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

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FEBRILE PATIENT

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

WHEN PATIENT AFEBRILE

• Critical phase
• 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

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• Day of the illness ?
• Evidence of plasma leakage ?
• Convalescent rash ?

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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

Dengue Fever

D4 without Fever

D3 with Fever

WBC

<5000/mm³

N-40% L-58%

TT + ve

Hct

%

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?

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

CLINICAL PARAMETERS

HCt

Urine output

(based on IBW)

General condition

Appetite

Vomiting

Bleeding

Peripheral Perfusion

Pulse volume

Skin colour� Skin Temp.� CRFT

Fluid Therapy

PR

RR

BP/PP

CLINICAL SCENARIO

• 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

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

Decision

Blood Transfusion

SCENARIO

Afebrile patient

• Puffy eyelids
• Distended

abdomen

• Tachypnea
• Dyspnoea
• orthopnea
• Respiratory

distress

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

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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