2010 INTERIM GUIDELINES ON FLUID MANAGEMENT OF DENGUE FEVER AND DENGUE HEMORRHAGIC FEVER

John Paul L. Oliveros, MD, DPPS

Objectives

To compare the dengue case classification used in the 2008 PPS Dengue evidencebased guidelines and the proposed 2009 WHO Dengue Guidelines To update the section on fluid management of the 2008 PPS Dengue evidence-based guidelines To develop clinical algorithms on fluid resuscitation of patients with dengue based on presenting clinical features and based on the presence of compensated and

Dengue Case Classification

Dengue Case Classification

Dengue Case Classification

Dengue Case Classification

Fluid Management

DF/DHF (Dengue without danger signs) who are not admitted

ORS

should be given

Reduced

osmolarity (Na+ 45-60mmol/L Sports drinks (Na+ < 20meqs) should not be given

Fluid Management

Admitted patient without shock (DF/DHF I-II or dengue without warning signs)
Isotonic
D5LR,

solutions
D5NSS, D5 0.9NaCl

Maintenance

rate

Fluid Management

Admitted Patients with some dehydration but without shock

Fluid Management

Admitted patients with some dehydration but without shock

Fluid Management

Important Tips:
Periodic

assessment Monitor Clinical parameters and correlate with hematocrit IVF decreased anytime as necessary based on clinical assessment If patient shows signs of deterioration, manage as compensated shock or hypotensive shock

Clinical Parameters

Annotations

If hematocrit is not available, assess hemodynamic status Assessment of improvement should be based on 7 parameters
Mental status Heart rate Blood pressure Respiratory rate Capillary refill time Peripheral blood volume extremities

Annotations
Crystalloids

Colloids

Safe effective as colloids in reducing shock and mortality 1st line in moderately severe/compensate d shock

Increased risk of allergic reactions Increased risk of new bleeding manifestations More expensive

Annotations
Crystalloids

Colloids

0.9% saline (normal saline) /NSS

Dextrans

Repeated large volumes lead to hyperchloremic acidosis Lower sodium and chloride 273 mOsm/L May not be suitable for patients with severe hyponatremia Avoided in liver failure and in patients taking metformin

Ringers lactate

Bind to Von Willebrand factor/Factor VIII complex Impair coagulation the most Potential to cause osmotic renal injury in hypovolemic patients

Starch Gelatin

Least effect on coagulation Highest risk of allergic reactions among colloids

Annotations

Inotropes

Dopamine:

Dopamine 200mg/5ml + d5water 245ml= 200mg/250ml Premixed: 200mg/250ml; 400mg/250ml Formula: weight x dose (5-20mcg/kg/min)x 0.075 = cc/hr

Dobutamine:

Dobutamine 250mg/20ml or 12.5mg/ml amp (20cc) + d5water 230 cc= 250mg/250ml Premixed: 250mg/250ml; 500mg/5ml Formula: weight x dose (5-20mcg/kg/min) x 0.06= cc/hr
Epinephrine 5amps (5cc) + d5water 45ml=5mg/50ml Formula: weight x dose (0.3-2mcg/kg/min) x 60= cc/hr
100

Epinephrine:

Annotations

Hypotension
Adult: SBP <90mmHg or MAP <70mmHg or decrease in SBP >40 mmHg of <2 SD below normal for age Children <10yo:

lowest SBP or <5th tile of SBP = 70 + (age in years x 2)

Urine Output
Good urine output indicates sufficient circulatory volume Index or guide for decreasing the amount of fluid administered 0.5-1cc/kg/hr Monitor q hourly until out of shock then q 2 hrs Serum creatinine if acute renal failure is suspected

Thank You
Good Morning