1. 2. Fluid Management in Dengue Hemorrhagic Fever
Dengue Expert Advisory Group

2. Dengue Virus Infection
Asymptomatic
Symptomatic – Undifferentiated Febrile Illness – Dengue Fever – Dengue Hemorrhagic Fever  Non Shock  Shock

3. Dengue Hemorrhagic Fever
Febrile Phase
Critical phase characterized by plasma leak
Convalescent Phase

4. Dengue “Leak” Fever Plasma leak during critical phase is the hall mark
Leading to 3rd space losses – peritoneal cavity – pleural cavity
Variable in magnitude and exact timing

6. Pathogenesis of leak Infection with a virulent dengue virus
Presence of antibodies that enhance dengue virus infection (ADE)
Intense immune activation

7. Pathogenesis
Rapidly elevated cytokines (TNF-a, IL-2, IL-6, IL-8, IL-10, IL-12, and IFN-g)
Malfunction of vascular endothelial cells
Plasma leakage from intra to extravascular space

8. Pathogenesis In severe DHF the loss of plasma is critical
Patient becomes hypovolaemic
Signs of circulatory compromise
Progress to shock, organ failure, death

9. Pathogenesis
Cytokine Storm
Self limited
Ends after 48 hours

10. Clinical Implications
Extravascular fluid loss at variable rate that has to be matched ml for ml
Lasting 48 hours
Resorption of fluid during convalescent phase

11. Key Points
Manage critical phase with appropriate volume – Don’t under transfuse – Don’t over transfuse
Meticulous monitoring during critical phase to match rate of fluid infusion with rate of leak

12. Monitoring Parameters
Clinical – Pulse Rate – Blood and Pulse Pressure – Capillary Refill Time – Urinary Output
Lab – Hematocrit

13. Fluid Management Critical Phase

14. Amount of Fluid? Based on weight
Adults – If less than 50kg use actual weight – If more take weight as 50 kg
Paediatrics – Current OR Ideal body weight whichever is lower

15. Ideal Body Weight Weight for height using a growth chart
Weight for age
Formulae in emergency

16. Growth Charts

18. Formulae <1 year : Age (in Months)+ 9/2 1-7 years : (Age x 2)+ 8
APLS : (Age in years + 4) x 2

19. Fluid Quota M + 5% = Maintenance + 5% of body weight
Over 48 hours if patient presents in the beginning of critical phase (without shock)
Over 24 hours for patients coming in shock

22. M + 5% - Adults
Maintenance – 1st 10 kg – 1000 mls – 2nd 10 kg – 500 mls – Remaining 30kgs – 600 mls – Sum = 2100 mls
5% deficit – 50 x 50 = 2500 mls
Total = 4600 mls

23. Child 22 kg Maintenance – 1000 + 500 + 40 = 1540 mls
5% Deficit – 50 x 22 = 1100 mls
Total mls

24. Types of Fluid
Crystalloids – 0.9% Saline – 5%Dextrose 0.9% Saline – 5% Dextrose ½ saline

26. Monitoring – Critical Phase
Vital parameters - hourly
Fluid balance chart - assess three hourly
HCT - six hourly

27. Fluid Management in Dengue Shock Syndrome

28. Compensated Body compensates for fluid loss Tachycardia
Pulse Pressure narrows
Prolonged CRT
Fall in urine output to 0.5 mls/kg/hr

29. Decompensated
Pulse pressure narrows further leading to unrecordable pulse and BP
Urine output falls less than 0.5 mls/kg/hour

30. Fluid Resuscitation Crystalloids – N Saline
Colloids – Dextran 40 in N. Saline – 6% Starch
All boluses part of fluid quota

31. Indications for Colloid
Failure of crystalloid boluses to normalize pulse /BP
Development of shock – with fluid overload – amount of fluid exceeding M + 5% deficit
10 ml/kg over 1 hour

32. Colloids
Dextran may sometimes interfere with grouping and cross matching
3 doses of Dextran 40 during a 24 hour
5 doses of 6% Starch during 24 hour
Remain in circulation for much longer

35. Refractory Shock - ABCS
Blood – packed cells – whole blood
Bicarbonate
Glucose
Calcium

36. Monitoring During Shock
15 minute monitoring of vital signs
HCT immediately before and after each fluid bolus and then at least two to four hourly

37. Key Points – Managing DHF
Recognizing the start of critical phase of DHF
Predicting the rate of leak which may vary from patient to patient and within the same patient
Matching the rate of infusion to rate of leak
Being cognizant of the end of critical phase

38. Key Points – Managing DSS
Meticulous monitoring
Switching appropriately from crystalloids to colloids
Recognizing need for blood transfusion