MANAGMENT OF DF AND DHF

"IT GIVES INSIGHT INTO CLINICAL MANAGMENT OF DENGUE FEVER AND DENGUE HEMORRHAGIC FEVER."

DURING FEBRILE PERIOD:

NO NEED TO REFER TO TERTIARY CARE HOSPITAL UNTIL THERE IS SOME ASSOCIATED CONDITION WHICH WARRANTS IT.

ANAEMIA AND THROMBOCYTOPENIA MAY BE PRESENT IN CHRONIC DISEASES.

PROPER HISTORY AND CLINICAL EXAMINATION

NO NSAIDS LIKE BRUFEN OR ASPIRIN DURING ANY PHASE OF DENGUE FEVER.

1. BED REST

2. FOR FEVER ONLY PARACETAMOL, AS AND WHEN REQUIRED BUT DO NOT REPEAT THE DOSE BEFORE 6 HOURS.

3. SPONGING, WITH TAP WATER.

4. INCREASE ORAL FLUID INTAKE, LIKE LEMON WATER –SHAKANJABEEN, ORS ETC BUT THERE IS NO SPECIAL ROLE OF FRESH APPLE JUICE, POMEGRANADE JUICE, SUGAR CANE JUICE OR PAPEETA LEAVES.IF YOU WANT TO USE IT USE ONLY GOOD QUALITY PACKED JUICES BECAUSE THEY ARE STERILIZED.

5.IF THERE IS VOMITING OR PATIENT IS UNABLE TO TAKE ORALLY THEN THE I/V RINGER LACTATE 500ML IN 4 HOURS SHOULD BE GIVEN.

MONITORING DURING FEBRILE PHASE

ON FIRST DAY OF FEVER               BP PP TEMP HB TLC DLC HCT PLATELET COUNT FOR COMPARISON AND TO RULE OUT BACTERIAL INFECTION.

ON 2^ND AND 3^RD DAY               BP PP TEMP SIGNS OF DEHYDRATION

ON FOURTH DAY

IF NOT AFEBRILE THEN
ASK FOR URINE C/E, CBC ,TYPHIDOT AND BLOOD FOR MP
IF AFEBRILE THEN
IN PATIENTS WITH NORMAL BP PP        ASK ONLY FOR CBC AND FOLLOW UP
IN PATIENTS WITH LOW BP OR PP < 20MM OF Hg OR VOMITING AND PAIN ABDOMINAL OR INCREASED THIRST WITH LOW URINE OUT PUT ASK FOR CBC AND ABDOMINAL U/S TO RULE OUT OR CONFIRM PLASMA PERITONEAL LEAK OR PLEURAL EFFUSION WHICH IF PRESENT THEN IT IS DHF AND THE PATIENT IS IN CRITICAL PHASE WHICH WILL LASTS FOR 24-48 HRS.NOTE THE TIME OF START AND END OF THIS PHASE.

DURING CRITICAL PERIOD:

TOO MUCH FLUID IS BAD AND TOO LITTLE FLUID IS BAD.ONLY USE RIGHT FLUID IN RIGHT VOLUME AND IN RIGHT TIME.

WHILE GIVING I/V FLUIDS

BE CAREFUL IN
HTN,
CRF,
IHD,
CCF
AND CHILDREN.

RISK FACTORS FOR DHF/DSS

1. REINFECTION WITH A HETEROTYPIC DENGUE STRAIN

2. DHF/DSS IS MORE COMMON IN WELL NOURISHED AND OBESE RATHER THAN MALNOURISHHED.

3. PRIMARY INFECTION IN INFANTS BORN TO DENGUE IMMUNE MOTHERS WITH A HETEROTYPIC DENGUE INFECTION- A PROBLEM TO COME IN FUTURE YEARS.

DO NOT PASS NG TUBE IN PATIENTS WITH PLATELET COUNT LESS THAN 50,000/CUMM

PATIENT SHOULD BE IN HOSPITAL FOR FLUID REPLACEMENT AND MONITORING IN DHF. IN OBESE PATIENTS IDEAL BODY WEIGHT,50KG IS CONSIDERED FOR CALCULATING FLUID REQUIREMENTS.

FLUID USED IS CRYSTALOID SOLUTION 5% DEXTROSE IN 0.9% SALINE IN CHIDREN UNDER 6 MONTHS OF AGE 5% DEXTROSE IN ½ N SALINE IS USED AMOUNT OF FLUID TO BE GIVEN I/V VARIES ACCORDING TO PATIENT,S CONDITION AND ASSESMENT OF DOCTOR INCHARGE.

IN ADULTS IT IS USUALLY 46OO ML IN 48 HOURS i.e 2300 ml in 24 hours or about 1000ml in 10-12 HOURS THAT IS 22 DROPS/MIN WILL DELIVER 100ML IN ONE HOUR.RATE OF INFUSION TO BE ADJUSTED ACCORDING TO PATIENTS CONDITION.

FLUID THERAPY GENERALLY SHOULD NEVER BE CONTINUED AFTER 48 HOURS.

IDEA IS TO KEEP URINE OUT PUT > 0.5 ML/KG/HR.

IF HCT CONTINUES TO RISE AFTER I/V CRYSTALLOIDS THEN IT MEANS THAT CRYSTALLOIDS BEING GIVEN ARE ALSO LEAKING INTO THE THIRD SPACE SO AFTER SECOND BOLUS START COLLOIDS I/V WHICH SHOULD BE DEXTRAN 40% OR 6%STARCH IN BOLUS MAX 3 TIMES.IN THE MIDDLE OF COLLOID INFUSION GIVE LASIX IF FLUID OVERLOAD.

CALCULATING FLUID REQUIREMENT IN DHF PATIENTS.:

½ MANITANANCE	40-50ML/Kg/24HRS
MAINTANANCE	80-100ML/Kg/24HRs
MANTAINANCE FLUID PLUS 5% DEFICIT	100-120ML/Kg/24HOURS.
MAINTAINANCE PLUS	7% DEFICIT 120-150ML/Kg/24HRS

IN CHILDREN:

0-10 KG               100ML/KG/24HRS

10-20 KG        1000 PLUS        50ML/KG/24HR FOR EACH Kg ABOVE 10Kg

20-30KG        1500 PLUS 20ML/KG/24HR FOR EACH Kg ABOVE 20Kg

THEN 10ML/KG/24 HOURS FOR EACH KG MORE THAN 30 KG

UNDER 1 YEAR MAINTAINANCE -- AGE IN MONTHS PLUS 9 DIVIDED BY 2

ABOVE 1 YEAR MAINTAINANCE ----AGE IN Y PLUS 4 MULTIPLIED BY 2

IN SHOCK 500ML IN ½ AND HR AND NEXT 500ML IN NEXT ½ AN HR,MAY BE MORE IF NO CONTRAINDICATION PRESENT.

IN CASE OF SIGNIFICANT BLEEDING REPLACE WITH SCREENED AND CROSSMATCHED BLOOD.

NEGLECT MINOR BLEEDS.

DOPAMINE AND DOBUTAMIE HAVE ROLE IN TREATMENT OF SHOCK IN SPECIAL CIRCUMSTANCES BUT AFTER RESTORING INTRAVASCULAR VOLUME.

WATCH FOR HYPOGLYCAEMIA,HYPONATRAEMIA, HYPOCALCAEMIA AND HYPOKALAEMIA.

GIVE CALCIUM SANDOS INJ 10ML WITH 10ML DEXTROSE SALINE SLOWLY IN INFUSION.

IF KCL IS REQUIRED, NEVER USE IT WITH Ca AS IT PRECIPITATES.

MONITORING

BP        PP        HB        POLY’S        LYMPHOCYTES        HCT        CRFT        RR        UOP        SaO2,

AUSCULTATE LUNG BASES FOR EVIDENCE OF FLUID OVERLOAD.

CHEST X-RAY RT. LATERAL DECUBITUS VIEW.

IN DHF MONITOR THE PATIENT AS

DHF 1AND 2               1 HOURLY

DHF 2 AND 3               ½ HOURLY