Case Presentation 1
1
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

•
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•
2
Social History
Working in Taman University ( dengue area ) in a textile
factory
Recently engaged
Currently lives with family



3
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
•
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4
•
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•
•
•
CVS : DRNM
Lungs : Clear, A/E equal
Abd : Soft, non- tender
No rashes/ bruises seen
No lymphadenopathy
Estimated body Wt - 50kg
Diagnosis
Dengue Fever
Differential : Acute gastroenteritis
FBC from A&E :







5
Hemoglobin 144 G/L
Hematocrit 39.9
Platelet 15 G/L
WCC 2.2
What is the diagnosis?
 DF with warning signs

Clinical warning signs of severe dengue or high possibility
of rapid progression to shock
6
What phase of Dengue illness is the patient in now?


The Critical Phase
The critical phase occurs either


Towards the late febrile phase


or
Around defervescence

7
Often after 3rd day of fever
Usually between 3rd day to 5th day of fever; but may go up to the 7th
day of fever
8
9
Investigations taken
FBC
– BUSE/ Creatinine/ LFT
– Dengue Serology
– BFMP x 3
– CXR
– Stool
–
•
10
Ova and cyst, C & S
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
11
•
•
•
•
•
CVS : DRNM
Lungs : Clear, A/E equal
Abd : Soft, non- tender
No rashes/ bruises seen
No lymphadenopathy
Diagnosis
Dengue Fever
Differential : Acute gastroenteritis
Comment on the clerking of this
dengue patient
12
Clerking Dengue patients
1.
2.
Day…….fever
Temp chart –

Febrile phase

Critical phase

Hours of defervescence
3.
Clinical warning signals – Yes/No

Abdominal pain or tenderness,

Persistent vomiting

Restlessness or lethargy,

Liver enlargement > 2 cm
4.
Bleeding tendency – Yes/No

If yes – is it significant?
13
Clerking Dengue patients
4.
Evidence of plasma leakage – Yes/No
Pleural effusion / Ascites
Hemodynamic instability - INCLUDING TACHYCARDIA
(PR>90)
Increase in HCT
High HCT on admission





14
>46 for males; > 40 for females
And the diagnosis is…..

DF


Warning signals – Yes / No
DHF – non shock

Warning signals – Yes / No

DHF – compensated shock

DHF – decompensated shock
15
Plan of management
•
•
•
•
•
•
•
•
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
16
Does the patient fulfill the criteria
for DHF ?
17
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
1.
18
Evidence of plasma leakage
Haemoconcentration (20%
above baseline)
A drop in haematocrit following
fluid replacement
Adult male
 Hct >46%
3rd space
fluid
accumulation
Adult female
Hct >40%
In addition, unexplained tachycardia
19
Pleural
effusion,
Ascites

Comment on the fluid regime given ?


There is no evidence of hemodynamic instability
Bolus not necessary


20
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
21
Comment on these orders
‘T. Ranitidine 150 mg bd’
‘4 hourly FBC’
‘TDS MO review’
•
•

22
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’

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’
23
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 )





24
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
Monitoring in dengue

Comment on the review frequency

This patient is in critical phase and has alarm signals



25
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)

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’


26
New onset of epigastric pain
Pulse rate increasing
 All this implies the need for closer monitoring
 More frequent HCT estimation
Pathophysiology of DHF
Clinical manifestations of vasoconstriction (secondary
to plasma leakage) in various systems are;

Skin


Cardiovascular system


lethargy, restlessness, apprehension, reduced level of consciousness
Respiratory system

27
vomiting and abdominal pain
Central nervous system


reducing urine output
Gastrointestinal system


raised diastolic blood pressure and a narrowing pulse pressure
Renal system


coolness, pallor and delayed capillary refill time
tachypnoea (respiratory rate >20/min)
27
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
28

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

29
3rd space accumulation of fluids – pleural effusion and ascites
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
30

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

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
31
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
32

What will be correct
diagnosis of the current
patient condition?



DHF grade 3
Compensated shock
Need to rule out
hemorrhage
33
DATE /
TIME
20/5
21/5
7PM
7AM
5PM
HCT
39.9
39.3
35.5
HB
14.4
13.6
11.8
PLT
15
19
13
WCC
2.2
2.1
4.2
ALGORITHM FOR FLUID MANAGEMENT
FOR DSS
34
If no improvement after the 1st bolus
35
If no improvement after the 2nd bolus
36
If improvement after the bolus(es)
37
36 hours defervescence( 22/5/08, 8am ) –
Day 6 fever onset

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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
38



Input /Output charting
20/5/08 : 3300 / 1000 cc
21/5/08 : 4700/ 1500 cc
39
DATE /
TIME
20/5
21/5
22/5
7PM
7AM
5PM
12MN
HCT
39.9
39.3
35.5
32.5
HB
14.4
13.6
11.8
11.7
PLT
15
19
13
22
WCC
2.2
2.1
4.2
7.6
40

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?

41
Transfusion of fresh whole blood or packed cells
42
43
DATE /
TIME
20/5
21/5
22/5
7PM
7AM
5PM
12MN
7AM
HCT
39.9
39.3
35.5
32.5
29.5
HB
14.4
13.6
11.8
11.7
10.4
PLT
15
19
13
22
26
WCC
2.2
2.1
4.2
7.6
12.9
48 hours post defervescence ( 22/5/08, 1pm )
– Day 6 fever onset
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
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
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
44
45
DATE /
TIME
7PM
7AM
5PM
12MN
7AM
12PM
HCT
39.9
39.3
35.5
32.5
29.5
30.6
HB
14.4
13.6
11.8
11.7
10.4
10.4
PLT
15
19
13
22
26
24
WCC
2.2
2.1
4.2
7.6
12.9
14.9
46
20/5
21/5
22/5

Comment on the usage of frusemide at this stage




47
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
Date
20/5
21/5
22/5
T. Bil
22
53
107
ALT
407
491
2476
AST
1230
1573
-2*
CK
359
-
-
LDH
1912
-
-
Creat
0.07
0.03
0.06
PTT
-
76.6
62.4
INR
-
1.3
2.11
* Very deranged result ( markedly increase )
48

What else is happening


The patient is developing liver failure
Liver failure in dengue infection may be secondary to


49
Inadequate and timely resuscitation
In some patients with severe dengue infection, liver failure is out of
proportion to the degree of plasma leakage.
Ultrasound report
•
50
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
Day 3 at 57 hours post admission ( 23/5/08,
5am ) – Day 7 fever onset


Staff nurse noted patient become more unwell
Doctor ( on call ) review




51
Septic looking E4M4V4
BP 149/72mmHg PR 84/min ( good volume )
Lungs clear CRT < 2 sec
Order
 Put back IVD 5 pint over 24 hours
 Continue antibiotic
 Hourly vital sign monitoring
 ABG stat – compensated severe metabolic acidosis pH
7.38 HCO3 8 BE -14
D3 admission (23/5/08, 8am )- at 60 hours
post defervescence
•
•
Abdominal pain persistent
Clinically :
• Septic looking; T : 37.4oC E4V2M5
• BP : 140/89 mmHg PR : 92/min
• Warm peripheries , CRT < 2 sec
• Spo2 100% , N/prong oxygen 10L/min
• Lungs- rhonchi with ↓ air entry left basal
• Abdomen – soft, distended
• Bilateral pedal oedema
52
Investigation results


ABG – worsening compensated metabolic acidosis
pH 7.36 HCO314 BE -9 pCO2 27
Management :
 IV frusemide 40mg stat
 Transfer to HDU
 IVD 1 pint over 24 hours
 IV NaHCO3 50cc slow bolus
53

Comment on the sodium bicarbonate infusion
54






No indication in this scenario as cause of acidosis here is
due to hypovolemic shock both from plasma leak and
occult hemmorhage
Does more harm than good
1) paradoxical intracellular acidosis- increases CO2
2)worsens fluid overloads
3)hyperosmolar - hypernatremia
The indication to give in very severe metabolic acidosis
where the pH is <7.1 is also just as a temporary measure
while awaiting renal replacement therapy which is
definative treatment
55
Further management at D3 admission
(23/5/08, 11.15am ) at HDU




Planned for 1 pint PC and 2 units FFP transfusion
IVD 4 pints Normal Saline / 24 H
Intubated for Type 1 respiratory failure at 65 hours of
admission ( 1pm )
CXR – bilateral pleural effusion
56
Further management at D3 admission
(23/5/08) at ICU ( 69 hours post admission )




Septic workup – then IV Tazocin 2.25g QID for ?
Acute cholecystitis ( ultrasound findings ) /
Nosocomial infection
IV Gelafundin bolus 250cc
IV Frusemide 40mg stat
Referred to surgical team – conservative management
for ? Acute cholecystitis
57
DATE /
TIME
20/5
21/5
22/5
7PM
7AM
5PM
12MN
7AM
12PM
HCT
39.9
39.3
35.5
32.5
29.5
30.6
HB
14.4
13.6
11.8
11.7
10.4
10.4
PLT
15
19
13
22
26
24
Date
58
23.05.08
Time
10AM
8PM
HCT
24.9
24.8
Hb
8.7
9.2
PLT
70
94
Date
20/5
21/5
22/5
23/5
T. Bil
22
53
107
134
ALT
407
491
2476
5885
AST
1230
1573
-2*
-32*
CK
359
-
-
801
LDH
1912
-
-
8401
Creat
0.07
0.03
0.06
0.12
PTT
-
76.6
62.4
65.8
INR
-
1.3
2.11
3.44
* Very deranged result ( markedly increase )
59
What is happening in this patient now?
How would you manage him?
60

Occult Bleeding causing a drastic drop in Hb and Hematocrit

Marked clinical deterioration from organ failures especially liver
failure (hepatitis and severe coagulopathy , no DIC screen but
possibly in DIC), and with lung injury and renal impairment
ORGAN FAILURE IS TOO LATE TO REVERSE AND SEE THE TIME
FRAME AND RAPIDITY THAN THE PATIENT DETERIORATED
Management : PURELY SUPPORTIVE
Transfusion of blood and blood products accordingly; also realising
that all this is going to impair your oxygenation and patient will soon
require intubation, inotropes and CVVHD



61
D4 admission (24/5/08) – 85 hours post
admission









Day 8 Illness
GC worsened
BP : 135/83 mmHg, PR : 131/min
Not on inotropic support
ABG : Compensated metabolic acidosis
Hb reducing trend (Hb : 14  10.6  7.4)
Abdomen more distended
Urine output ↓↓  Anuric
PT/PTT/INR : 32.5 / 65.8 / 3.44
62
Further management






IV frusemide 80 mg stat
Reduce IVD 42 ml/hour + oral feeding 40ml/hour –
2litre /day
Started CVVHDF
Given DIVCx2 regime with Whole blood 6 pints of
blood in total – first pint whole blood given at
11.30am, 24/5/08 ( 87 hours post admission )
Started on inotropic support – Dopamine with added
on Noradrenaline
Needing increase ventilatory support , BP ↓ and
developed AF
63
DATE /
TIME
20/5
21/5
7PM
7AM
5PM
12MN
7AM
12PM
HCT
39.9
39.3
35.5
32.5
29.5
30.6
HB
14.4
13.6
11.8
11.7
10.4
10.4
PLT
15
19
13
22
26
24
Date
64
22/5
23.05.08
24.05.08
Time
10AM
8PM
12MN
6AM
6PM
HCT
24.9
24.8
20.8
19.2
24.9
Hb
8.7
9.2
7.9
7.4
9.2
PLT
70
94
89
104
104
Important investigations
Date
20/5
21/5
22/5
23/5
24/5
T. Bil
22
53
107
134
105
ALT
407
491
2476
5885
1619
AST
1230
1573
-2*
-32*
5112
CK
359
-
-
801
984
LDH
1912
-
-
8401
5869
Creat
0.07
0.03
0.06
0.12
0.35
PTT
-
76.6
62.4
65.8
69.5
INR
-
1.3
2.11
3.44
4.38
* Very deranged result ( markedly increase )
65
Further management





Started IV amiodarone
Bleeding tendency – oozing from femoral site
Hypothermic
BP dropping despite inotropic support.
Patient succumb to her illness at 112 hours post
admission
66
DATE /
TIME
20/5
7PM
7AM
5PM
12MN
7AM
12PM
HCT
39.9
39.3
35.5
32.5
29.5
30.6
HB
14.4
13.6
11.8
11.7
10.4
10.4
PLT
15
19
13
22
26
24
Date
67
21/5
22/5
23.05.08
24.05.08
25.05.08
Time
10AM
8PM
12MN
6AM
6PM
2AM
HCT
24.9
24.8
20.8
19.2
24.9
25.3
Hb
8.7
9.2
7.9
7.4
9.2
9.5
PLT
70
94
89
104
104
68
Important investigations
Date
20/5
21/5
22/5
23/5
24/5
26/5
T. Bil
22
53
107
134
105
225
ALT
407
491
2476
5885
1619
817
AST
1230
1573
-2*
-32*
5112
2358
CK
359
-
-
801
984
986
LDH
1912
-
-
8401
5869
4605
Creat
0.07
0.03
0.06
0.12
0.35
0.21
PTT
-
76.6
62.4
65.8
69.5
56.9
INR
-
1.3
2.11
3.44
4.38
1.97
* Very deranged result ( markedly increase )
68
69
Results

Dengue Serology (21/5/08) –day 4 illness



Dengue Serology (26/5/08) – day 9 illness




Ig G : Non – reactive
Ig M : Non – reactive
Ig G : Reactive
Ig M : Non – reactive
Blood C&S (22/5/08)  No sample
Blood C&S (23/5/08)  No growth
70
Can you interpret the Dengue
serology results?
71

Answer for this from Dr salmah
72
 Liver

73
biopsy tissue sample sent for :
Dengue PCR  Dengue Type 1 detected