Complication of Fluid overload in

Dengue shock Syndrome

(2 Case reports)

K.C.Rithea, P.C.Sokhamony, Ng.Watnak

Lorn try Patrich,MD, DES, AFSA, DCH, DHM
A/Prof.of Pediatric, SHU, IU
Kg-Cham Provincial Hospital
 Abstract
Improper diagnosis and triage of dengue—delayed diagnosis of dengue and/or severe dengue,
Improper management of shock lead complication fluid overload.
Case report: -A-11-years-old children female was admitted in emergency room of Pediatric ward in
Kampong-Cham Provincial hospital on 23.Sep.2018 with 5 days of fever and warning signs
abdominal pain, vomiting and Shock. She received 1500 ml IV fluid in 3 days before admission. She
presented WBC=4700/mm3,Platelet=35000/mm3 ,Ht=52% ,ALAT=139/ASAT=54,
Alb=36g/l,PT=14.1,aPTT=57, ANR=1.06. She received IV fluid NSS0.9% , Dextran 40, transfusion
PRC, Correct acidosis, Blood sugar, Calcium and Vitk1.
Conclusion :Puffy eyelids, very distended abdomen Dyspnea/ Tachypnea Positive lung signs:
crepitation, wheezing, rhonchi was the early sign of fluid overload. Detect and correct common
complications: ABCSF: acidosis, bleeding, hypocalcemia, hypoglycemia and fluid overload if the lab
no available. Late presentation in shock and patients with complications (organ involvement, fluid
overload)
Key-words : Dengue shock Syndrome, Fluid Overload, Improper diagnosis and management
Trend dengue in 2007,2012 and 2019 at Kg-
cham Provincial Hospital (Pediatric ward)
Chart Title
700
653
600

500

400 407
381
355
300 291

223 219 226

200 188
153
120
100 91 91
79
41 52
28 18
20 34 15
36
23 28
0 11
3 1 12 6 14
4
Jan Feb March Apr May Jun jul Aug Sep Oct Nov Dece
2007 2012 2019
Introduction
• Dengue is a major problem worldwide, and improving case
management is a significant priority.
• Improper diagnosis and triage of dengue—delayed diagnosis of
dengue and/or severe dengue.
• During the critical stage, there is an increase in capillary permeability
and shock can result if a large volume of plasma is lost through
leakage. The recommended regimen for the treatment of DSS is:
immediate and rapid replacement of the plasma loss.
Introduction
• Improper recognition and management of plasma leakage—delayed
fluid resuscitation, fluid overload
• Fluid overload is a significant contributor to morbidity and mortality,
and balancing parenteral fluid therapy at a level just sufficient to
maintain cardiovascular stability and critical organ perfusion during
the phase of vascular leakage requires considerable skill and
experience.
• In hyperendemic regions, where many DSS cases may present each
day, identification of patients with profound leakage early in the
course of shock could facilitate more effective use of limited
resources.
Objectives
• Understand early signs of fluid overload
• Describe management of fluid overload in critical phase and in
reabsorption phase
Case report
Case 1
Patient Profile : PLD age 11 years female from Prekrolous village Commune Prek
bak , Stung trang District, Kampong-Cham Province admitted on 23.09.2018 for
shock
• Presenting History
• Presents with 5 days history of
• Fever
• Abdominal pain
• Vomiting
• Loss appetite
• Iv fluid at private 1500 ml/3days
 Past medical History
- DHF last year
- No long-term medications/drug use

• Examination
• Weight= 17,5 kg, Height = 112 cm
• T = 36°C, pulse : weak, cold extremity, CRT>3 ‘’
• BP 70/60 mmHg,
• HR 100/min
• Vomiting
• Lethargic
• Anorexia
• Abdomen : distension
• urine : No urine output >4 hours
Blood results on admission
• Ht= 52% Calcium=5.9 mg/dl (8.1-10.4)
• WBC= 4700/mm3 Sodium = 136
• Blood group =B Potassium= 4.7
• Platelet = 35 000/mm3 Chloride =98
• PT= 14.1 (12-16) Creatinine=0.57/dl (0.5-0.9)
• aPTT=57 (24-36)
• INR= 1.06(0.9-1.3)
• Glycemia= 162 mg/dl
• AST = 139, ALT= 54
• Albumin= 36 mg/l (38-51 )
• CRP Negative
Date Time BP T PR RR Hct Rx S&S

23 18.35 70/60 36 weak 24 52 SSN 0.9% 340 ml in 2 hour(10ml/kg/h),02

Sep

20.35 90/60 36 120 26 37 0.9% NSS 200ml in 2 hour (6 ml/kg/h)

22.35 10/60 36 120 26 0.9% NSS 200ml in 2 hour (6 ml/kg/h)

00.35 10/7 36 124 28 0.9% NSS 200ml in 2 hour (6 ml/kg/h)

2 .35 90/70 36 1weak 30 46 Dextran 40 170 ml ( 10ml/kg/hr) in 1hour

18 .35 – 2.35 = 340+200+200+ 170 = total 910 ml urine = 150 ml (1.10ml/kg/hr)

24/sep 3.35 90/60 120 30 Abdominal distension,agitation

0.9% NSS 200ml in 2 hour (6 ml/kg/h)
5.30 100/80 36 weak 35 44 Abdominal distension,agitation,urine 50 ml,melena
Transfusion PRC 100ml
6.30 100/80 36 138 F 30 51 Na Bicarbonate ,Cal,Glucose,Vit k1 ,02, Urine= 40 ml,
0.9% NSS 270ml in 2 hour (8 ml/kg/h)

8.30 100/80 36 week 40 51 Puffy eylids, tarchypnea, spnea,abdominaldistension

Dextran 40 170ml (10ml/kg/h) 30 mn Furosemide 1mg/kg IV
 Date Time BP T PR RR Hct Rx S&S

24 9h30 100/90 36. 120 48 Puffy eylids, tarchypnea,

Sep
Intake in 8 hr = 200 + 270 +170+170= 810 ml
tarchypnea,abdominaldistension
Dextran 40 170ml (10ml/kg/h) 30 mn Furosemide
1mg/kg IV
Urin =110cc
Urine = 160 ml :1.20ml/kg/h(with stool melena)

10.30 100/80 36 130 42 48 Puffy eylids, tarchypnea, tarchypnea,

abdominaldistension Na Bicarbonate ,Cal,Glucose,Vit
k1 ,02, Urine= 40 ml, 0.9% NSS 270ml in 2 hour (8
ml/kg/h)

12.30 120/80 36 120 Puffy eyelids, coughing,Abdominal distension

Furosemide 1mg/kg IV
SSN 0.9% 1.5 ml/kg/h

16.30 110/80 36 110 40 Furosemide 1mg/kg IV

SSN 0.9% 1.5 ml/kg/h

110/70 37 100 28 40 Furosemide 1mg/kg IV

20.30 SSN 0.9% 1.5 ml/kg/h
Lab Monitor
23/09 25/09 26/09 27/09
Calcium 5.9 7.4 7.6 7.5
sodium 136 132 131 131
potassium 4.7 3.5 2.5 2.7
Glucose random 162 82 106
Case2 :A 7 years old Female 18 kg Admission PediED, Kg.Cham
Provincial Hospital on 21.05.2019 at 9.40 AM from Koh sotin
District, Kg.Cham Provincial

• Present History:
• 4 days of Fever
• Abdominal pain
• Vomiting 3 times
• IV fluid 5 bottles (500ml)/2 days before arrive)
• Past History
• No Disease
On 21.05.2019 at 9.40 AM
Examination
• Pulse=100/mn, Temp=37oc,BP=90/60cmHg,Sato2=98% room air,
RR=22/mn ,Weight=18 kg.
• Abdomen: Soft and non tender but pain, No mass, No Hepatomegaly,
No stool
• Lung : clear
• H S1 S2 no murmurs
• Neurology: Consciencious normal
Lab results

D4 of illness
WBC 4700
HCt 44
Platelet 152000
CRP 6mg/dl
Glycemia 89 mg/dl
Management (at 9.40 AM)
• IV fluid D5.1/2S in 20 drop/mn (3ml/kg/h)
• ORS
• Paracetamol (500 mg)1/2x4 time/day if Temp>38 0c
At 8 PM
BP= indetectable, Pulse indetectable, Cold extremities, RR=30/mn
Ht=56%
Summary Lab
21.05.19 WBC=3700/mm3,Platelet=129000/mm3,Glycemia=146/dl
22.05.19 WBC=14000/mm3,Platelet=64000/mm3
AST=197,ALT=94
Albuminemia=23 mg/l (38-51)
Cal=7.5mg/dl
Management (8 PM)
• NSS 180 ml(10ml/kg) Bolus
• At 9 PM Pulse weak, BP indetectable, No Extremity, No Urine output
Voluven 180 ml(10ml/Kg/h) (1 dose)
• At 10PM Pulse restore, BP=10/7,Ht= 41%
NSS 40 drop/mn(6 ml/kg/h)
• 22.05.19 (7 AM)
• Cold extremity
• Pulse weak
• Abdomen distension
• BP 9/7.5,RR= 32/mn, urine output=300ml/12h(1.38ml/kg/h) ,Ht=60%
Voluven 180 ml (10ml/kg/h)( 2 ed Dose)
• At 8AM(22/05/19)
Pulse restore,Abdominal Distension, BP=100/75,RR=36/mn,Ht=56%,
NSS 180 ml(10ml/kg/h),Cal1o%5 ml IV,Vitk1 5mg IV,Bicarbonate de
sodium 8.4% 10 ml IV
NSS 300 ml (8ml/kg/h) 2 hours
• At 4 PM(22/05/19)
BP=100/70, Pulse recordable, Abdominal Distension , RR=48/mn
Urine Output=50ml/8 h(0.35ml/kg/h)
Continuous the same drop for 2 hours
• At 6 PM Abdominal Distension, RR=40/mn, No crepitation ,BP=90/65
Decrease drop (6ml/kg /h) for 3 hours)
At 9 PM: BP=90/70,Pulse weak, Abdominal Distension, RR=40/mn
Urine output=100cc/8h(0.69ml/kg/h)
Voluven 180 ml(10ml/kg/h)
At 10 PM
BP=90/60, Abdominal distension, RR=48/mn No crepitation
No urine output
Continuous NSS 6ml/kg/h for 3 hours
At 1 AM (23/05/19)
Pulse recordable, BP= 90/60 Abdominal Distension, No urine output
Continuous NSS 3 ml/kg/h for 3 hours
• At 4 AM (23/05/19) Puffy eyelids, distended abdomen
,tachypnea,Caugh (RR=52/mn,BP=120/80, No Urine output)
pleural effusions, tense ascites, agitation, confusion
Furosemide 20 mg IV
NSS 0.9% 1.5 ml/kg/h,Oxygen mask
At 4.30AM urine=400ml
At 5 AM Urine output = 600 ml (under Furosemide, keep the rate
1.5ml/kg/h), Ht= 40%,BP=90/60
On 24.05.19 Start Appetite, BP=10/60, good urine output, No
tachypnea
Lung No sound
Discharge on 25.05.19
Discussion
The most common complication in DHF/DSS is fluid overload.
• Early signs and symptoms: Puffy eyelids, distended abdomen
(ascites), tachypnea, mild dyspnea.
• Late signs and symptoms: All of the above, moderate to severe
respiratory distress, shortness of breath, wheezing (not due to
asthma) is an early sign of interstitial pulmonary edema and
crepitation, restlessness/ agitation and confusion are signs of hypoxia
and impending respiratory failure.
Discussion
Causes of fluid overload
• Early inappropriate IV fluid in the early febrile phase.
• Use of hypotonic solutions (Dextrose ½ saline, Dextrose 1/3 saline)
• Continuation of IVF after plasma leakage has resolved
• Not giving blood transfusion when there is concealed bleeding and
continue giving crystalloid and colloid solutions.
• Not calculating amount of IV fluid according to ideal Body Weight in
obese/overweight patient.
• Not stopping IV fluid when entering convalescence period.
• Not using colloidal solution when indicated
• Co-morbid conditions such as congenital or ischaemic heart disease,
chronic lung and renal diseases
Conclusion
Detect and correct common complications
• A – Acidosis – Prolonged shock with possible liver/ renal/ respiratory
failure
• B – Bleeding – No rising Hct or dropping Hct
• C – Hypocalcemia and other electrolyte imbalance (Hypokalemia,
hyponatremia)
• S – Hypoglycemia (30% in DSS)
• F - Fluid overload – Signs & symptoms of fluid overload or persistent
high Hct > 25%
Conclusion
Case 1: Fluid overload with Dengue shock syndrome
Dextran + furosemide (in the middle or after 10-15 mins)
• Shock
• During critical period,
• Not in reabsorption phase
Case 2: Fluid overload in reabsorption phase
Only use Furosemide
References
1. Siripen Kalayanarooj, Alan L. Rothman,and Anon Srikiatkhachorn, Case Management of Dengue:
Lessons Learned , The Journal of Infectious Diseases, SUPPLEMENT ARTICLE, Case Management
of Dengue • JID 2017:215 (Suppl 2) • S79
2. Cambodia National Guideline for Clinical Management of Dengue,Ministry of Health, 2018,version3
3. Professor Siripen Kalayanarooj , Best Practice: Critical Management & Care of Dengue Patients in
ICU
4. Clinical Practice Guidelines of Dengue/Dengue Hemorrhagic Fever Management for Asian Economic
Commun, September 2014
5. Bridget Wills, Volume Replacement in Dengue Shock Syndrome , Dengue Bulletin – Vol 25, 2001 .
6. NGUYEN THANH HUNG,* NGUYEN TRONG LAN, HUAN-YAO LEI, YEE-SHIN LIN, LE BICH LIEN,
VOLUME REPLACEMENT IN INFANTS WITH DENGUE HEMORRHAGIC FEVER/DENGUE SHOCK
SYNDROME, Am. J. Trop. Med. Hyg., 74(4), 2006, pp. 684–691 Copyright © 2006 by The American
Society of Tropical Medicine and Hygiene.
7. Adisorn Wongsa, FLUID AND HEMODYNAMIC MANAGEMENT IN SEVERE DENGUE, Vol 46
(Supplement 1) 2015
8. Verdeal JCR, Costa Filho R, Vanzillotta C, Macedo GL, Bozza FA, Toscano L et al, Guidelines for the
management of patients with severe forms of dengue, SPECIAL ARTICLE, Rev Bras Ter Intensiva.
2011; 23(2):125-133
THANK FOR
YOUR
ATTENTION