Case Presentation 1

1. Case Presentation 1

2. Presenting Symptoms ( Admit 20/5/08 8pm ) • V.S / Indian / Female / 39 years • Fever x 4/7 • a/w chills but no rigors • Diarrhoea and vomiting x 2 days • No bleeding tendency • No SOB • No chest pain • LMP : 16/5/08 ( currently day 4 menstruation ) • Not staying at dengue area ( No recent fogging ) • No history of recent travel • No family members with similar problem

3. Social History • Working in Taman University ( dengue area ) in a textile factory • Recently engaged • Currently lives with family

4. Physical Examination • Conscious , alert • GCS full • BP : 126/75 • PR : 58 (good volume) • T : 37 • GM : 6.9 • CRT < 2 sec • Clinically pink, no jaundice • Dehydrated • CVS : DRNM • Lungs : Clear, A/E equal • Abd : Soft, non- tender • No rashes/ bruises seen • No lymphadenopathy Estimated body Wt - 50kg

5. Diagnosis • Dengue Fever • Differential : Acute gastroenteritis • FBC from A&E : • Hemoglobin 144 G/L • Hematocrit 39.9 • Platelet 15 G/L • WCC 2.2

6. What is the diagnosis? • DF with warning signs Clinical warning signs of severe dengue or high possibility of rapid progression to shock

7. What phase of Dengue illness is the patient in now? • The Critical Phase • The critical phase occurs either • Towards the late febrile phase • Often after 3rd day of fever or • Around defervescence • Usually between 3rd day to 5th day of fever; but may go up to the 7th day of fever

10. Investigations taken • FBC • BUSE/ Creatinine/ LFT • Dengue Serology • BFMP x 3 • CXR • Stool • Ova and cyst, C & S

11. Physical Examination Diagnosis Dengue Fever Differential : Acute gastroenteritis • Conscious , alert • GCS full • BP : 126/75 • PR : 58 (good volume) • T : 37 • GM : 6.9 • CRT < 2 sec • Clinically pink, no jaundice • Dehydrated • CVS : DRNM • Lungs : Clear, A/E equal • Abd : Soft, non- tender • No rashes/ bruises seen • No lymphadenopathy

12. Comment on the clerking of this dengue patient

13. Clerking Dengue patients • Day…….fever • Temp chart – • Febrile phase • Critical phase • Hours of defervescence • Clinical warning signals – Yes/No • Abdominal pain or tenderness, • Persistent vomiting • Restlessness or lethargy, • Liver enlargement > 2 cm • Bleeding tendency – Yes/No • If yes – is it significant?

14. Clerking Dengue patients • Evidence of plasma leakage – Yes/No • Pleural effusion / Ascites • Hemodynamic instability - INCLUDING TACHYCARDIA (PR>90) • Increase in HCT • High HCT on admission • >46 for males; > 40 for females

15. And the diagnosis is….. • DF • Warning signals – Yes / No • DHF – non shock • Warning signals – Yes / No • DHF – compensated shock • DHF – decompensated shock

16. Hourly vital signs monitoring until stable Notify as Dengue Haemorrhagic Fever Run 2 pint NS fast Maintenance IVD 8 pints Normal Saline over 24 H IV Maxolon 10 mg tds T. Ranitidine 150 mg bd 4 hourly FBC TDS MO review Plan of management

17. Does the patient fulfill the criteria for DHF ?

18. WHO classification - DHF • Features of dengue fever And 2. Hemorrhagic manifestations evidenced through one or more of the following: a. Positive tourniquet test b. Petechiae / ecchymosis / purpura c. Mucosal bleeding: Epistaxis, gum bleeding d. Bleeding from injection or other site e. Hematemesis, melena, hematuria, PV bleeding 3. Thrombocytopenia with platelets 100,000 / m3 or less And 4. Any evidence of plasma leakage due to increased capillary permeability manifested by one or more of the following: a. A >20% rise in hematocrit for age or sex b. A > 20% drop in hematocrit following treatment with fluids as compared to base line c. Pleural effusion / ascites / hypoproteinemia

19. In addition, unexplained tachycardia

20. Comment on the fluid regime given ? • There is no evidence of hemodynamic instability • Bolus not necessary • Unnecessary boluses will contribute to the extravasation of fluids to the extravascular space such as pleural and abdominal cavity resulting in massive pleural effusion and ascites. • Calculation for normal maintenance fluid is wrong

22. Comment on these orders ‘T. Ranitidine 150 mg bd’ ‘4 hourly FBC’ ‘TDS MO review’ • H2-antagonist is not indicated • At least in critical phase of dengue illness – every FBC taken must be reviewed and action taken based on the result, hemodynamic status and other clinical parameters. • ‘Dengue infection is a dynamic disease. Its clinical course changes as the disease progresses’

23. For patients in the critical phase, a good doctor’s order must include • Fluid regime that is based on ml/hr or ‘1 pint every….hour’ • The time for next clinical review • The time for next FBC • The fluid regime must be applicable only until the next clinical review • ‘Frequent adjustment of maintenance fluid regime is often needed during the critical phase’

24. Next review - 13 hours defervescence– Day 5 fever onset ( 21/5/08 , 9am ) • Vomit x 1 , Epigastric pain • No diarrhoea or hematuria • BP : 107/70 mmHg PR : 81 sPO2 100% ↓Room Air • Lungs : clear • Order ( by doctors ) • Trace FBC taken at 7.00AM • T Omeprazole 40mg OD ( off T Ranitidine ) • Watch out for bleeding tendency • Cont IVD 8 pint Normal Saline over 24 hours • Transfer to Dengue Ward after review result

25. Monitoring in dengue • Comment on the review frequency • This patient is in critical phase and has alarm signals • A review by the on-call doctor is necessary in order to pick up early evidence of leakage • We need to find a way to risk stratify our dengue patients and the management of high risk cases must be a by a dengue team. • It is not enough if we just try to place all our dengue patients in one ward (which is often overflowing)

26. What are the signs of deterioration that were not appreciated by the doctor? • In dengue infection it is more important to look out for plasma leakage than ‘watch out for bleeding tendency’ • New onset of epigastric pain • Pulse rate increasing • All this implies the need for closer monitoring • More frequent HCT estimation

27. Clinical manifestations of vasoconstriction (secondary to plasma leakage) in various systems are; Skin coolness, pallor and delayed capillary refill time Cardiovascular system raised diastolic blood pressure and a narrowing pulse pressure Renal system reducing urine output Gastrointestinal system vomiting and abdominal pain Central nervous system lethargy, restlessness, apprehension, reduced level of consciousness Respiratory system tachypnoea (respiratory rate >20/min) Pathophysiology of DHF 27

28. 18 hours defervescence(21/5/08, 2pm ) • Not transferred to Dengue Ward yet • Blood Investigations taken at 7.00AM reviewed : • ALT : 407 / AST : 1230 • CK : 359 / LDH : 1912 • WCC : 2.10 Hb : 13.6 Hct : 39.3 Plt : 19.4 • Cr: 70 / Urea :3 / K :2.85 • PT:15 / PTT:76.6 / INR : 1.3 • CXR : Clear lung fields

29. Comment on the HCT value at 7.00AM • HCT is 39.3 despite fluid replacement • Early and excessive fluid replacement is masking the raise in HCT • Input /Output charting 20/5/08 : 3300 / 1000 cc • HCT values must be interpreted in the context of the patient’s clinical progress and the amount of fluid replacement. • Other evidence for plasma leakage must be looked for during clinical examination • 3rd space accumulation of fluids – pleural effusion and ascites

30. 25 hours defervescence(21/5/08, 9pm) • Reviewed by doctor on call : • Comfortable ????? • sPO2 99% ( room air ) • BP : 116/52mmHg • PR : 104 /min • T : 37.7oC • ABG : pH 7.43 pCO2 44 PO2 153 HCO3 28 BE 4 • Order – Continue ward management

31. Comment on the use of ABG at this stage • Acidosis is a late sign of disease severity in Dengue • There are other indicators that the patient is deteriorating • Pulse rate 104/min • In the previous review and subsequent review, the doctors have mentioned about ‘epigastric pain’, which is a warning sign • Respiratory rate is a useful marker of 3rd space fluid loss and hence need to be assessed

33. What will be correct diagnosis of the current patient condition? • DHF grade 3 • Compensated shock • Need to rule out hemorrhage

34. ALGORITHM FOR FLUID MANAGEMENT FOR DSS

35. If no improvement after the 1st bolus

36. If no improvement after the 2nd bolus

37. If improvement after the bolus(es)

38. 36 hours defervescence( 22/5/08, 8am ) – Day 6 fever onset • Still abdominal pain T : 38oC • BP 130/60 mmHg PR 92/min • Abdomen – distended and tender but soft • Lungs – clear • Mild pedal oedema • Order by doctor • PR to look for malena • ↓IVD to 6 pints/24 hours • Refer HDU/ICU care

39. Input /Output charting • 20/5/08 : 3300 / 1000 cc • 21/5/08 : 4700/ 1500 cc

41. What do you think is happening? • HCT is dropping but there is no clinical improvement • Very likely patient is hemorrhaging • What will be the appropriate management at this stage? • Transfusion of fresh whole blood or packed cells

44. 48 hours post defervescence ( 22/5/08, 1pm ) – Day 6 fever onset • Noted lungs crepts • Periorbital swelling • Bilateral leg and arm oedema • Order by doctor • DIVC screen • GXM 2 pint pack cells • Off IVD • IV frusemide 40mg stat • IV antibiotics – Ceftriaxone after blood culture • Ultrasound abdomen urgent

47. Comment on the usage of frusemide at this stage Periorbital swelling, pedal oedema and possibly pleural effusion is evidence of extravasation of fluid to extravascular space Initial overzealous fluid replacement can be the cause of this However patient is still in the leakage phase and hence has intravascular depletion Frusemide makes this worse

48. * Very deranged result ( markedly increase )

49. What else is happening • The patient is developing liver failure • Liver failure in dengue infection may be secondary to • Inadequate and timely resuscitation • In some patients with severe dengue infection, liver failure is out of proportion to the degree of plasma leakage.

50. Ultrasound report • U/S Abd done 22/5/08 4.30 p.m. • Normal liver echotexture • Ascites with minimal bilateral perinephric fluid ?cause • Thickened gallbladder wall may represent acute cholecystitis or due to presence of ascites • Evidence of liver abscess not seen • Hypoechoic lesion posterior wall of uterus, possibly a fibroid