Dengue Fever (DF)

 Dengue virus (Flavivirus) transmitted by Aedes aegypti or Aedes albopictus causes

increased permeability of capillaries resulting in leakage of fluid in capillaries.

 Usually leakage is uncommon, 90% of children have DF only.

 When child leaks he leaks into body cavities.

Phases of Dengue

1) Dengue fever in Febrile phase

2) DF with Leakage (Critical) Phase [DHF]
3) DF in Leakage phase + Grade III Shock
4) DF in Leakage phase + Grade IV Shock
5) Recovery phase

Dengue Disease Progression

D1-2; Dengue Fever

D3-4; DF in Leakage Phase

D5; Child usually recovers

1) DF in Febrile phase

 Fever, Myalgia, Arthralgia, retro-orbital pain, bleeding – mucosal bleeding or epistaxis,

PLT<150]

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 FBC – PLT <150, WBC decreased

 Confirm Dengue – a) Dengue Ag - Day 1-5

b) Dengue Ab – D5 onwards
o IG M – Acute Infection
o IG G- Past Infection

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Mx;

 Paracetamol
 Admit child if child is unwell and cannot tolerate oral fluids. He requires IV fluids.
 Temperature chart
 Monitor BP, PR, RR every 4 hourly
 IP/OP Chart
 Oral or IV Fluids - Maintenance ONLY, given over 24 hours

o First 10kgs = 100ml/kg

o Next 10 kgs = 50ml/kg
o >20kg = 20ml/kg

- ORS / other fluids if child if not vomiting

- IV fluids if child is vomiting or can’t take orally

 Repeat FBC next day

 Don’t do vigorous activities .
 Don’t give any reddish or blackish colour drinks like plain tea or coca cola
 Notify about Dengue Pt – Fill the notification form and send to relevant MOH . The MOH
will send relevant PHI for field visit .

2) DF in Leakage (Critical) phase [DHF] but not in SHOCK

 DF features + leakage phase features - Ascites, pleural effusions, pericardial effusions

 Biochemical features - PLT<100, HCT rise by 20% from baseline or HCT>42,
 Ca2+ decreased, Protein (Albumin) decreased, Cholesterol decreased
 BP Normal, PR Normal,

IX
 FBC - PLT <100,
 HCT 20% rise from baseline or >42 (Normal HCT = 35)

 Hypocalcaemia, Hypoalbuminemia, Hypocholesterolemia

 Right lateral decubitus CXR - pleural effusion
 2D ECHO - pericardial effusion
 USS Abdomen - Ascites (check for free fluid in Ab)

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Mx;
 PCM
 Temp chart
 Monitor BP, PR, RR every hour
 IP/OP Chart

 IV Fluids Quota =Maintenance + 5% Deficit given over 48h

o First 10 kgs = 100ml/kg

o Next 10 kgs = 50ml/kg
o Next kg = 20ml/kg
o 5% Deficit = 5% of total Body Wt

- 5% deficit is given due 5% loss of child’s body weight during leakage

phase.
- Fluid Quota is given to avoid fluid overload which will result in heart
failure.
- Fluid quota is one day maintenance + 5% deficit which is given over
48 hours
- Fluid rate is adjusted according to monitoring parameters [HCT,
Pulse, BP, CRT, and UOP]. The best marker to guide fluid rate is
UOP
- UOP must be maintained in a range of 0.5-1 ml/kg/h
- Leakage Phase lasts for 48h

E.g. 30Kg Child’s Fluid Quota

Maintenance = [ (100ml x10) + (50ml x 10) + (20ml x 10) ]

1700 ml
5% Deficit = 30kg x (5/100)
1.5kg (1g = 1ml)
1500ml
Total Fluid Quota = 3200ml over 48 hours

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Q3) DF in Leakage phase + Grade III Shock
 DF Leakage features + Normal BP (SBP Normal, DBP Elevated), PR Increased, Narrow
pulse pressure [Pulse pressure<30 abnormal], CRT > 2 sec

o When child goes into leakage, intravascular volume decreases so circulatory volume
decreases so BP tends to drop. Hence compensatory mechanism occurs to maintain BP.
o First the HR increases to maintain BP. Tachycardia is the first sign child is entering
shock.
o When increased HR is not enough to maintain BP, peripheral vasoconstriction occurs.
This causes DBP to increases and since SBP is normal, Narrow Pulse pressure occurs as a
result. Also CRT is prolonged due to vasoconstriction.

Mx

1) NS Fluid Bolus – 10ml/kg/ over 1 h [bolus is given slowly] {During 1h- have blood crossmatched}

Narrow Pulse Pressure after bolus [No Response]

2) Repeat NS Bolus Dose – 10ml/kg/ over 1 h [bolus is given slowly]

Narrow Pulse Pressure after 2nd bolus [No Response]

3) Give Colloid [Dextran40 / Hetastarch] – 10ml/kg/h {FFP has no place in Mx of Dengue}

HCT decreases HCT decreases HCT Increases No Response to Fluids (3 boluses given)
& Child Improves & Child Deteriorates & Child Deteriorates

Reduce Fluid Rate Child is Bleeding Child is still Leaking Fluid Refractory Shock

Exclude Causes;

Give Blood Transfusion A- Acidosis ----- Ix; Venous Blood Gas

Rx; HCO3-
B – Bleeding---- Usually internal
Bleeding occurs
Repeat Colloid Ix; HCT Decreases
& Child Deteriorates
Rx; Blood Transfusion
C – Ca2+ decreased ------ Ix; Serum Ca2+
Rx; Ca2+
S- Hypoglycemia----------Ix; RBS
Rx; Dextrose

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Anywhere along the pathway, when there’s a response to Rx (i.e. child is recovering), Reduce
(adjust) fluid rate according to monitoring parameters.

4) DF in Leakage phase + Grade IV Shock

 DF Leakage features+ Unrecordable BP, very weak or Unpalpable pulse, cold
peripheries, drowsy child

o If no interventions are done to Grade III shock, the compensatory

mechanisms will fail resulting in unrecordable BP and very weak or
Unpalpable pulse.

Mx

1) NS Fluid Bolus – 20ml/kg/ as rapidly as possible

No Response

2) Give Colloid [Dextran40 / Hetastarch] – 10ml/kg/h

No Response

3) Check HCT

HCT decreases HCT decreases HCT Increases

& Child Improves & Child Deteriorates & Child Deteriorates

4) Reduce Fluid Rate Give Blood Transfusion Repeat Colloid

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DF Recovery Features

1) Child’s appetite improves

2) Pruritus
3) Erythematous rash with white dots [white islands in red sea]
4) Polyuria
5) Relative Bradycardia
6) HCT drops
7) Plt count starts to rise [Best marker of Dengue recovery]
8) WBC count starts to rise [WBC rises first than PLTs]

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 Case Book
A 6 years old child was admitted to Kalubovila hospital from Kirulapone with 3 days history
of fever, gum bleeding. His FBC revealed platelet count of 110 with PCV -35 % .

1.What would you do as the initial assessment ?

History Examination

He is alert,PR -80 bpm, BP -110/70, CRT -2s . His urine output =1 .2cc /kg / h . His body weight
is 35kg.

2. What is your interpretation ?

3.Prescribe the fluid management for this child for next 24 hours

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4.What are the other important management principles ?

4 hours later you found that he is developing a pleural effusion and ascites. PCV -43%

What is the condition that the child is having now ?

5.How do you alter the fluid management at this movement ?

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4 hours later you found that his blood pressure is 100/85mmHg ,PR -115bpm and UOP =0.3
cc/kg / hour

6.How do you manage the child now ?

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Staff has mismanaged the fluid therapy and 2 hours later you found that he is drowsy, blood
pressure unreportable and pulses are not palpable.

7. How do you manage this child ?

8. What are the features of Dengue recovery ?

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MCQ Points

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