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
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
• Day of the illness ?
• Evidence of plasma leakage ?
• Convalescent rash ?
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
D4 without
Fever
D3 with Fever
WBC
<5000/mm3
N-40% L-58%
TT + ve
Hct
%
HOW TO TIME THE ONSET OF CRITICAL
PHASE?
17th
8 am
D3
18th
8 am
D4
18th
8 pm
D4
19th
8 am
D5
19th
8 pm
D5
20th
8 am
D6
20th
8Pm
D6
21st
8 am
D7
21st
8 pm
D7
WBC 3200 2800 1900 2900 3700 4500 6000 7000 7300
N % 53 41 31 26 25 31 33 43 58
L % 44 56 68 71 73 67 66 55 41
PCV
%
39 36 39 42 43 39 44 43 38
Plt 25200
0
12100
0
11000
0
61000 22000 18000 12000 8000 19000
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
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