CPG MANAGEMENT OF DENGUE

IN ADULTS
By : Dr Din , KK WCY
Supervisor : Dr Ezani , FMS KK WCY
 “Dengue is one disease entity with
different clinical presentations and
often with unpredictable clinical
evolution and outcome”

Expert consensus groups in Latin America (Havana, Cuba,

2007), (Kuala Lumpur, Malaysia, 2007), WHO headquarters
in Geneva, Switzerland, 2008

CPG Management of Dengue Infection in Adults (3rd Edition)

 Spectrum of dengue infection
• Incubation period : 4-7 days (range 3-14)

• Asymptomatic  undifferentiated mild febrile illness 

severe disease

• Symptomatic dengue infection :

 systemic and dynamic disease
 clinical, haematological and serological profiles
changing from day to day

CPG Management of Dengue Infection in Adults (3rd Edition)

 INTRODUCTION
• “First encounter” at frontline health services:
emergency dept & outpatient clinic setting
• Detection of warning symptoms & signs
• Ensure timely, safe & appropriate
management
• Timely admission for in-hospital care

CPG Management of Dengue Infection in Adults (3rd Edition) 4

 In the course of the disease :
Where is the patient now ?

• Day of fever ?
• Warning signs ?
• Assessment : CCTVR
• Hemodynamic parameters?

• Diagnosis?
Dengue infection +/- warning signs
Which phase ?
Shock/ stable?
Severe dengue?
CPG Management of Dengue Infection in Adults (3rd Edition) 5
Clinical course of dengue infection

CPG Management of Dengue Infection in Adults (3rd Edition)

Febrile phase - 1

Clinical presentation
- Sudden high grade
fever
- Last 2-7 days
- Facial flushing, skin
erythema, generalised
body ache, myalgia,
arthralgia, headache
- Sore throat, injected
pharynx, conjunctival
injection +/-
- Anorexia,nausea,
vomiting
- Mild
CPG Management of Denguehaemorrhagic
Infection in Adults (3rd Edition)
Febrile phase - 2

Diagnostic challenges
• Recognizing dengue
• Sx non-specific
• Mimic many other diseases
& infections ( chikugunya ,
leptospirosis,malaria )

CPG Management of Dengue Infection in Adults (3rd Edition)

Critical phase - 1
When ? Clinical :
Late febrile phase Varying degree of
circulatory
or around
disturbances
defervescence (D3- Lab :
D5 up to D7) • Plt &  HCT
usually detectable
before subsidence
of fever & onset of
shock
• HCT correlates well
How long ? with plasma vol
loss and disease
Lasts 24-48 severity
hours •  AST > ALT

CPG Management of Dengue Infection in Adults (3rd Edition)

 Critical phase - 2

During this phase if,

• Minimal or no plasma • Critical volume of plasma leakage

leakage occurs occurs
– Varying degrees of circulatory
– Patient feels better as the disturbances occur depending
temperature subsides on the degree of plasma
– Dengue fever without leakage
warning signs – Dengue fever with warning
signs/Dengue shock syndrome

11
CPG Management of Dengue Infection in Adults (3rd Edition)
 Critical phase - 3
Shock- occurs when a critical volume of plasma is lost through
leakage
– Often preceded by warning signs

CPG Management of Dengue Infection in Adults (3rd Edition)

Recovery phase - 1
When ?
48–72 hours after critical
phase
What happens ?
Gradual reabsorption of
extravascular compartment
fluid
General well-being improves
Appetite returns
GI symptoms abate
Haemodynamic status, HCT
stabilizes Diuresis ensues
WBC recovery followed by
platelet CPG Management of Dengue Infection in Adults (3rd Edition)
 Recovery phase - 2
 Herman’s rash- “isles of
white in the sea of red”

 HCT stabilizes/lower due

to the dilutional effect of
reabsorbed fluid

 WBC soon after

defervescence while the
recovery of platelet count
is typically later than that
of WBC.

CPG Management of Dengue Infection in Adults (3rd Edition)

PATHOPHYSIOLOGY OF PLASMA LEAKAGE
IN SEVERE DENGUE INFECTION
• Acute increase in vascular permeability leads
to leakage of plasma into the extravascular
compartment  resulting in
haemoconcentration and hypovolaemia or
shock Hypovolaemia leads to reflex
tachycardia and generalised vasoconstriction
due to increased sympathetic output If the
hypovolaemia is not corrected , the patient
will progress to a refractory shock state.
Clinical manifestations of vasoconstriction in various
systems are as follows:
• Skin - coolness, pallor and delayed capillary refill time
• Cardiovascular system - raised diastolic blood
pressure and a narrowing of pulse pressure
• Renal system - reducing urine output
• Gastrointestinal system - persistent vomiting,
persistent diarrhoea and abdominal pain
• Central nervous system – lethargy, restlessness,
apprehension, reduced level of consciousness
• Respiratory system – tachypnoea (respiratory rate
>20/min)
 •Lethargy
•Restlessness
•Apprehension
•Reduced level of • ↑dBP
consciousness • narrowing of
pulse pressure
tachypnoea
•Vomiting
•Abdominal pain
•Coolness
•Tender enlarged
•Pallor
•Delayed capillary liver
refill time
•Poor pulse volume

↓↓ urine output
Clinical manifestation of
vasoconstriction

CPG Management of Dengue Infection in Adults (3rd Edition)

Frontline Evaluation

CPG Management of Dengue Infection in Adults (3rd Edition) 18

Frontline Evaluation

CPG Management of Dengue Infection in Adults (3rd Edition) 19

Hemodynamic Assessment - Clinical Parameters
Parameters

Conscious
level 3a. Organ perfusion (brain)
Capillary
refill time
Extremities
(color, temp) 1. Peripheral perfusion
Peripheral
pulse
volume
Heart rate
(HR)
Pulse 2. Cardiac output
pressure
(PP)
Blood
pressure
(BP) 4. Respiratory compensation for tissue hypoxia
Respiratory
rate (RR) 3b. Organ perfusion (kidney)

Urine output CPG Management of Dengue Infection in Adults (3rd Edition)

Hemodynamic Assessment - Stable Circulation
Parameters Stable Circulation

Conscious level Clear and lucid 3a. Normal Brain Perfusion

Brisk (<2 seconds)
Capillary refill time

Extremities (color,
Warm and pink 1. Normal Peripheral perfusion
temp)
Peripheral pulse Good volume
volume

Heart rate (HR) Normal HR for age

Pulse pressure (PP) Normal PP for age 2. Normal Cardiac output

Blood pressure (BP) Normal BP for age

Respiratory rate (RR) Normal RR for age

4. No Respiratory compensation
Urine output Normal 3b. Normal kidney perfusion

CPG Management of Dengue Infection in Adults (3rd Edition)

Hemodynamic Changes in Compensated
Shock

Normal or elevated systolic

pressure
Rising diastolic pressure

Narrow pulse pressure – weak pulse

Tachycardia

Reduced peripheral perfusion

Cool/cold and pale extremities
Prolonged capillary refill time

LUCID conscious level

Decreased urine output

LCS Lum
CPG Management of Dengue Infection in Adults (3rd Edition)
Hemodynamic Assessment - Compensated Shock
(cont.)
Parameters Stable Circulation Compensated shock

Conscious
Clear and lucid Clear and lucid
level
Capillary Brisk (<2 sec)
Prolonged (>2 sec)
refill time
Note that changes
Extremities Warm and pink Cool peripheries are seen in all
Peripheral
parameters except
pulse
Good volume
Weak & thready conscious level and
volume systolic blood
Heart rate pressure
Normal HR for age Tachycardia for age
(HR)
Blood Normal systolic
pressure Normal BP for age pressure, rising
(BP) diastolic pressure
Pulse
Narrowing PP
pressure Normal PP for age
Postural hypotension
(PP)
Respiratory
Normal RR for age “Quiet” tachypnea
rate (RR)
Urine
Normal Reducing trend
output
Hemodynamic Changes in Hypotensive
Shock
Increasing tachycardia

Systolic and diastolic pressures

Feeble
disappear or absent peripheral pulse
suddenly

Reduced peripheral perfusion

Very cold, clammy extremities
Mottled, peripheral cyanosis
Very prolonged capillary refill time

Kussmaul breathing

Decreased level of conscious

Oliguria or anuria

LCS Lum
CPG Management of Dengue Infection in Adults (3rd Edition)
Hemodynamic Assessment – Hypotensive Shock
(cont.)
Key clinical signs of deterioration: Changes in Mental
State
• Restless, confused, extremely lethargic
• Seizures
• Agitation alternating with drowsiness

Imminent total cardiorespiratory collapse!

CPG Management of Dengue Infection in Adults (3rd Edition)

Hemodynamic Assessment – Monitoring urine
output
Why is monitoring of urine output crucial in haemodynamic
monitoring?
Reflects renal blood flow -- kidneys regulate intravascular volume.
In early shock state, kidneys conserve fluids by reducing urine volume.
In severe shock, no urine is produced.

What is considered adequate urine output?

In outpatient setting, the patient should drink enough fluids to pass urine about 4
to 6 times a day.
A patient with dengue shock should pass at least 0.5 ml/kg urine per hour.
An indwelling catheter will give an accurate measurement. If the urine volume
exceeds this amount, consider reducing the IV fluid

CPG Management of Dengue Infection in Adults (3rd Edition)

Hemodynamic Assessment – Hypotensive Shock
(cont.)
Stable Compensated
Parameters Circulation shock Hypotensive shock

Conscious Clear and lucid Clear and lucid Restless, combative

Reduced brain perfusion
level
Capillary Brisk (<2 sec)
Prolonged (>2 sec) Very prolonged, mottled skin
refill time
Reduced
Extremities Warm and pink Cool peripheries Cold, clammy peripheral
Peripheral
perfusion
Good volume
pulse Weak & thready Feeble or absent
volume
Heart rate Normal HR for
Tachycardia for age
Severe tachycardia or
(HR) age bradycardia in late shock Reduced
Blood Normal systolic cardiac
Normal BP for Hypotension
pressure age
pressure, rising
diastolic pressure Unrecordable BP output
(BP)
Pulse Narrowing PP
Normal PP for Narrowed pulse pressure
pressure age
Postural
hypotension (<20 mmHg)
(PP)
Respiratory Normal RR for
Severe tissue acidosis
age
“Quiet” tachypnea Kussmaul breathing
rate (RR)
Urine No kidney perfusion
Normal Reducing trend Oliguria or anuria
output
 Pearls in clinical examination of dengue
patients
The “5-in-1 maneuver” magic touch – CCTV-R
Hold the patient’s hand to evaluate peripheral perfusion.
Save life in 30 seconds by recognizing shock
2. 3. 4.
1. 5.
Capillary Temperatu Pulse
Colour Volume Pulse Rate
refill re

CPG Management of Dengue Infection in Adults (3rd Edition)

Frontline evaluation

CPG Management of Dengue Infection in Adults (3rd Edition) 29

Frontline Disposition

CPG Management of Dengue Infection in Adults (3rd Edition) 30

 31
CPG Management of Dengue Infection in Adults (3rd Edition)
 MANAGEMENT OF DENGUE INFECTION

Out patient management :

• The management of dengue infection is symptomatic
and supportive.
• should be provided with an outpatient dengue
monitoring record .
• Primary care providers with no immediate haematocrit
facilities and/or point of care tests should refer patient
to the nearest health facility for further management.
• Point of care tests (RCT or NS1 antigen) should be
done when dengue infection is suspected
CPG Management of Dengue Infection in Adults (3rd Edition) 33
CPG Management of Dengue Infection in Adults (3rd Edition) 34
CPG Management of Dengue Infection in Adults (3rd Edition) 35
 For home care patient

1. Able to tolerate orally well, good urine output and no history of bleeding
2. Absence of warning signs (refer Table 3)
3. Physical examination:
 Haemodynamically stable
 No tachypnoea or acidotic breathing
 No tender liver or abdominal tenderness
 No bleeding manifestation
 No sign of third space fluid accumulation
 No alterations in mental state
4. Investigation:
 Stable serial HCT
5. No other criteria for admission (i.e. co-morbidities, pregnancy, social
factors)

CPG Management of Dengue Infection in Adults (3rd Edition) 36

 CRITERIA FOR HOSPITAL REFERRAL /
ADMISSION
Referral from Primary Care Providers to Hospital
• The decision for referral and admission must
not be based on a single clinical parameter but
should depend on the Total Assessment of the
patient.
1. Symptoms:
• Warning signs
• Bleeding manifestations
• Inability to tolerate oral fluids
• Reduced urine output
• Seizure

2. Signs:
• Dehydration
• Shock
• Bleeding
• Any organ failure
3. Special situations:
• Patients with co-morbidity e.g. Diabetes,
Hypertension, Ischaemic Heart Disease,
Coagulopathy, Morbid Obesity, Renal failure, Chronic
Liver disease, COPD
• Elderly more than 65 years old
• Patients who are on anti-platelet and/or
anticoagulants
• Pregnancy
• Social factors that limit follow-up e.g. living far from
health facility, no transport, patient living alone, etc.

4. Laboratory criteria: Rising HCT accompanied by

reducing platelet count