Transcript M + 5% = Maintenance + 5% of body weight

2. Fluid Management in
Dengue Hemorrhagic Fever
Dengue Expert Advisory
Group
Dengue Virus Infection
• Asymptomatic
• Symptomatic
– Undifferentiated Febrile Illness
– Dengue Fever
– Dengue Hemorrhagic Fever
 Non Shock
 Shock
Dengue Hemorrhagic Fever
• Febrile Phase
• Critical phase characterized by plasma
leak
• Convalescent Phase
Dengue “Leak” Fever
• Plasma leak during critical phase is the
hall mark
• Leading to 3rd space losses
– peritoneal cavity
– pleural cavity
• Variable in magnitude and exact timing
Pathogenesis of leak
• Infection with a virulent dengue virus
• Presence of antibodies that enhance
dengue virus infection (ADE)
• Intense immune activation
Pathogenesis
• Rapidly elevated cytokines (TNF-a, IL-2,
IL-6, IL-8, IL-10, IL-12, and IFN-g)
• Malfunction of vascular endothelial cells
• Plasma leakage from intra to extravascular
space
Pathogenesis
• In severe DHF the loss of plasma is critical
• Patient becomes hypovolaemic
• Signs of circulatory compromise
• Progress to shock, organ failure, death
Pathogenesis
• Cytokine Storm
• Self limited
• Ends after 48 hours
Clinical Implications
• Extravascular fluid loss at variable rate
that has to be matched ml for ml
• Lasting 48 hours
• Resorption of fluid during convalescent
phase
Key Points
• Manage critical phase with appropriate
volume
– Don’t under transfuse
– Don’t over transfuse
• Meticulous monitoring during critical phase
to match rate of fluid infusion with rate of
leak
Monitoring Parameters
• Clinical
– Pulse Rate
– Blood and Pulse Pressure
– Capillary Refill Time
– Urinary Output
• Lab
– Hematocrit
Fluid Management
Critical Phase
Amount of Fluid?
• Based on weight
• Adults
– If less than 50kg use actual weight
– If more take weight as 50 kg
• Paediatrics
– Current OR Ideal body weight whichever
is lower
Ideal Body Weight
• Weight for height using a growth chart
• Weight for age
• Formulae in emergency
Growth Charts
Formulae
• <1 year
:
Age (in Months)+ 9/2
• 1-7 years : (Age x 2)+ 8
• >7 years
:
• APLS
: (Age in years + 4) x 2
Age x 3
Fluid Quota
• M + 5% = Maintenance + 5% of body
weight
• Over 48 hours if patient presents in the
beginning of critical phase (without shock)
• Over 24 hours for patients coming in
shock
M + 5% - Adults
• Maintenance
– 1st 10 kg
– 1000 mls
– 2nd 10 kg
– 500 mls
– Remaining 30kgs – 600 mls
– Sum
= 2100 mls
• 5% deficit – 50 x 50 = 2500 mls
• Total
= 4600 mls
Child 22 kg
• Maintenance
– 1000 + 500 + 40 = 1540 mls
• 5% Deficit – 50 x 22 = 1100 mls
• Total
2640 mls
Types of Fluid
• Crystalloids
– 0.9% Saline
– 5%Dextrose 0.9% Saline
– 5% Dextrose ½ saline
Monitoring – Critical Phase
• Vital parameters - hourly
• Fluid balance chart - assess three hourly
• HCT - six hourly
Fluid Management in
Dengue Shock
Syndrome
Compensated
• Body compensates for fluid loss
•
•
•
•
Tachycardia
Pulse Pressure narrows
Prolonged CRT
Fall in urine output to 0.5 mls/kg/hr
Decompensated
• Pulse pressure narrows further leading to
unrecordable pulse and BP
• Urine output falls less than 0.5 mls/kg/hour
• Supply to myocardium and brain
compromised
Fluid Resuscitation
• Crystalloids – N Saline
• Colloids
– Dextran 40 in saline
– 6% Starch
• All boluses part of fluid quota
Indications for Colloid
• Failure of crystalloid boluses to normalize
pulse /BP
• Development of shock
– with fluid overload
– amount of fluid exceeding M + 5%
deficit
• 10 ml/kg over 1 hour
Colloids
• Dextran may sometimes interfere with
grouping and cross matching
• 3 doses of Dextran 40 during a 24 hour
• 5 doses of 6% Starch during 24 hour
• Remain in circulation for much longer
Refractory Shock - ABCS
• Blood
– packed cells
– whole blood
• Bicarbonate
• Glucose
• Calcium
Monitoring During Shock
• 15 minute monitoring of vital signs
• HCT immediately before and after each
fluid bolus and then at least two to four
hourly
Key Points – Managing DHF
• Recognizing the start of critical phase of
DHF
• Predicting the rate of leak which may vary
from patient to patient and within the same
patient
• Matching the rate of infusion to rate of leak
• Being cognizant of the end of critical
Key Points – Managing DSS
• Meticulous monitoring
• Switching appropriately from crystalloids to
colloids
• Recognizing need for blood transfusion