3. Documentation and Monitoring of Dengue Patients Dengue Expert Advisory Group

Why Monitor Dengue Patients? To differentiate DHF from DF Assessing onset of Critical Phase of DHF Smooth manipulation of fluids averting prolonged shock and fluid overload Early detection of complications Recognition of unusual presentations

Basic Monitoring All Patients Pulse rate Pulse pressure CRFT Respiratory rate FBC - HCT Intensity of monitoring depends on Phase of the illness Severity Aggressiveness of fluid therapy Accurate fluid balance charts

Ministry of Health Sri Lanka

Febrile Patient Dengue or not? DF or DHF ? Clinical FBC Leucopaenia + thrombocytopaenia DF or DHF ? Plasma leakage + or – If DHF – what is the phase ?

When Patient Afebrile Critical phase Aggressive monitoring Time of entry Predicted time of end Aggressive monitoring Calculate the fluid quota Dynamic approach to fluid therapy Final diagnosis – precise (DF or DHF & grade)

Critical Phase Facts Dropping Platelets HCT rise of more than 20% of base line Conforms DHF as it signify leak. Even If HCt rise less than 20% but pleural effusion/ascites present conforms diagnosis of DHF/DSS( it is mostly due to early volume replacement or bleeding).

Recognize the Stage of the Disease Febrile phase Critical phase Convalescent phase Day of the illness ? Evidence of plasma leakage ? Convalescent rash ? Assess

Monitoring & Documentation Critical Phase Detection of shock Pulse pressure < 20 mm Hg CRFT > 2 secs HCT increase of 20% or more from baseline Efficacy of IV fluid therapy Pulse pressure, capillary refill time, hypotension To keep urine output at least 0.5 – 1.0 ml/kg/hr Early detection of Fluid overload Respiratory rate > 20/mt Lung bases SaO2 < 92% CXR

Warning Misjudging of critical phase which could begin as early as day 3 (if fever drop on day 3). Delay in doing the WBC, platelets and Hct determinations. which help predict the critical stage/shock Lead to misdiagnosis and/or delay until shock occur.

Monitoring Chart I - for Management of Dengue Patients – Febrile Phase Hct % D3 with Fever WBC <5000/mm3 N-40% L-58% TT + ve Dengue Fever D4 without Fever

Entry in to critical phase D4 with Fever TT + ve, WBC <5000/mm3 N-40% L-58% Tender Liver

How to time the onset of critical phase? 8 am D3 18th D4 8 pm 19th D5 20th D6 Pm 21st D7 WBC 3200 2800 1900 2900 3700 4500 6000 7000 7300 N % 53 41 31 26 25 33 43 58 L % 44 56 68 71 73 67 66 55 PCV % 39 36 42 38 Plt 252000 121000 110000 61000 22000 18000 12000 8000 19000 Onset End

Monitoring IV Fluid Therapy Phase of the illness – be fully aware Adequacy of fluid therapy Pulse Pressure >20 mmHg CRFT <2 sec Pulse Rate <80/mt UOP > 0.5 ml/Kg/hr HCT Early detection of fluid overloading Respiratory rate > 20/mt Lung bases SaO2 < 92% CXR Shift ICU

Skin colour Skin Temp. CRFT Clinical Parameters Fluid Therapy PR RR BP/PP General condition Appetite Vomiting Bleeding Peripheral Perfusion Pulse volume Skin colour Skin Temp. CRFT HCt Urine output (based on IBW)

Clinical Scenario Decision IV Fluid Bolus If Afebrile Pt. Restless Irritable Pulse rate Pulse volume poor CRFT>2 sec Skin cold Pulse pressure<20 HCT Urine output<0.5 ml/kg Decision IV Fluid Bolus

Scenario Decision Blood Transfusion Afebrile Restless Confused Pulse volume poor Skin pale CRFT>2 sec Urine output < 0.5ml/kg/hr PR BP PP HCt Blood Transfusion

Dextran 40 with frusemide Scenario Vital Signs Pulse volume good Skin colour normal Skin temp. normal Pulse pressure wide Urine output > 1ml/kg/hr CRFT< 2 sec PR BP HCt Afebrile patient Puffy eyelids Distended abdomen Tachypnea Dyspnoea orthopnea Respiratory distress Decision Dextran 40 with frusemide

Warning Be vigilant to recognize DSS as most of the patients remain in good conscious and have narrow pulse pressure with increased diastolic pressure(e.g.BP=110/90, 100/80mm Hg) without hypotension. Avoid misdiagnosis of DHF in Infants(<1 year) with fits as sepsis/infection followed by LP leading to bleeding/ hematoma(platelets )

Pearls Your initial timing of critical phase may prove to be sometimes wrong Be prepared to change what you decided earlier or shift the timing based on more information you receive while Mx.

Pearls Try to Master the ways of giving ‘ THE SMOTHEST AND THE MOST UNEVENTFUL RECOVERY’ for the patient. Avoid both shock and fluid overload. Keep ‘CHECKING ON A TIME SCALE’… R u heading for fluid overload? If so, switch to a colloid.

Pearls At ‘END OF LEAKING PHASE’ even if PCV is high but patient is well, pulse, BP is OK Don’t try to correct PCV as re absorption will start soon and PCV will come down so.. WAIT.

Pearls About 60% of DSS can be successfully resuscitated by using crystalloid solution only, 20% need colloidal and 15% need blood transfusion (+blood components). With rapid recognition of shock and proper treatment rapid and dramatic recovery is the rule