DISEASE MONITORING Dr Mahiran Mustafa Chairman of CPG Development Committee

1. DISEASE MONITORING Dr Mahiran Mustafa Chairman of CPG Development Committee

2. CONTENTS • Brief review on different phases in dengue infection • Issues at different phases • Clinical monitoring for each phase • Laboratory monitoring for each phase

3. INTRODUCTION • Monitoring dengue cases require the understanding that dengue infection is a systemic and dynamic disease. • Its clinical, haematological and serological profiles changing from day to day and accelerate by the hour during the critical phase, particularly in those with plasma leakage • Failure in recognising and interpreting the clinical and laboratory manifestations can lead to delay in appropriate management thus cause intractable shock and death

4. CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS

6. OUTPATIENT MONITORING Symptoms: • Warning signals • Bleeding manifestations • Inability to tolerate oral fluids • Reduced urine output • Seizure Signs: • Dehydration • Shock • Bleeding • Any organ failure Laboratory: • HCT • Hb • Platelet

7. DISEASE MONITORING CARD DENGUE DISEASE PROGRESSION CARD Patient’s name: ________________________________ I/C No. : _______________________________ Date of onset of fever : __________________________

8. CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS

9. Clinical deterioration often occurs during the critical phase because of marked plasma leakage • Evidence of plasma leakage includes: raised HCT haemodynamic instability fluid accumulation in extravascular space

10. Pathophysiology • Inadequate perfusion of the tissue leads to increased anaerobic glycolysis and resultant lactic acidosis • Shock that leads to DIC and bleeding • Vascular permeability leads to leakage • Haemoconcentration • Hypovolaemia leads to reflex tachycardia and vasoconstriction

11. WARNING SIGNALS • Vomiting • Abdominal pain • Restlessness or altered mental state • Mucosal Bleed • Sudden change of temperature to subnormal • Raising HCT with rapid drop in platelet

13. CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS

14. SEVERE MANIFESTATIONS • Acute abdomen • Hepatitis and hepatic failure • CNS manifestations • Carditis or cardiomyopathy

15. Pathophysiological changes from normal circulation to compensated and decompensated shock

18. Fluid Guidelines

19. Fluid Therapy: Non Shock Recommendation • Encourage adequate oral fluid intake. (Grade C) • IV fluid is indicated in patients who are vomiting or unable to tolerate oral fluids. (Grade C) • IV fluid is also indicated in patients with increasing HCT (indicating on-going plasma leakage) despite increased oral intake. (Grade C) • Crystalloid is the fluid of choice for non shock patients. (Grade C)

20. Indications for referral to Intensive • Recurrent or persistent shock • Requirement of respiratory support (non-invasive and invasive ventilation) • Significant bleeding • Encephalopathy or encephalitis

21. DISCHARGE CRITERIA • Afebrile for 48 hours • Improved general condition • Improved appetite • Stable haematocrit • Rising platelet count • No dyspnoea or respiratory distress from pleural effusion or ascites • Resolved bleeding episodes • Resolution/recovery of organ dysfunction

22. Summary:Principles of disease monitoring 1.Dengue is a systemic and dynamic disease. Therefore disease monitoring is governed by different phases of the disease. 2. The critical phase (plasma leakage) may last for 24-48 hours. Monitoring needs to be intensified and frequent adjustments in the fluid regime may be required. 3. Recognition of onset of reabsorption phase is also important because intravenous fluid regime needs to be progressively reduced/ discontinued