MANAGEMENT OF

DENGUE FEVER
PROF. S.SHIVAKUMAR, PROF. S.SHIVAKUMAR, M.D.,( M.D.,(Gen.Med Gen.Med) FRCP( ) FRCP(Glasg Glasg) )
PROFESSOR & HOD OF MEDICINE ( PROFESSOR & HOD OF MEDICINE (Retd Retd.) .)
GOVT.STANLEY MEDICAL COLLEGE & GOVT.STANLEY MEDICAL COLLEGE &
HOSPITAL, CHENNAI. HOSPITAL, CHENNAI.
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Dengue fever Fever / Headache /
Myalgia
Dengue
Hemorrhagic
Above +
Thrombocytopenia +
CLINICAL MANIFESTATIONS CLINICAL MANIFESTATIONS
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Hemorrhagic
Fever
Thrombocytopenia +
Spontaneous Bleeding +
Plasma leakage
Dengue Shock
syndrome
Above + shock
GRADING OF SEVERITY GRADING OF SEVERITY
DF DF Headache, Headache, retroorbital retroorbital pain, pain, Myalgia Myalgia
DHF I DHF I Above signs + positive tourniquet test Above signs + positive tourniquet test
DHF II DHF II Above signs + Spontaneous bleeding Above signs + Spontaneous bleeding
DHF III DHF III Above Signs + Circ. Failure Above Signs + Circ. Failure
DHF IV DHF IV Profound shock Profound shock DSS DSS
Lab. DHF Lab. DHF Thrombocytopenia, Thrombocytopenia, Hct Hct 20% 20%
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DISEASE COURSE DISEASE COURSE
Febrile phase 2 Febrile phase 2--7 days 7 days
Afebrile Afebrile phase 2 phase 2--3 days 3 days
(critical phase) (critical phase)
Convalescent phase Convalescent phase
Pathogenesis of DHF Pathogenesis of DHF
Capillary leak Capillary leak
Thrombocytopenia Thrombocytopenia
DIC DIC
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INVESTIGATIONS INVESTIGATIONS
Confirm Confirm diagnosis diagnosis of of DF DF
Thrombocytopenia Thrombocytopenia (< (< 100 100,,000 000/c /c..mm) mm)
Evidence Evidence of of plasma plasma leakage leakage due due to to increased increased
capillary capillary permeability permeability
>>20 20%%rise rise in in Hct Hct >>20 20%%rise rise in in Hct Hct
>>20 20%%drop drop in in Hct Hct following following treatment treatment
Signs Signs of of plasma plasma leakage leakage pleural pleural effusion, effusion, ascites ascites,,
hypoproteinemia hypoproteinemia
Evidence Evidence of of blood blood loss loss Hct Hct Hb Hb
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TREATMENT OF DF/ DHF TREATMENT OF DF/ DHF
Febrile Febrile phase phase
Bed Bed rest rest
Paracetamol Paracetamol 44 times/day times/day
Avoid Avoid Aspirin Aspirin && Brufen Brufen
Avoid Avoid antibiotics antibiotics Avoid Avoid antibiotics antibiotics
Oral Oral Rehydration Rehydration therapy therapy fluid fluid loss loss due due to to
vomiting / high temp. (2.5 vomiting / high temp. (2.5--4 4 litres litres /day) /day)
Afebrile Afebrile phase phase -- observe observe
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DHF (GRADE I & II) DHF (GRADE I & II)
Febrile Febrile phase phase
as as for for dengue dengue fever fever
Afebrile Afebrile phase phase
Initiate Initiate IV IV fluid fluid therapy therapy ((66ml/kg/Hr) ml/kg/Hr) Initiate Initiate IV IV fluid fluid therapy therapy ((66ml/kg/Hr) ml/kg/Hr)
Crystalloid Crystalloid solution solution (GNS/RL) (GNS/RL) 11 -- 22 hrs hrs
Improvement Improvement
Reduce Reduce fluid fluid therapy therapy ((33ml/kg/Hr) ml/kg/Hr) 66 --12 12
hrs hrs discontinue discontinue after after 24 24 Hrs Hrs
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Contd.. Contd..
No Improvement No Improvement
Increase fluid therapy crystalloids Increase fluid therapy crystalloids
(10ml/kg/Hr) for 2 Hrs (10ml/kg/Hr) for 2 Hrs
Improvement Improvement Improvement Improvement
reduce fluids 10ml reduce fluids 10ml 6ml 6ml 3ml/kg/Hr 3ml/kg/Hr
discontinue after 24 discontinue after 24 --48 hrs. 48 hrs.
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No improvement/ unstable vitals No improvement/ unstable vitals
Hct Hct -- IV IV colloids colloids ((Dextran Dextran 40 40)) or or plasma plasma
10 10 ml/kg/hr ml/kg/hr
Hct Hct -- Blood Blood Transfusion Transfusion ((10 10ml/kg/hr) ml/kg/hr)
Platelets Platelets <<5000 5000cu cu..mm mm-- platelet platelet transfusion transfusion
Improvement Improvement crystalloid crystalloid as as above above
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DHF DHF
CRYSTALLOIDS 6ml/kg/hr Improvement 3ml/kg/hr CRYSTALLOIDS 6ml/kg/hr Improvement 3ml/kg/hr
(RL/DNS) (RL/DNS)
Discontinue after Discontinue after
66--12 hrs 12 hrs
CRYSTALLOIDS CRYSTALLOIDS 6ml/kg/hr No Improvement 10ml/kg/hr 6ml/kg/hr No Improvement 10ml/kg/hr
No No Improv Improv
ment ment ment ment
Plasma ( Plasma (Hct Hct))
Blood ( Blood (Hct Hct))
Improvement Improvement
Crystalloids Crystalloids
Discontinue 10 Discontinue 10--66--3ml 3ml
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AFEBRILE AFEBRILE PHASE PHASEshock shock // Oliguria Oliguria
Immediate Immediate rapid rapid volume volume replacement replacement
Crystalloid Crystalloid solution solution 10 10--20 20ml/kg/Hr ml/kg/Hr
Improvement Improvement
DENGUE SHOCK SYNDROME DENGUE SHOCK SYNDROME
Improvement Improvement
Reduce Reduce fluid fluid 20 20--10 10ml/kg, ml/kg, 10 10--66ml/kg ml/kg
66--33ml/kg ml/kg
Discontinue Discontinue 24 24--48 48 hrs hrs later later
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Contd.. Contd..
No improvement No improvement -- Oxygen therapy Oxygen therapy
Hct Hct -- IV Colloid ( IV Colloid (Dextran Dextran ) or Plasma ) or Plasma
10ml/kg/HR as IV bolus 10ml/kg/HR as IV bolus
HCt HCt Blood transfusion(10ml/kg/Hr) Blood transfusion(10ml/kg/Hr)
Improvement Improvement -- crystalloid as above crystalloid as above
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DSS DSS
CRYSTALLOIDS Improvement Reduce CRYSTALLOIDS Improvement Reduce
(10 (10--20 ml/kg/hr) 20 ml/kg/hr) 10 10--66--3 ml/Kg/hr 3 ml/Kg/hr
CRYSTALLOIDS No Improvement CRYSTALLOIDS No Improvement Blood ( Blood (Hct Hct ))
Plasma ( Plasma (Hct Hct )) Plasma ( Plasma (Hct Hct ))
CRYSTALLOID CRYSTALLOID
10 10--66--3ml 3ml
Discontinue Discontinue
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SUMMARY OF TREATMENT SUMMARY OF TREATMENT
OF DHF OF DHF
Cases Cases of of DHF DHF should should be be observed observed every every hour hour..
Serial Serial platelet platelet && Hematocrit Hematocrit determination determination
necessary, necessary, drop drop in in platelets platelets && rise rise in in HCt HCt are are
essential essential for for diagnosis diagnosis of of DHF DHF..
Timely Timely IV IV therapy therapy crystalloid crystalloid solution solution can can Timely Timely IV IV therapy therapy crystalloid crystalloid solution solution can can
prevent prevent shock shock and/or and/or lessen lessen its its severity severity..
If If the the patients patients condition condition worsen worsen after after giving giving
20 20ml/kg/HR ml/kg/HR for for one one hour, hour, replace replace crystalloid crystalloid
solution solution with with colloid colloid solution solution such such as as dextran dextran or or
plasma plasma.. As As soon soon as as improvement improvement occurs occurs replace replace
with with crystalloid crystalloid..
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Cont Cont
If If improvement improvement occurs, occurs, reduce reduce the the speed speed from from 20 20 ml ml to to
10 10 ml, ml, then then to to 66 ml ml and and finally finally to to 33 ml/kg ml/kg..
If If Hct Hct falls, falls, give give blood blood transfusion transfusion 10 10/ml/kg /ml/kg and and then then give give
crystalloid crystalloid fluid fluid at at the the rate rate of of 10 10 ml/kg/Hr ml/kg/Hr.. For For severe severe
bleeding bleeding give give 20 20 ml/kg ml/kg for for two two hours hours..
In In case case of of shock, shock, give give oxygen oxygen.. In In case case of of shock, shock, give give oxygen oxygen..
For For correction correction of of acidosis, acidosis, use use sodium sodium bicarbonate bicarbonate..
Do Do not not use use antibiotics, antibiotics, aspirin, aspirin, brufen brufen and and steroids steroids..
Change Change of of fluid fluid therapy therapy should should not not be be drastic drastic..
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