ECG changes common
defervescence
• May develop severe disease → critically ill
• Most patients may improve during this phase and do
not develop severe disease
• Rapid decrease in platelet count with associated rise
in haematocrit
• Presence of warning signs
• Clinical manifestations:
o Period of clinically significant plasma leakage
lasts 24-48 hours (ascites, pleural effusion)
o Severe abdominal pain
• Laboratory Findings
o Liver enlargement of >2cm
o Haematocrit stabilizes or slightly lower due to
o Persistent vomiting (≥ 3 episodes within 24
dilutional effect of reabsorbed plasma
hours)
o WBC starts to rise
o Lethargy or restlessness
o Platelet count increases with WBC recovery
o Shock preceded by warning signs:
➢ Subnormal temperature
Stepwise Approach to the Management of Dengue
➢ Progressive organ impairment
1. Overall assessment
➢ Metabolic acidosis and DIC
o History, including information on symptoms,
past medical history and family history
o Physical examination, including full physical
and mental assessment
o Investigation, including routine laboratory and
dengue-specific laboratory
2. Diagnosis, assessment of disease phase and severity
3. Management
o Disease notification
o Management decisions, depending on the
clinical manifestations and other
circumstances, patients may:
 ➢ Be sent home (group A) o Haematocrit
➢ Be referred for in-hospital • Treatment:
management (group B) o Obtain reference haematocrit before fluid
➢ Require emergency treatment and therapy
urgent referral (group C) o Give isotonic solutions such as 0.9% saline or
Ringer’s lactate
Group A criteria: Be Sent Home ➢ Start with 5-7mL/kg/hr for 1-2 hours, then
• Group criteria reduce to 3-5mL/kg/hr for 2-4 hours, then
o Dengue WITHOUT warning signs reduce to 2-3mL/kg/hr or less according to
o Able to tolerate adequate volumes of oral fluids clinical response
and to pass urine at least once every 6 hours • Reassess clinical status and repeat haematocrit:
• Laboratory tests: o If haematocrit remains the same or rises only
o Full blood count minimally, continue with 2-3mL/kg/hr for
o Haematocrit another 2-4 hours
• Treatment: o If worsening of vital signs and rapidly rising
o Advice for: haematocrit, increase rate to 5-10mg/kg/hr for
➢ Adequate bed rest 1-2 hours
➢ Adequate fluid intake • Reassess clinical status, repeat haematocrit and
➢ Paracetamol, 4g/day (max) in adults and review fluid infusion rates accordingly:
accordingly in children o Reduce intravenous fluids gradually when the
• Patients with stable haematocrit can be sent home rate of plasma leakage decreases towards the
• Monitoring: end of the critical phase
o Daily review for disease progression: • This is indicated by:
➢ Decreasing white blood cell count o Adequate urine output and/or fluid intake
➢ Defervescence o Haematocrit decreases below the baseline value
➢ Warning signs (until out of critical period) in a stable patient
• Advice for immediate return to hospital if • Monitoring:
development of any warning signs, and written advise o Vital signs and peripheral perfusion (1-4 hourly
for management (e.g. home care card for dengue) until patient is out of critical phase)
o Urine output (4-6 hourly)
Group B criteria: Referred for In-hospital Management o Haematocrit (before and after fluid replacement,
• Group criteria then 6-12 hourly)
o Patients with any of the following features: o Blood glucose
➢ Co-existing conditions such as pregnancy, o Other organ functions (renal profile, liver profile,
infancy, old age, diabetes mellitus, renal coagulation profile, as indicated)
failure
➢ Social circumstances such as living alone, Group C criteria: Require Emergency Treatment
living far from hospital • Group criteria
• Laboratory tests: o Patients with any of the following features:
o Full blood count (FBC) ➢ Severe plasma leakage with shock and/or
o Haematocrit (HCT) fluid accumulation with respiratory distress
• Treatment: ➢ Severe bleeding
o Encouragement for oral fluids ➢ Severe organ impairment
o If not tolerated, start intravenous fluid therapy • Laboratory tests
0.9% saline or Ringer’s lactate at maintenance o Full blood count (FBC)
rate o Haematocrit (HCT)
• Monitoring: o Other organ function tests as indicated
o Temperature pattern • Treatment of compensated shock
o Volume of fluid intake and losses o Start IV fluid resuscitation with isotonic
o Urine output (volume and frequency) crystalloid solutions at 5–10 ml/kg/hr over 1
o Warning signs hour. Reassess patients’ condition.
o Haematocrit, white blood cell, and platelet • If patient improves:
counts o IV fluids should be reduced gradually to 5–7
OR ml/kg/hr for 1–2 hours, then to 3–5 ml/kg/hr for
• Group criteria 2–4 hours, then to 2-3 ml/kg/hr for 2–4 hours
o Existing warning sign and then reduced further depending on
• Laboratory tests: haemodynamic status;
o Full blood count
 o IV fluids can be maintained for up to 24–48
hours.
• If patient is still unstable:
o Check HCT after first bolus;
o If HCT increases/still high (>50%), repeat a
second bolus of crystalloid solution at 10–20
ml/kg/hr for 1 hour;
o If there is improvement after second bolus,
reduce rate to 7–10 ml/kg/hr for 1–2 hours and
continue to reduce as above;
o If HCT decreases, this indicates bleeding and
need to cross-match and transfuse blood as soon
as possible.
• Treatment of hypotensive shock
o Initiate IV fluid resuscitation with crystalloid or
colloid solution at 20 ml/kg as a bolus for 15
minutes.
• If patient improves:
o Give a crystalloid/colloid solution of 10 ml/kg/hr
for 1 hour, then reduce gradually as above.
• If patient is still unstable:
o Review the HCT taken before the first bolus;
o If HCT was low (<40% in children and adult
females, <45% in adult males) this indicates
bleeding, the need to cross-match and transfuse
(see above);
o If HCT was high compared to baseline value,
change to IV colloids at 10–20 ml/kg as a second
bolus over 30 minutes to 1 hour; reassess after
second bolus.
o If patient is improving reduce the rate to 7–
10ml/kg/hr for 1–2 hours, then back to IV
crystalloids and reduce rates as above;
o If patient’s condition is still unstable, repeat HCT
after second bolus.
o If HCT decreases, this indicates bleeding (see
above);
o If HCT increases/remains high (>50%), continue
colloid infusion at 10–20 ml/kg as a third bolus
over 1 hour, then reduce to 7–10 ml/kg/h 1–2
hours, then change back to crystalloid solution
and reduce rate as above.
• Treatment of haemorrhagic complications
o Give 5–10 ml/kg of fresh packed red cells or 10–
20 ml/kg of fresh whole blood.
Laboratory Investigations (ABCS) for patients who present with Discharge advice:
profound shock or have complications, and in cases with no • Avoid trauma, sport, aggressive behaviour 3-5 days
clinical improvement in spite of adequate volume replacement after discharge for some cases may have low platelet
Laboratory count; platelets usually rise in 90% of patients
Abbreviation Note
Investigation simultaneously within 7 days after critical period
• People in the same house who are sick with high fever
Indicate prolonged
(they are likely to have dengue infection) are advised
shock. Organ
Blood Gas to seek consult
involvement should
A – Acidosis (Capillary or • Give advice how to prevent and control dengue at
also be looked into;
Venous) home and school (vector control and personal
liver function and
protection)
BUN, creatinine.

If HCT decreases in
comparison with the
Complete Blood previous value or not
B – Bleeding
Count rising, do cross-match
for possible blood
transfusion.

Hypocalcaemia is
found in almost all
cases of DHF but
asymptomatic. In
more
severe/complicated
cases, calcium
Electrolytes, supplement is
C – Calcium
Calcium indicated at dosage of
1mL/kg, dilute two
times, IV push slowly;
maybe repeated
every six hours, if
needed (max dose
10mL of calcium
gluconate)

Most severe DHF

cases have poor
appetite together
with vomiting. Those
D – Blood sugar Blood sugar with impaired liver
function may have
hypoglycaemia. Some
cases may have
hyperglycaemia.

Indications for Discharge:

• Absence of fever for at least 24 hours without the use
of antipyretics
• Return of appetite
• Visible clinical improvement
• Good urine output
• Minimum 2-3 days after recovery from shock
• No respiratory distress from pleural effusion and no
ascites
• Platelet count of more than 50,000/mm3