Presentation is loading. Please wait.

Presentation is loading. Please wait.

Best Practice in Dengue infections

Similar presentations


Presentation on theme: "Best Practice in Dengue infections"— Presentation transcript:

1 Best Practice in Dengue infections
Professor Siripen Kalayanarooj Consultant, WHO Collaborating Centre for Case Management of Dengue/ DHF/ DSS (Director ), Queen Sirikit National Institute of Child Health, Bangkok, Thailand

2 จำนวนผู้ป่วยไข้เลือดออกในประเทศไทย พ.ศ. 2501 - 2560
174,286 115,768 144,952 101,689 53,189 68,386 2,158 38,768 สำนักระบาดวิทยา กรมควบคุมโรค กระทรวงสาธารณสุข

3 อัตราป่วยตายของผู้ป่วยไข้เลือดออกในประเทศไทย พ.ศ. 2501 -2560
13.9 3.16 1.95 0.34 0.58 0.10 สำนักระบาดวิทยา กรมควบคุมโรค กระทรวงสาธารณสุข

4 Reported cases of dengue 2014-2017
2013 2014 2015 2016 2017 Morbidity 150,174 40,278 142,925 63,310 53,189 Dead 131 41 148 61 63 CFR 0.09 0.10 0.1

5 ใครบ้างที่มีโอกาสเป็นไข้เลือดออก
: เป็นโรคของเด็กๆ (อายุ < 15 ปี) 2530 – 2540: ผู้ใหญ่เริ่มมีรายงาน 10-15% 2552: จากรายงานของสำนักระบาดวิทยา – ผู้ใหญ่เป็นเท่ากับเด็ก 2553 – 2557: ผู้ใหญ่ป่วย 54% 2558: ผู้ใหญ่ป่วย 64.4% ตาย 66.2% 2559: ผู้ใหญ่ป่วย 62.1% ตาย 49.2%

6 เปรียบเทียบจำนวนผู้ป่วยไข้เลือดออกเด็กและผู้ใหญ่ พ.ศ. 2539 -2559
สำนักระบาดวิทยา กรมควบคุมโรค กระทรวงสาธารณสุข

7 Peak incidence of dengue infections: 2017
Age range (year) % 15-24 26.65 10-14 20.11 25-34 14.59 Top 5 provinces: Songkla – /แสน Pattalung – /แสน Pattani – /แสน Phuket – / แสน Narathiwas – ตถใตจ/แสน Top Region: S – 88.31/แสน N – 27.68/แสน C – 23.45/แสน NE – 18.19/แสน

8 Situation in Thailand 2016-2017
60% in adults 40% in children CFR 0.10% Children 30% Adults 70% Oldest age 92 years! Youngest – before birth!!! (Vertical transmission)

9 Dengue Serotypes Queen Sirikit National Institute of Child Health 1973-2015 (April 15)
AFRIMS

10 Dengvaxia SanofiPasteur
Age >9 – 45 Years, dosage 0,6, 12 months Efficacy – 65% Against Den 1 – 50% Against Den 2 – 40% Against Den 3 – 70% Against Den 4 – 70% Reduce hospitalization 80% Reduce severity 90% Not use in sero-negative individual Repeated infections – more severe ADE – Antibody Dependent Enhancement

11 Dengue virus infection
10,000 Asymptomatic Symptomatic Viral syndrome Dengue fever DHF 1,000 9,000 100 500 400 Plasma leakage Expanded dengue syndrome Prolonged shock: liver failure, renal failure,…Encephalopathy… Co-morbidities 3. Co-infections 4. True dengue infection - encephalitis DHF DSS 1-5

12 Management targets on DHF/DSS with plasma leakage
Among 1,000 dengue patients, probably 100 DHF with plasma leakage and DSS (depends on early detection of plasma leakage) Majority of dengue patients are not severe No predictors of severe diseases at present

13 Dengue Fever (Infection)
Headache Retro-orbital pain Myalgia Arthralgia/ bone pain (break-bone fever) Rash Hemorrhagic Manifestations Leukopenia (WBC < 5,000 cells/ mm3) Platelet count ≤ 150,000 cells/mm3 Rising HCT 5-10% Diagnosis : Tourniquet test positive + WBC  5,000 cells/cu.mm (positive predictive value = 83%)

14 Dengue Hemorrhagic Fever
Clinical High, continuous fever 2-7 days Hemorrhagic manifestations: tourniquet test positive, petechiae, epistaxis, hematemesis, etc… (Liver enlargement) (Shock) Laboratory Evidence of plasma leakage; rising Hct ≥ 20%, pleural effusion, ascites, hypoalbuminemia (serum albumin < 3.5 gm% or <4 gm% in obese patients), UTZ Platelet count ≤ 100,000 cells/ mm3. Note: Patients who have definite evidence of plasma leakage, hemorrhagic manifestations and thrombocytopenia might not be present as the exception.

15 Severity of DHF Grade I – No shock
Grade II – No shock, spontaneous bleeding Grade III – Shock Grade IV – Profound shock (immeasurable BP/ Pulse)

16 Pathophysiologic Hallmark of DHF
Plasma leakage – major problems Abnormal hemostasis - usually minor bleeding in early febrile phase except in those with underlying peptic ulcer or those who took NSAID, Aspirin, Steroid

17 Tourniquet test + Natural course of DHF Fluid overload
Day Shock Fever Pleural effusion, Ascites Hematocrit Plasma leakage Stop leakage Reabsorption Fluid overload IV fluid: NSS, DAR, DLR Colloid: 10%Dextran-40 M+5% Deficit (= 4,600 ml in adult) WBC Tourniquet test + WBC ,000-9, ≤5,000 Platelet count 200, ≤100, <50,000 Hct (rising 20%) Albumin ≤3.5 gm% Cholesterol ≤100 mg% Professor Siripen Kalayanarooj

18 Prolonged shock > 10 hours untreated - Death!!!
Liver failure- prognosis 50% Liver + Renal failure - prognosis10% 3 organs failure (+respiratory failure) – Prognosis is a miracle!!!

19

20 Compare using different classifications at QSNICH
WHO 1997, 2011 WHO 2009 OPD (2009): 1,500 cases (TT positive + Leukopenia) IPD (3 months in 2009) 100 DHF/DSS cases for close monitoring Increase to 30,000 cases when applying only 2 warning signs (abdominal pain and vomiting) Increase to 300 SD for close monitoring

21 Lahore, Pakistan Experienced (Sep.-Nov. 11)
Total suspected cases : 600,000 cases Confirmed 20,000 cases (< 4%) At the peak: 4,000-6,000 patients/day Admission cases/day Death cases per day

22 Multi-country study: 18 countries Validation study of the revised classification
Revised not classified Dengue without Warning Signs Dengue With Warning Signs Severe dengue Total Not classify 23 57 159 29 268 DF 7 551 684 75 1,317 DHF 2 8 240 39 289 DSS 12 76 88 32 616 1,095 219 1,962 Barniol J et al: BMC Infectious Disease 2011,11: 106

23 Warning signs Non-specific, low specificity (20- 50%)
Increase workload beyond management by existing healthcare personnel 20 times at OPD 3 times at IPD

24 High risk patients Infants, Elderly, Pregnancy Obese patients
Prolonged shock Significant Bleeding Encephalopathy Underlying diseases

25 Important steps in Dengue Case management
Early diagnosis of dengue infections Early detection of plasma leakage and proper IV fluid management Detect and correct common complications: ABCS, Fluid overload Management of bleeding Dx & Management of unusual cases: BBH

26 1. Early clinical Diagnosis
Think of dengue in every patients who present with high fever (except in adults) High continuous fever Bleeding manifestations: petechiae, epistaxis, gum bleeding, hematemesi, melena, hematuria, hemoglobinuria, menstruation, abnormal vaginal bleeding… Ache and pain; headache, retro-orbital pain, myalgia, arthralgia/ bone pain Rash; Petechial, MP-rash

27 Case 1 : 21-year-old, 129 Kgs Fever for 5 days Headache Bodyache
Poor appetite Nausea, no vomiting Loose stool 2 times/day since yesterday T 39 degree, BP 100/70 mmHg, P 94/min, RR 20/min Others – WNL, no skin rash

28 Case no. 1 : A 21-year-old man, 129 kgs

29 CBC Hb 15.1 gm%, Hct 45%, wbc 4,350, P 67, L 25, AL 8, platelet 35,000 cells/cumm.

30 LFT Albumin 3.6 gm% (normal > 4.0 gm%), Cholesterol 72 mg% (normal > 150mg%), AST 286, ALT 156 U

31 Follow up the next day (Day 6)
Fever 38.1, BP 100/60, P 90, RR 20 Still nausea, no vomiting Poor appetite Hct q 6 hrs revealed: dropped from 45% to 43%, 42% and 41% this morning

32 Lessons Learnt Early diagnosis of dengue infections
CBC: WBC, Platelet count, Hct - Not done even though they can refer patients to be done in the nearest hospital (recommend to do CBC starts from day 3 of illness – clinical or warning signs cannot help to detect plasma leakage) No NS1Ag available but most people prefer this even though it does not guide clinicians for IV fluid management

33 Dengue diagnostic options and sensitivity
Fever phase (D1-5) NS1Ag – sensitivity 40-70% - specificity 99% Late phase (D>5) Dengue IgM – sensitivity 60% on shock day - specificity 99% Courtesy of Armed Forces Research Institute of Medical Sciences

34 2. Early detection of plasma leakage and proper IV fluid management
Evidence of Plasma Leakage Rising Hct ≥ 20% Pleural effusion, ascites Physical examination CXR – Right lateral decubitus Ultrasound Hypoalbuminemia Albumin < 3.5 gm% in normal patients Albumin < 4 gm% in obese patients

35 Lessons Learnt Delay detection of plasma leakage - major cause of fluid overload and possible lead to dead Not isotonic Too early Too much Too long No Dextran available (other colloidal solutions are not effective including albumin) Too little - causes prolonged shock and organs failure

36 Indication for IV fluid in DHF patients
Entering critical period – thrombocytopenia; platelet count ≤ 100,000 and throughout plasma leakage time, 1-2 days (and hours beyond) Shock: difficult to detect because patients are in good consciousness, able to walk and talk Not before and after stop leakage, if IV fluid is extend beyond this leakage phase, patients are at risk of fluid overload which is one of the major causes of death

37 Principles of IV fluid in DHF patients during leakage period
Isotonic salt solution: NSS, DAR, DLR with or without dextrose Check blood sugar if given IV without dextrose 30% of DSS patients have hypoglycemia Limited amount of fluid (oral + IV) during leakage period (M +5% deficit or 4.6 L in adults) – If give more IV fluid, more leakage that will interfere with respiration If more volume is needed, switch to Dextran-40 (hyper-oncotic), plasma expander

38 Principles of IV fluid in DHF patients during leakage period
Adjust rate of IV fluid according to monitoring parameters: clinical, vital signs, Hct and amount of urine Discontinue IV fluid when reabsorption occurs (convalescence phase; stable Hct, diuresis, bradycardia, convalescence rash)

39 Dengue Shock Syndrome Plasma leakage Bleeding
Narrowing of Pulse Pressure ≤ 20 mmHg Hypotension Systolic < 80 in adult < 70 + (Age in year X 2) in children Orthostatic hypotension Fainting Adults have more significant bleeding Aware of significant bleeding in: - Patients with menstruation or abnormal vaginal bleeding - Hemoglobinuria - Severe abdominal pain (concealed GI bleeding)

40 Other causes of shock in Dengue patients
Hypoglycemia Excessive vomiting Co-infections

41 Rate of IV fluid Shock Non-shock
DSS – NSS (D) 10 ml/kg/hr or 500 ml/hr in adult, If profound shock – free flow mins, then reduce rate Non-shock: rate depends on degree of thrombocytopenia & rising Hct

42 Lessons Learnt 3. Detect and correct common complications:
A – Acidosis – Prolonged shock with possible liver/ renal failure B – Bleeding – No rising Hct or dropping Hct C – Hypocalcemia and other electrolyte imbalance (Hypokalemia, hyponatremia) S – Hypoglycemia (30% in DSS) Fluid overload – Signs & symptoms of fluid overload or persistent high Hct > 25%

43 Practical management when no lab. for correction of A, B, C & S
Check Blood Sugar 10% Ca gluconate 10 ml dilute to 20 ml IV push in 10 min (1 ml/kg/dose, maximum dose 10 ml) Vitamin K1 IV 10 mg NaHCO3 1 ml/kg IV if cyanosis or persisted cold, clammy skin after IV fluid resuscitation

44 Indications for switching to colloidal solution
Signs and symptoms of fluid overload Puffy eyelids, distended abdomen with ascites Dyspnea/ Tachypnea Positive lungs signs: crepitation, rhonchi, wheezing Continue rising Hct Persistent high Hct > 25-30% Too much crystalloid solutions before plasma leakage

45 Type of Colloidal solution used in DHF/DSS
Plasma expander (high osmolarity, high oncotic pressure than plasma) 10% Dextran-40 in NSS Plasma substitute 6%Dextran-70 or 6%Dextran-40 Starch Gelatin

46 Dextran infusion (10% Dextran-40 in NSS)
Dextran rate 10 ml/kg/hr or 500 ml in adults Dextran will bring down PCV by 10 points, but not below baseline PCV If Hct drops > 10 points or below baseline – Think of bleeding Maximum dose per day = 30 ml/kg/day (may be used up to 60 ml/kg/hr in 48 hrs) All through the course, may use up to 6 doses Aware of sticky urine

47 Management of fluid overload
Insert urinary catheter Furosemide 1 mg/kg/dose IV (with or without dextran) Record vital signs q 15 min X 4 times After 1 hr, change IV to crystalline solution at the rate appropriate for the timing 1 ml/kg/hr if overt signs of fluid overload and adjust the rate of IV according to urine output (0.5 ml/kg/hr) KVO if pass the critical period

48 Dextran + furosemide (in the middle or after 10-15 mins)
Shock During critical period, Not in reabsorption phase Furosemide depletes intravascular volume, (not deplete ascites or pleural effusion) Dextran holds intravascular volume or draws back ascites and pleural effusion

49 4. INDICATION FOR BLOOD TRANSFUSION
Significant blood loss: > 10% of total blood volume (> 6-8 ml/kg) HCT dropping but no clinical improvement in spite of adequate volume replacement (Usually blood transfusion when HCT 40-45%) No rising HCT enough to explain shock (Usually rising HCT about 20-30% from baseline for shock)

50 AMOUNT OF BLOOD REPLACEMENT
Transfuse equal to the amount of estimated loss (if can estimate the amount of blood loss) Transfuse 10 ml/kg or 1 unit of whole blood if cannot estimate the blood loss or 5 ml/kg of packed red cell (PRC) if the patients have signs of fluid overload Do the HCT before and after transfusion to access the rising HCT (about 5 points in children for the above recommended dose) * Rate of transfusion depend on the patients’ conditions – usually as rapid as possible in 1-2 hours

51 ROLE OF PLASMA IN DHF/DSS
Almost no role !!! The osmolarity of plasma is equal to the patients’plasma so it will not hold the plasma volume and it will leak into the pleural and peritoneal spaces To correct the abnormal coagulogram, the dose is ml/kg (equal to the patients’ plasma volume). There is no available space for that large volume

52 INDICATION FOR PLATELET TRANSFUSION
Significant blood loss. Indicate for all cases that need blood transfusion. Platelet transfusion is only the adjunct therapy. If no platelet concentrate available, the patients will recover anyway. Even with indication for platelet transfusion, if those patients have signs of fluid overload, platelet transfusion is contra-indicated! For it may cause life-threatening heart failure or acute pulmonary edema.

53 PLATELET PROPHYLAXIS No prophylaxis platelet transfusion in children even for those patients who have very low platelet count (< 10,000 cell/mm3) In adult patients who had underlying hypertension or heart diseases and platelet count < 10,000 cells/mm3, prophylaxis platelet transfusion is recommended.

54 Early Late convalescence

55 Convalescence A – appetite B – bradycardia
C – Convalescence rash, itching D – Diuresis: aware of Hypokalemia

56 Lessons Learnt Management of bleeding
Delayed blood transfusion because of concealed bleeding, normal Hct, no shock, good clinical Delayed transfer patients to the nearest hospitals that have blood bank until they have shock with massive bleeding and Hct markedly drops

57 5. Management of Unusual/ Complicated cases
Cases present with shock and high fever ± Platelet < 100,000 cell/cumm. especially < 50,000 cells/cumm. Bleeding Look for evidence of plasma leakage: rising Hct, albumin < 3.5 gm% or < 4 gm% in obese patients, ascites, pleural effusion by CXR, UTZ

58 If evidence of plasma leakage
Look for complications: DSS with superimposed bacterial infections DSS with concealed bleeding DSS with hepatitis (liver injury, liver failure)

59 Shock with fever DSS VS Septic shock
Platelet usually ≤ 50,000 cells/cumm ESR ≤ 20 (usually < 5 mm/hr) Evidence of plasma leakage (pleural effusion, ascites) by UTZ, low serum albumin LFT: Albumin < 3,5 gm% in normal person (< 4 in obese person) Elevation of AST/ALT Platelet is not ≤ 50,000 cells/cumm at first presentation ESR - > 30 mm/hr No evidence of plasma leakage LFR Normal albumin > 3,5 gm% Mild or no elevation at presentation

60 Lessons Learnt 5. Management of unusual cases
No experience and often misdiagnosis with septic shock or other diseases Patients came late with prolonged shock and organs failure Patients came with co-morbidity/ co-infections

61 DSS vs Hypovolemic shock (Diarrhea)
Mild to moderate dehydration Rising Hct ≥ 20% May have history of few loose stool Severe dehydration Rising Hct not > 10% History of massive watery diarrhea

62 Usually misdiagnosed as Septic Shock
Not typical as DSS No leukopenia – Leukocytosis and increase PMN No rising Hct – (Concealed) bleeding CXR - Portable and very difficult to detect pleural effusion Clinical: Pleural effusion & ascites - Too late when detect Usually misdiagnosed as Septic Shock Especially in adults

63 Lessons Learnt Causes of death: Thailand experience
Fluid overload – 75% Delayed/ Miss diagnosis > 50% (including expanded dengue syndrome) Delayed blood transfusion – 40% Prolonged shock – 40% Organs failure (liver follows by kidney and respiratory failure) Expanded dengue syndrome – 20%

64 Thank you!


Download ppt "Best Practice in Dengue infections"

Similar presentations


Ads by Google