CPG Management of Dengue Infection in Adults (3rd Edition) : December 2015
CPG Management of Dengue Infection in Adults (3rd Edition) : December 2015
CPG Management of Dengue Infection in Adults (3rd Edition) : December 2015
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KEY MESSAGES
LABORATORY INTERPRETATION
1
QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF DENGUE INFECTION IN ADULTS (THIRD EDITION)
Overall assessment
1. History
• Date of onset of fever/illness
• Oral intake
• Assess for warning signs
• Change in mental state/seizure/dizziness
• Urine output (frequency, volume and time of last voiding)
• Other important relevant histories:
-- Pregnancy
-- Co-morbidities
2. Physical examination
i. Assess mental state and GCS score
ii. Assess hydration status
iii. Assess haemodynamic status
-- Skin colour (C), capillary filling time (normal <2 seconds) (C), cold/
warm extremities (T), pulse volume (V) and rate (R) - CCTVR
-- Blood pressure and pulse pressure
iv. Look out for tachypnoea/acidotic breathing/pleural effusion
v. Check for abdominal tenderness/tender liver/ascites
vi. Examine for bleeding manifestation
3. Investigation
i. FBC and HCT
ii. Point of care test for dengue infection (RCT or NS1 antigen)
Based on evaluations in history, physical examination ± FBC, HCT and point of care
test, the clinicians should be able to determine:
1. Likelihood of dengue infection
2. The phase of dengue infection (febrile/critical/recovery)
3. Severity of the illness
Plan of management
2
QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF DENGUE INFECTION IN ADULTS (THIRD EDITION)
Haemodynamic
status
• CCTVR
• BP 2-4 hourly depending
• Pulse pressure on clinical status
Respiratory status 4-6 hourly depending
• RR on clinical status In shock 4-6 hourly
• SpO2 Every 15-30 minutes till
Neurological Status stable then 1-2 hourly
• Conscious level
• Restlessness
• Seizures
• Treating patients with unnecessary fluid boluses based on raised HCT or warning
signs as the sole parameter without considering other clinical parameters.
• Excessive and prolonged fixed fluid regime in stable patients.
• Infrequent monitoring and adjustment of infusion rate.
• Continuation of intravenous fluid during the recovery phase.
• Excessive fluid therapy in patients with co-morbidities (such as heart disease and
renal disease).
3
QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF DENGUE INFECTION IN ADULTS (THIRD EDITION)
GRADED FLUID BOLUS REGIME IN NON-SHOCK PATIENTS (DF with Warning Signs)
• Obtain a baseline HCT before fluid therapy.
• Give crystalloids solution (such as 0.9% saline).
• Start with 5 ml/kg/hour for 1–2 hours, then reduce to 3 ml/kg/hr for 2–4 hours, and then
reduce to 2 ml/kg/hr or less according to the clinical response.
• If the clinical parameters are worsening and HCT is rising, increase the rate of infusion.
• Reassess the clinical status, repeat the HCT and review fluid infusion rates accordingly.
4
QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF DENGUE INFECTION IN ADULTS (THIRD EDITION)
COMPENSATED SHOCK
(systolic pressure maintained but has signs of reduced perfusion)
• Fluid resuscitation with isotonic crystalloid 5-10 ml/kg/hr for 1 hour
• Obtain FBC, HCT, RP, LFT, RBS, PT/APTT, CK, Lactate/HCO3, GXM1 before
fluid resuscitation.
IMPROVEMENT*
YES NO
Check HCT
if HCT decreases,
consider transfusion YES
with packed red
cells and/or blood
components
• If patient improves, reduce to
• Consider to stop IV fluid at 7-10 ml/kg/hr for 1-2 hours
48 hours of plasma leakage/
defervescence. • Then reduce further
* Reassess the patient’s clinical condition, vital signs, pulse volume, capillary refill
time, urine output and temperature of extremities.
** Colloid is preferable if the patient has already received previous bolus of crystalloid
DECOMPENSATED SHOCK
• Fluid resuscitation with 20 ml/kg colloid / crystalloid within 15 - 30 minutes
• Obtain HCT/FBC, RP, LFT, RBS, PT/APTT, CK, Lactate/HCO3, GXM1 before
fluid resuscitation.
IMPROVEMENT* NO
YES
Review 1 HCT
st
• Crystalloid/colloid
10ml/kg/hr for 1 hour,
then continue with:
if HCT
increases,
c o n s i d e r
bolus fluid
administration HCT or high HCT
or increase fluid
administration;
* Reassess the patient’s clinical condition, vital signs, pulse volume, capillary refill time and
temperature of extremities.
^ Colloid is preferable if the patient has already received previous bolus of crystalloid.
All the above types of shocks need to be supported by echocardiography and non-invasive cardiac
output monitoring and treatments tailor to each patient.
This Quick Reference provides key messages and a summary of the main recommendations in the
Clinical Practice Guidelines (CPG) Management of Dengue Infection in Adults 2015 (Third Edition).
Details of the evidence supporting these recommendations can be found in the above CPG,
available on the following websites:
Ministry of Health Malaysia: www.moh.gov.my
Academy of Medicine Malaysia: www.acadmed.org.my