1. Dengue hemorrhagic fever and Dengue shock syndrome - Severe Dengue Fever 奇美醫學中心楊俊杰醫師

2. Outlines  Clinical presentations  Laboratory examinations  Diagnosis  Management

3. Clinical Presentations Before admission Fever Vomiting, watery diarrhea with blood in stool Periumbillical abdominal pain for 1 day After admission Cold peripheral perfusion, mottled skin, shortness of breath Fresh blood from NG tube, mouth, endotracheal tube, anal tube Diffuse petechiae over trunk

4. Laboratory Examinations (1) WBC (/uL)5800 D 1 27700 ↑ D 25 band (%)15 ↑ D 1 Platelet (/uL)14000 ↓ D 1 CRP (mg/ml) 88.8 ↑ D 1 146.9 ↑ D 8 PCT (ng/ml)2.73 ↑ D 1 23.15 ↑ D 12 Dengue NS1 Ag rapid test (+) D 1

5. Laboratory Examinations (2) Hb (g/dL)18.9 ↑ D 1 7.9 ↓ D 4 Hct (%)51.6 ↑ D 1 27.9 ↓ D 5 PT/APTT (Sec)14.4 ↑ /48.0 ↑ D 1 15.1 ↑ /59.6 ↑ D 3 D-Dimer (ng/ml)7463.4 ↑ D 1 FDP (ug/ml)27.6 ↑ D 1 Fibrinogen (mg/dL)231 D 1

6. Laboratory Examinations (3) Lactate (mmol/L)4.1 ↑ /7.9 ↑ D 1 /D 3 PO 2 /FiO 2 (mmHg)76.6 ↓/66.3 ↓ D 2 /D 4 (Day 4) CPPV mode, Vt: 360 ml, PEEP: 18 cmH 2 O, FiO 2 : 100%, PIP: 42 cmH 2 O, P plateau : 40 cmH 2 O, Fetanyl + Ativan + Nimbex GOT/GPT (U/L)4319 ↑/1366 ↑ D 1 7718 ↑/1257 ↑ D 2 Bil-T/D (mg/dL)4.45 ↑/3.17 ↑ D 1 18.54 ↑/13.78 ↑ D 19 Ammonia (umol/L)135 ↑ D 2

7. Laboratory Examinations (4) BUN/Cr. (mg/dL)50 ↑/4.14 ↑ D 1 194 ↑/12.46 ↑ D 21 Amylase (IU/L)225 ↑ D 2 931 ↑ D 7 Lipase (IU/L)594 ↑ D 2 1359 ↑ D 7 Abdominal CT: diffuse mild swelling of pancreas D 11 Albumin (g/dL)3.7 D 1 1.8 ↓ D 3

8. Diagnosis Severe Dengue fever (Dengue hemorrhagic fever and Dengue shock syndrome) with acute hepatitis, acute kidney injury, disseminated intravascular coagulation, gastrointestinal bleeding, acute pancreatitis, probable coexisting bacterial infection and severe sepsis acute respiratory failure s/p mechanical ventilation

9. Management Treat underlying diseases Dengue & coexisting bacterial infection: inflammation, bleeding Hospital acquired infection: VAP, catheter related sepsis Hemodynamic support and Fluid status management Perfusion pressure, perfusion, O 2 delivery, intravascular volume Internal and external fluid status Mechanical ventilation Lung protective ventilatory strategy

10. Underlying diseases (1) Bleeding Diffuse bleeding Platelet ↓ PT/APTT ↑ Hb ↓ Hb (g/dL) D 1 :18.9 - D 4 :10.5 Plt: (/uL) D 1 :14K - D 4 :55K PT (Sec) D 1 :14.4 - D 4 :12 APTT (Sec) D 1 : 48 - D 4 :46.7 PRBC:10U FFP:38U Plt:7U Cryo.:20U CNS Pain, agitation, delirium Sedation withdrawal Fetanyl + Ativan + Nimbex PIP < 35 cmH 2 O, FiO 2 ≦ 50%, PPEP ≦ 10cmH 2 O, GI work Tramadol, Zyprexa zydis, Haldol, Ativan, Etumine, Mesyrel, Inderal

11. Underlying diseases (2) Circulation Cold peripheral perfusion Elevated lactate level D 2 :cold D 4 : warm Lac.(mmol/L) D 3 : 7.9 D 5 : 2.0 D 1-3 : + 22600 ml D 2 :GEDI/CI (626/4.27) D 3 :GEDI/CI (787/5.64) D 4 :GEDI/CI (766/3.89) Lung Acute pulmonary edema, mixed type PO 2 /FiO 2 D 2 :76.6 D 3 :119 D 4 :66.3

12. Underlying diseases (3) GI UGI bleeding Ileus Gastroparesis PPI Prokinetics: promeran, mopride NJ tube Liver Acute hepatitis Jaundice Hyperammonemia Nutrition support (parenteral and enteral) Urso

13. Underlying diseases (4) Kidney Acute oliguric renal failureFluid (Crystalloid firstly, colloid) Diuretics CVVH H/D Recirculation problem Pancreas Acute pancreatitisSupportive care Pain control + Nutrition support

14. Underlying diseases (5) Infection Community acquired Hospital acquired Antibiotics ??? Fever (adrenal insufficiency?) WBC/band% Plt CRP/PCT Endocrine Type 2 DM Relative adrenal insuffiiciency Insulin Steroid

15. Hemodynamic support & Fluid status management

16. Everyday in ICU Hemodynamic StatusFluid Status Evaluation hydrostatic pressure/permeability/oncotic pressure Perfusion pressure ？ Perfusion ？ (Flow, Cardiac output) ？ Oxygen delivery (C.O, Hb, SaO 2 ) ？ Int. human bodyExt. human body Pulmonary edema Pul. congestion Pleural effusion Ascites Bowel edema ？ Sclera Scalp Trunk Limbs Inner side of thigh Genital area

17. Fluid choice: Crystalloid or Colloid? Hydrated status Dehydrated Normal hydratedEdematous Albumin level Chemosis Peripheral edema Permeability ？ Na + K + Cl - Crystalloid 0.9% N/S Lactated Ringer’s Colloid

18. Hemodynamic Status on Day 4 Adequate perfusion pressure BP: 113/75 mmHg MAP: 89 mmHg Adequate perfusion (cardiac output) Cold to Warm Perfusion SVI: 23 to 41 ml/m 2 CI: 2.72 to 3.81 L/min/m 2 Adequate O 2 delivery (Q, Hb, SaO 2 ) Lactate: 7.9 to 2.4 mmol/L (Lactate: 2.0 mmol/L D 5 ) Adequate Intravascular Volume GEDI: 569 to 766 ml/m 2

19. Fluid Status Management (1) Day 1Day 4

20. Fluid Status Management (2) Day 4Day 15

21. 敬請指教 謝謝！