Dengue CME.pptx

Editor's Notes

• #2: In Malaysia especially in Klang Valley, dengue infection is one of the most common and important vector borne viral disease transmitted by Aedes Mosquito. Therefore, it is important for primary care physician to be trained in order to make right management and proper monitoring.
• #4: Dengue disease comprises of wide spectrum of clinical manifestation with unpredictable clinical evolution and outcome for example, severe dengue cannot be predicted and can develop with or without warning signs. Therefore, close monitoring is important.
• #5: Basically, dengue infection can be divided into 3 phases that is febrile, critical and recovery phase. Critical phase usually happen after day 3 of febrile illness when the fever starts to settle and lasts for 24-48 hours. Clinical presentation and severity depends on the presence and degree of plasma leakage. It is crucial to identify the critical phase as some dengue patient might deteriorate further during this phase. As it is a dynamic disease and its clinical course changes as the disease progresses, therefore it is important to monitor the clinical presentation and serial full blood count and hematocrit level should be closely monitored.
• #6: Once dengue patient is diagnosed, either suspected or confirmed, we need to decide which phase of the disease the patient is in at that moment that is either febrile, critical or recovery phase.
• #7: During critical phase, those dengue patients with warning signs might progress to severe dengue or shock more rapidly if not identified and treated. Therefore, all patients with warning sign, should be admitted for inpatient management. The warning signs are any abdominal pain or tenderness, persistent vomiting or diarrhea (3 times or more over 24 hours), evidence of 3rd space accumulation such as ascites, pleural and pericardial effusion, spontaneous bleeding tendencies such as epistaxis, and GIT bleeding, lethargy, restlessness and confusion, liver tenderness and last but not least raised hematocrit with rapid drop in platelet. Please be caution that the level of hematocrit may differ between age group and gender.
• #8: After diagnosing patient with dengue, we need to determine the hemodynamic status of the patient and to decide whether the patient is in shock or not. Hemodynamic assessment of the patient can be evaluated by using acronym of CCTVR which is skin color, capillary refill, temperature, pulse volume and pulse rate. In less than 30 seconds, you can tell whether the peripheral perfusion is normal, reduced or very reduced.
• #9: Prolonged capillary refill time of more than 2 second is suggestive of poor peripheral perfusion. Moreover, narrowing of pulse pressure less than 20mmHg is suggestive of shock.
• #10: By assessing the patient’s hemodynamic status, we will be able to identify the compensated shock earlier. Therefore, prompt fluid resuscitation can be started to prevent further progression to decompensated shock.
• #11: Now we move on to monitoring blood test in dengue. There are 3 parameters used for monitoring which are hematocrit, white cell count and platelet count.
• #12: I will explain the changes in blood parameters in the disease progression. White cell count and platelet count are usually within normal limits during early febrile phase. As the disease progresses, the white cell count and platelet count decreases rapidly. The decrease in white cell count is accompanied by platelet reduction. In the recovery phase, the white cell count normalizes followed by platelet count. Always remember, there is no correlation between the disease severity and the platelet count and it is not predictive of bleeding tendency.
• #13: Now we look at hematocrit. The normal hematocrit of males of 60 years and below is 46%. In males above 60 years old is 42% and in females of any age is 40%. Lastly, rising of hematocrit above the normal limit in both males and females is the marker of plasma leakage. Therefore, it is very crucial to monitor serial full blood count and hematocrit in patient diagnosed with dengue.
• #14: After evaluating the patient’s history, doing relevant physical examination and blood investigations, the frontliners should be able to determine the likelihood of dengue infection, identify the phases of dengue fever and the severity of the illness which can be identify from the presence of warning signs, hydration and hemodynamic status of the patient. This will finally helps us to develop a good and safe management decision. In general, management decision can be divided into 3 groups. Group A are among those who can safely be discharged. Group B are high risk patients who have comorbidities and warning signs but no evidence of shock but they should be referred to the hospital as they may deteriorate further. Group C are patients with severe dengue and require emergency treatment and urgent referral and transfer to the hospital.
• #15: Dengue infection is usually treated symptomatically. Frequent monitoring on clinical and serial full blood count and hematocrit level until afebrile for at least 24 to 48 hours without antipyretic is important to recognize early plasma leakage and shock. Advise patient to return to hospital as soon as the warning signs or severe dengue arise.
• #16: Once dengue infection is diagnosed, either suspect or confirmed, notification should be done using e-notification, phone or fax to the nearest district health office within 24 hours. If admission is not indicated, arrange for close follow-up and monitoring. Patient should be admitted if present of warning signs or fulfil any of the admission criteria.
• #18: Home care advice leaflet should be provided to alert patient on warning signs in order to seek early treatment in nearest hospital or emergency department.
• #19: Home care leaflet also provide appropriate advice on what should or should not be done at home. For example, patient should not take any form of oral or injectable NSAIDS or painkiller such as Ponstan or Voltaren as it can aggravate bleeding manifestation in dengue patient. Antibiotics are usually not required as it is a viral febrile illness.
• #20: By prescribing unnecessary antibiotics or NSAIDs, it can cause medication induced warning signs such as epigastric pain or rashes.
• #21: Worst still, the unnecessary use of NSAIDs can induce profuse bleeding tendency in dengue patients.
• #22: Fever clerking sheet should be used for all febrile cases at presentation to identify dengue infection earlier.
• #23: Dengue clerking sheet should be used for all suspected or confirmed dengue cases to avoid missing important history and warning signs. It also help to ensure adequate hemodynamic and clinical assessment.
• #24: Dengue monitoring card should be provided to ensure relevant informations are available for continuity of care by healthcare providers.
• #26: The decision for referral and admission must not be based on single clinical parameters but it should be depends on the total assessment of the patients which includes symptoms, signs and laboratory criteria. The assessment must also consider the high risk cases especially those with specific comorbidities.
• #27: The first symptom that we should elicit is the presence of warning signs.
• #28: We know doctors love mnemonic. Hopefully this mnemonic will help the practitioner to remember better.
• #29: Another important component is to ask these 3 golden questions on input, output and activity of daily living. For input, ask whether they can drink and types of fluid that they are taking. They should be able to take 6 to 8 glasses of fluid per day. For output, quantify the frequency, volume of the urine and time of last voiding. In general, a person should be able to pass urine every 6 hours about 4 to 6 times per day. While for ADL, assess activities the patient can do during febrile illness. Are they just confined to bed due to lethargy or unable to do self care such as eating, drinking or ambulating.
• #30: Next symptom is seizure. It may be due to sign of cerebral hypoperfusion or dengue encephalitis which warrant urgent admission. The history of seizure can be elicited from the eye witness such as family member.
• #31: Apart from warning signs, primary care physician need to identify several high risk group that may make management of dengue more complicated. Hence, this should be consider for early admission. These are presence of comorbids such as diabetes, hpt, IHD, coagulopathy, renal liver or heart failure and COPD. Elderly of more than 65 years old, infant, morbid obesity, patient who are on antiplatelet or anticoagulant, pregnancy, social issue that may limit follow-up example living alone and without reliable means of transport. Last but not least, previous history of dengue infection is also an important factor as it may worsen current condition.
• #32: Now, lets talk about fluid therapy. Fluid therapy which involve oral or IV is the mainstay of therapy in dengue infection. In general, patients without comorbidities who can tolerate orally, adequate oral fluid intake of 2-3 litres daily should be encouraged. For certain group which is group B and C, appropriate intravenous fluid therapy will improve overall clinical outcome. However, caution need to be taken to avoid inappropriate fluid therapy as it may prolong hospitalization and cause fluid accumulation.
• #33: These are 3 groups that require IV fluid therapy. First, patient without warning signs but unable to tolerate orally and there is evidence of hemoconcentration. Two, patient with warning signs but without shock. Three, patient in compensated or decompensated shock.
• #34: This slide shows the fluid regime for patients without warning signs but unable to tolerate orally or has increasing hematocrit trend. By giving maintenance IV fluid of 1.2 to 1.5 ml/kg/hour is indicated. However, for obese and overweight patient, the maintenance can be calculated based on adjusted body weight using above formula.
• #35: Rapid fluid replacement in patient warning signs is the key to prevent progression to shock. In patient with persistent warning signs, the graded bolus maybe initiated with caution. Begin with 5ml/kg/hour of crystalloid solution for 1-2 hours then reduce to 3ml/kg/hour and subsequently to 2ml/kg/hour according to the clinical response.
• #36: Dengue shock syndrome is a medical emergency. Recognition of both compensated and decompensated shock is vital to initiate prompt fluid resuscitation. Do you still remember the clinical features of both? For compensated shock, start fluid resuscitation with crystalloid of 5-10ml/kg/hour for 1 hour. While for decompensated shock, give a bolus of 20mlkg/hour of crystalloid within 15-30 minutes. If the first 2 cycles failed, further bolus of colloids should then be considered.
• #37: This is an important slides. It has been a pitfall in many dengue mortality before. Primary care physician has to ensure all effort must be taken to optimize patient condition before transfer. To communicate with the receiving hospital/emergency department before transfer. Adequate and essential information must be sent together in the referral letter which include fluid chart, monitoring chart and investigation results. Patient who is in shock should be transferred to the nearest hospital by ambulance and should be accompanied by a doctor. To activate emergency medical response, please call 999.
• #38: This is a sample of a good referral letter.