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3. Documentation and Monitoring of Dengue Patients

3. Documentation and Monitoring of Dengue Patients. Dengue Expert Advisory Group. Why Monitor Dengue Patients?. To differentiate DHF from DF Assessing onset of Critical Phase of DHF Smooth manipulation of fluids averting prolonged shock and fluid overload Early detection of complications

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3. Documentation and Monitoring of Dengue Patients

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  1. 3. Documentation and Monitoring of Dengue Patients Dengue Expert Advisory Group

  2. Why Monitor Dengue Patients? To differentiate DHF from DF Assessing onset of Critical Phase of DHF Smooth manipulation of fluids averting prolonged shock and fluid overload Early detection of complications Recognition of unusual presentations

  3. Basic MonitoringAll Patients • Pulse rate • Pulse pressure • CRFT • Respiratory rate • FBC - HCT • Intensity of monitoring depends on • Phase of the illness • Severity • Aggressiveness of fluid therapy • Accurate fluid balance charts

  4. Ministry of Health Sri Lanka

  5. Febrile Patient • Dengue or not? • Clinical • FBC • Leucopaenia + thrombocytopaenia • DF or DHF ? • Plasma leakage + or – • If DHF – what is the phase ?

  6. When Patient Afebrile • Critical phase • Time of entry • Predicted time of end • Aggressive monitoring • Calculate the fluid quota • Dynamic approach to fluid therapy • Final diagnosis– precise (DF or DHF & grade)

  7. Critical Phase Facts • Dropping Platelets • HCT rise of more than 20% of base line Conforms DHF as it signify leak. Even If HCt rise less than 20% but pleural effusion/ascites present conforms diagnosis of DHF/DSS( it is mostly due to early volume replacement or bleeding).

  8. Recognize the Stage of the Disease Assess Febrile phase Critical phase Convalescent phase Day of the illness ? Evidence of plasma leakage ? Convalescent rash ?

  9. Monitoring & DocumentationCritical Phase • Detection of shock • Pulse pressure < 20 mm Hg • CRFT > 2 secs • HCT increase of 20% or more from baseline • Efficacy of IV fluid therapy • Pulse pressure, capillary refill time, hypotension • To keep urine output at least 0.5 – 1.0 ml/kg/hr • Early detection of Fluid overload • Respiratory rate > 20/mt • Lung bases • SaO2 < 92% • CXR

  10. Warning • Misjudging of critical phase • which could begin as early as day 3 (if fever • drop on day 3). • Delay in doing the WBC, platelets and Hct determinations. • which help predict the critical stage/shock • Lead to misdiagnosis and/or delay until shock • occur.

  11. Monitoring Chart I - for Management of Dengue Patients – Febrile Phase Hct % D3 with Fever WBC <5000/mm3 N-40% L-58% TT + ve Dengue Fever D4 without Fever

  12. Entry in to critical phase D4 with Fever TT + ve, WBC <5000/mm3 N-40% L-58% Tender Liver

  13. How to time the onset of critical phase? Onset End

  14. MonitoringIV Fluid Therapy Shift ICU Phase of the illness – be fully aware • Adequacy of fluid therapy • Pulse Pressure >20 mmHg • CRFT <2 sec • Pulse Rate <80/mt • UOP > 0.5 ml/Kg/hr • HCT • Early detection of fluid overloading Respiratory rate > 20/mt • Lung bases • SaO2 < 92% • CXR

  15. Clinical Parameters Fluid Therapy PR RR BP/PP General condition Appetite Vomiting Bleeding Peripheral Perfusion Pulse volume Skin colour Skin Temp. CRFT HCt Urine output (based on IBW)

  16. Clinical Scenario Decision IVFluid Bolus If Afebrile Pt. Restless Irritable Pulse rate Pulse volume poor CRFT>2 sec Skin cold Pulse pressure<20 HCT Urine output<0.5 ml/kg

  17. Scenario Decision BloodTransfusion Afebrile Restless Confused Pulse volume poor Skin pale CRFT>2 sec Urine output < 0.5ml/kg/hr PR BP PP HCt

  18. Scenario • Vital Signs • Pulse volume good • Skin colour normal • Skin temp. normal • Pulse pressure • wide • Urine output > 1ml/kg/hr • CRFT< 2 sec • PR • BP • HCt • Afebrile patient • Puffy eyelids • Distended • abdomen • Tachypnea • Dyspnoea • orthopnea • Respiratory • distress Decision Dextran 40 with frusemide

  19. Warning Be vigilant to recognize DSS as most of the patients remain in good conscious and have narrow pulse pressure with increased diastolic pressure(e.g.BP=110/90, 100/80mm Hg) without hypotension. Avoid misdiagnosis of DHF in Infants(<1 year) with fits as sepsis/infection followed by LP leading to bleeding/ hematoma(platelets )

  20. Pearls • Your initial timing of critical phase may prove to be sometimes wrong Be prepared to change what you decided earlier or shift the timing based on more information you receive while Mx.

  21. Pearls • Try to Master the ways of giving ‘ THE SMOTHEST AND THE MOST UNEVENTFUL RECOVERY’ for the patient. • Avoid both shock and fluid overload. • Keep ‘CHECKING ON A TIME SCALE’… R u heading for fluid overload? If so, switch to a colloid.

  22. Pearls • At ‘END OF LEAKING PHASE’ even if PCV is high but patient is well, pulse, BP is OK • Don’t try to correct PCV as re absorption will start soon and PCV will come down so.. WAIT.

  23. Pearls • About 60% of DSS can be successfully resuscitated by using crystalloid solution only, 20% need colloidal and 15% need blood transfusion (+blood components). • With rapid recognition of shock and proper treatment rapid and dramatic recovery is the rule

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