Managing DHF in children: pitfalls & challenges

Prof D.P S GunasekeraMBBS,MD, FRCP,FSLCP

10th Annual Academic Sessions, USJPApril 2015

What are the challenges?Is it viral fever OR Dengue fever?

Clinical features

High remittent fever

Severe arthralgia

Headache (retro-orbital)

Flushing of face

Pics –flushed face, petecahe

What are the challenges?In diagnosis

Is it viral fever OR Dengue fever?

Diagnostic tests help – Dengue Ag test(NS1)

Dengue Ab test

Dengue fever - simple Dengue fever?

OR DHF?

DF or DHF ?Clinical features

Warning signs

Ill looking – severe arthralgia

Headache (retro orbital)

Vomiting

RHC pain & tenderness (hepatomegally +)

Drowsy/ irritable/confused

Dizziness +

Bleeding from sites – petechae, gum bleeds, coffee ground vomitus

Deteriorates when fever settles

DF OR DHF?Warning signs

signs of circulatory compromise

Low volume pulse, colds peripheries

HR ↑

Pulse pressure ↓ (<20mmHg)

CRT > 2 sec

UOP ↓

Ix – HCT > 20% rise: pitfall- what is baseline HCT?

If DHF → SHOCK/ NON SHOCK ?

What is the baseline HCT?

DHF – what stage? Febrile phase – 2-7 days

Critical phase – 48 -72 hours (leaking +)

Convalescent phase

Clinical course of DHF

Source : WHO

In ManagementKey issues

Know clinical sequence of events

Meticulous monitoring in critical stage

replace lost fluid:

rapidly & adequately know when to stop!

*Do not overload*

Mx – critical phase Pitfalls – erratic rate of leakage

rapid leakage – in first 24 hours

extravasation of fluid –

into pleural &peritoneal cavities

Patient ay remain

conscious

Mx- critical phase (cont) METICULOUS monitoring

RAPID replacement with IV fluid

ADJUST IV fluid rates : (M + 5%) ↑↓

Give ISOTONIC solution (Normal saline)

Give colloids (Dextran 40) on time

CHALLENGE Too much fluid → more extravasation→

later→ pulmonary oedema

Too little fluid → shock

Challenges : critical phaseHaemorrhage Massive, concealed H’age

Pitfalls: hypovolemic changes already there

HCT already high → may not show classic ‘Low’

signs of H’age→ HR↑, systolic BP↓,M. acidosis +

Look for ‘drop’ in HCT

Replacement with Dextran - 40 bolus → reduces HCT by 10 (max)

Dengue Shock Syndrome(DSS)Management -

RAPID replacement of fluid:

10ml/kg IV bolus of N. saline

If no improvement → Dextran 40(10ml/Kg/hr)

If no improvement → LOOK for concealed H’age

Challenge

timely detection & Rx

Challenges in DSS early detection vital

Rapid replacement of fluid/blood

Prolonged shock → metabolic acidosis

organ dysfunction

liver failure, ARF, DIC

myocarditis

dengue encephalopathy

Convalescent Phase Clinical Improvement

Convalescent rash

Reabsorption of leaked fluid

Circ. Signs reversed -

HR↓

Pulse Pressure wide

CRT < 2 secs

UOP ↑

Challenges:Convalescent Phase

Risk of pulmonary oedema

Continue monitoring - HR↓, HCT↓, wide PP

Look for signs of pulmonary oedema -

Cough, RR↑, lungs – rhonchi & crepts

STOP IV fluid

Furosemide IV SOS only

ConclusionKey to success in Mx –

Know clinical sequence

Timely detection of leakage/shock

Meticulous monitoring – critical stage

Adequate replacement with IV fluid

Timely blood Txn

Rx associated problems – Met acidosis

hypocalcaemia

hypoglycaemia

Stop fluid at Convalescence

Thank You