1. E D NGUE WORKSHOP 2015 CHALLENGES IN THE MANAGEMENT OF DENGUE
DR LOW LEE LEE
ID PHYSICIAN
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5. What are the warning signs?
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8. Fluid resuscitation is needed to sustain the intravascular pressure : Compensated or decompensated shock

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12. Severe Dengue : Dengue with target organ involvement
Dengue with hepatitis
Vomiting
Right hypochrondriac pain
Baseline LFT ( if admitted)
Dengue with encephalitis
Headache, vomiting, altered sensorium, seizure
Comatose ( late stage)
Dengue with perimyocarditis
Chest pain, dypsnoea, palpitation,
Cardiogenic shock ( late stage)
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13. Atypical presentations
Diarrhoea
Myocarditis
Encephalitis
Myositis
Hepatitis
Acute abdomen
Severe bleeding without plasma leakage
Plasma leakage in febrile phase

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15. Dengue Clerking Sheet
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16. Pearls of management Fever + 2 other features .
Advise patient to return to clinic/ seek medical attention
If fever does not settle after 3days
Presence of warning signs
Do FBC ± Dengue rapid test (combo)
Home advice leaflet
Early notification
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17. HOME CARE ADVICE LEAFLET FOR DENGUE PATIENTS
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18. First step All fever must be considered probable dengue
Fever plus 2 symptoms: myalgia/arthralgia, nausea vomiting, rash, bleeding tendency, leucopenia and thrombocytopenia, any warning signs
Notify once diagnose clinically
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19. Ask yourself are Dengue Warning Signs present?
• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation
(pleural effusion/ascites)
• Mucosal bleed
• Restlessness or lethargy
• Liver enlargement >2 cm
• Laboratory: Increase in HCT concurrent with rapid decrease in platelet
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20. Second step Disease staging and severity assessment
1. Dengue diagnosis (provisional)
2. Phase of dengue illness if dengue is suspected (febrile/critical/recovery)
3. With or without warning signs
4. Hydration and haemodynamic status of patient (in shock or not)
5. Whether the patient requires admission
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21. CRITERIA FOR HOSPITAL REFERRAL / ADMISSION
Symptoms: 1. Warning signs 2. Bleeding manifestations 3. Inability to tolerate oral fluids 4. Reduced urine output 5. Seizure
Signs:
1. Dehydration
2. Shock
3. Bleeding
4. Any organ failure
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22. CONSIDER EARLY ADMISSION
Co-morbidity e.g. DM, HPT, IHD,
Coagulopathies, Morbid Obesity, Renal failure,
Chronic Liver disease, COPD
Elderly > 65
Pregnancy
Social factors: living far, living alone etc
Lab. criteria
Rising HCT with reducing platelet count
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23. If you are in KK/district hospital
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24. Continue resuscitation and monitoring during transportation
Stabilise patient
Continue resuscitation and monitoring during transportation
Patient should be accompanied by a medical officer
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25. How much fluid to give Fluid regime Dengue with no warning signs
Dengue with warning signs
Decompensated shock
Compensated shock
Fluid Resuscitation

26. Dengue without warning signs : but with poor oral intake or mild dehydration
Non-shock patient/no warning signs
Encourage adequate oral intake
Intravenous fluids are indicated in patients who are vomiting, diarrhoea and mild dehydrated.
4/2/1 ( 4ml/kg for first 10 Kg + 2 mls/kg for subsequent 10 kg + 1ml/Kg for every Kg )
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27. Estimated ideal body weight or IBW (kg)
Normal maintenance fluid (ml/hour) based on Holiday Segar formula 5 10 20 15 30 60 25 65 70 35 75 40 80 50 90
100
110
120
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28. Dengue with warning signs : 5/3/2
All patients with warning signs should be considered for monitoring in hospitals.
Obtain a baseline HCT before fluid therapy.
Give crystalloids solution (such as 0.9% saline).
Start with 5–7 ml/kg/hour for 1–2 hours, then
reduce to 3–5 ml/kg/hr for 2–4 hours, and
then reduce to 2–3 ml/kg/hr or less according to the clinical response.
If the clinical parameters are worsening and HCT is rising, increase the rate of infusion.(7 mls/5/3/2)
Reassess the clinical status, repeat the HCT and review fluid infusion rates accordingly.(during critical phase, review every 4 Hly, monitoring VS 2 Hly)
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35. Pearls of management
Dengue patient may bleed during febrile phase. For instance : UGIB In particularly in patient who has pre-existing PUD, is taking anti-platelet / NSAID
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37. Pearls of management Good triaging system ED & OPD
To determine whether urgent attention is required
Triage Checklist (TO BE SEEN STAT)
Warning signs
Vital parameters not stable
VS to be taken: Mental state, BP, pulse, temp., cold or warm peripheries
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38. Pearls in management Take good history on medical illness :
eg: DM / CCF / HPT
Take BP/PR / Pulse volume / RR
Good documentation
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40. How to prevent death Early recognition of dengue
Identification of clinical problems in different phases of dengue
Early recognition of dengue warning signs
Early recognition of shock
Early recognition of occult bleeding
Recognition of comorbidities and its complications
Look out for atypical presentations of dengue
Early notification
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41. THANK YOU ND
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