Fluid Management in
DHF Patients
Dr Rasnayaka M Mudiyanse
Senior Lecturer in Paediatrics
Faculty of Medicine Peradeniya
Short Duration Fever - OPD
Treat and
send home
1.
2.
3.
4.
5.
Treat Fever
Rest
Fluid
Specific drugs
Warning signs
Admit
No resuscitation
1.
2.
3.
4.
Immediate
attention
Fluid
Oxygen
Observation
DD
Dengue ( group A)
DD
Dengue (group B)
( No warning signs )
( with warning signs)
Viral fevers
Other D
Other infections
Other D
Need
Resuscitation
1. Evaluate & ABC care
2. Fluid boluses
3. Oxygen
4. Hand over MO-MO
DD
Dengue ( group C)
(Sever dengue )
Septicemia
Diarrhea
Anaphylaxis
Classification of Dengue
Old WHO classification
Classical Dengue Fever
Dengue Fever with hemorrhagic
manifestations
DHF grade one
DHF grade two
DHF grade three
DHF grade four
DHF with unusual manifestations
New WHO classification
Probable dengue ( group A - OPD
management)
Dengue with warning signs (
Group B - inward observation and
management)
( patients are admitted for social reasons and
when they are in high risk category)
Severe Dengue ( Group C resuscitation and management)
1. With compensated shock
2. With hypotensive shock
3. With severe organ impairment
Dengue Hemorrhagic Fever or
Dengue Leaking Fever
Essential Feature In DHF is Leaking
DF may have bleeding but not leaking
The Cause of Shock in Dengue
•
•
•
•
•
•
Plasma leakage
Bleeding – external and internal
Hypocalcaemia
Vascular involvement
Inadequate fluid intake
Myocarditis
What is the cause of
Plasma Leakage
Endothelial cell dysfunction rather than
destruction
Evidence of Plasma Leakage
• Rise in HCT
– 20% = children 35  42 adults 40  48
• Circulatory failure
• Fluid accumulation – Ascites, Pleural
effusions
• Albumin < 3.5 gr/dl
• Cholesterol < 100 mg%
Evidences
of
plasma
leakage
in
DHF
A. Rising hematocrit ~ 50%
(Rt. lateral decubitus position)
Rt pleural effusion
Ascites
Plasma Leakage  Shock  Prolonged shock
• Prolonged shock
– Organ hypo perfusion & Organ impairment
– Metabolic acidosis + DIC
– Severe Hemorrhage ( Drop HCT & rise of WBC )
All these complications may develop without obvious
plasma leakage or shock
Rising HCT indicate plasma leakage
• 20-30% rise  GIT ischemia including liver
• 30-40 % rise  Renal and brain ischemia
Patients at risk of major bleeding
•
•
•
•
•
•
•
Prolonged/refractory shock;
Hypotensive shock & renal or liver failure
Severe and persistent metabolic acidosis;
Receiving NSAID agents;
Pre-existing peptic ulcer disease;
On anticoagulant therapy;
Any form of trauma( IM injection)
Sensitivity of early diagnostic
indicators of Dengue
Flushi Tourqu Leucope
ng
et test nia
1st day 73% 53%
70%
within
24 hrs pt
2nd day 90% 90%
will enter
critical
phase
rd
3 day 85% 98%
Liver enzymes
AST rise 90%
AST > 60 – PPV 80%
AST > ALT (2-3
times)
Dengue is a Dynamic Disease
Febrile, Critical and Recovery Phase
1
2
53
3
105
51
104
140
103
49
47
102
120
101
45
43
100
100
99
41
39
98
80
37
35
60
Incubation period 5-8 days ( 3-14 days)
1
2
2-7 days
3
4
1-2 days
5
6
7
8
Rate of Fluid Leakage
1
2
53
3
105
51
104
140
M + 5%
103
47
102
120
101
45
43
100
100
99
41
39
Optimum
volume of
fluid …
98
1
49
2
3
4
80
37
35
60
5
6
7
8
Calculation of M +5%
• Calculation of M
– 1st 10 kg – 100 ml/kg/day ( 4 ml/kg/hr)
– 2nd 10 kg – 50 ml/kg/day ( 2 ml/kg/hr)
– Subsequent ..kg – 20 ml/kg/day ( 1ml/kg/hr)
• Calculation of 5%
– 5% = 50ml/kg/day ( 2ml/kg/hr)
Maximum Fluid for adult ( 50kg) = 4600
M+ 5% for boy 60kg (IBW 50kg ) = ?
Fluid Management
in DHF patients
Rational Use of Fluid = Management of Dengue
Avoid Prolong Shock
Avoid Fluid Overload
Spectrum of Dengue
• DHF Grade 4 ( SD with hypotnsive shock )
– No pulse – 20ml/kg rapid bolus
– Drop SBP (Pulse + ) – 10 ml/kg rapid bolus, Rpt sos
• DHF Grade 3 ( SD with compensated shock)
– 10 ml/kg/hr
• No circulatory failure ( D warning signs)
– DF +/- Bleeding ( oral fluid ? M+5%)
– DHF in Febrile phase (1.5 ml/kg/hr)
DF & DHF in Febrile Phase
DF & DHF in Febrile Phase
1
•
•
•
•
Parcetamole 15mg/kg 6 hrly
Physical methods of controlling fever
Don’t use Aspirin and NSAID
Fluid to maintain nutrition and hydration
– Oral – between M and M+5% ( 5ml/kg/hr)
Too much fluid during febrile phase can contribute
to fluid over load
Recognize the Time of Entry to the Critical Phase
( when blood vessels become leaky)
• Dropping platelet count below 100 000/dl
• Rising HCT & Evidence of plasma leakage
Fluid management during
Critical Phase not in shock
( when blood vessels become leaky)
•
•
•
•
•
Establish IV line & IV fluid to KVO
Limit total ( IV + Oral) fluid to 1.5 ml/kg/hr
Monitor UOP ( 0.5ml/kg/hr is OK)
Rising HCT - Increase fluid- 3-5-7-10 ml/kg/hr
Monitor for circulatory failure – Fluid boluses
HCT monitoring 4-6 hrly initially then hrly
Fluid Allocation for Non Shock Patient
10-20
20-10 ml/kg
1 5-10 ml/kg
10-5 ml/kg
2
53
3
105
3-5 ml/kg
104
51
5-3 ml/kg
140
103
47
3-1 ml/kg
102
1-3 ml/kg
101
120
100
KVO
1.5 ml/kg
80
M + 5%
48 hrs
2
3
4
41
39
98
1
45
43
100
99
49
37
35
60
5
6
7
8
Fluid Allocation for Non Shock Patient
10-20
20-10 ml/kg
1 5-10 ml/kg
10-5 ml/kg
2
53
3
105
3-5 ml/kg
104
51
5-3 ml/kg
103
3-1 ml/kg
102
1-3 ml/kg
101
47
120
100
KVO
1.5 ml/kg
80
M + 5%
48 hrs
2
3
45
4
41
39
98
1
49
43
100
99
Fluid over load
and shock
140
37
35
60
5
6
7
8
Fluid Allocation for Non Shock Patient
10-20
20-10 ml/kg
1 5-10 ml/kg
10-5 ml/kg
2
Shock
53
and Fluid Over Load51
3
105
5-3 ml/kg
3-5 ml/kg
104
140
103
47
3-1 ml/kg
102
1-3 ml/kg
101
120
100
KVO
1.5 ml/kg
80
M + 5%
48 hrs
2
3
4
41
39
98
1
45
43
100
99
49
37
35
60
5
6
7
8
Prolonged shock
Prolonged Shock
• Detecting absent pulse is too late
• Drop in SBP is too late
• Drop in pulse pressure, CRFT, Cold
extremities .. can detect early shock
• We can prevent shock !
Rise in HCT = loss of IV compartment
20% - compromise GIT blood supply
40% - compromise renal and brain
Prevent Shock – Manage PCV
10-20
20-10 ml/kg
1 5-10 ml/kg
10-5 ml/kg
2
53
3
105
3-5 ml/kg
104
51
5-3 ml/kg
140
103
47
3-1 ml/kg
102
1-3 ml/kg
101
120
100
KVO
1.5 ml/kg
80
M + 5%
48 hrs
2
3
4
41
39
98
1
45
43
100
99
49
37
35
60
5
6
7
8
Cause of Prolonged Shock in Dengue
• Failure to detect shock is rare in SL
• Clinicians thought prolonged shock is due to bleeding
as a result of low platelets
• Clinicians did not appreciate that shock precipitate
bleeding and other organ damage
• Clinicians did not monitor/manage PCV ( instead they
managed platelet count )
personal opinion
WHY
?
WHY
?and training
Lack
Failures
of knowledge
in teaching/training
programs
(DHF grade 4)
Severe Dengue with Hypotensive shock
5 year old boy; fever 5 days, cold
extremities and prolonged CRFT.
HCT 48, Plt 45 000/dl SBP 60/40.
1-10 yrs - 5th Centile SBP = 70+ (agex2)
Adults
SBP <90 mm Hg or MAP <70 mm Hg or Drop of SBP >40 mm Hg
Management of DHF Grade 4
Severe Dengue with Hypotensive shock
•
•
•
•
•
•
Oxygen,Keep flat +/- Head low
IV canula – Blood samples
Rapid Fluid bolus + Rpt SOS
Monitoring ABCS
Consider other possibilities
Record keeping & Communication
Investigations for DHF patients
•
•
•
•
•
•
•
•
FBC
Blood grouping and cross matching
Blood sugar
Blood electrolytes ( Na,Ca,K,HCo2)
Liver Function tests
Renal Function tests
Blood gases
Coagulation profile ( PTT,PT,TT)
Management of DHF Grade 4
Severe Dengue with Hypotensive shock
Fluid bolus 10-20 ml/kg Normal Saline / 15 mt
Improving , HCT coming down gradually , good UOP
•
•
•
•
•
Slow bolus – 10 ml/kg Crystalloid/colloids over one hour
Infusion 5- 7 ml/kg/hr for 1-2 hrs ( Hartmann)
Infusion rate 3- 5ml/kg/hr for 2-4 hrs
Infusion rate 3ml/kg/hr for 2-4 hrs
Stop fluid in 48 hrs
No improvement
HCT dropping – Blood transfusion
No improvement
HCT Rising – Colloid transfusion
Management of DHF Grade 4
(Severe Dengue with Hypotensive shock )
Fluid bolus 10- 20 ml/kg Normal Saline / 15 mt
Rpt fluid boluses – 2 crystalloids'  colloids
NO IMPROVEMENT
Check HCT before fluid bolus or after fluid bolus
If HCT is dropping
< 40 for Children and female
< 45 for adult male
Blood transfusion
whole blood 10 -20 ml/kg
Packed RBC 5-10 ml/kg
Rising HCT
2ndBolus - Colloids
1. 10 – 20 ml/kg/ ½-1 hr
3rd bolus - Colloids
1. 10 – 20 ml/kg/1 hr
DHF Grade 3
Dengue with Compensated Shock
10 year old boy; fever 5 days. Cold
extremities. Tender Hepatomegaly. PCV
52, Platelets 50 000/dl
CRFT 5 sec. SBP 100/85.
5th Centile SBP = 70+ (agex2)
Management of DHF grade 3
(Severe Dengue with Compensated shock)
Fluid bolus 5-10 ml/kg Normal Saline / 1hr
Improving , HCT coming down gradually , good UOP
•
•
•
•
Hartmann - 5- 7 ml/kg/hr for 1-2 hrs
Hartmann - 3- 5ml/kg/hr for 2-4 hrs
Hartmann - 2-3 ml/kg/hr for 2-4 hrs
Stop fluid in 48 hrs
Management of DHF grade 3
(Severe Dengue with Compensated Shock)
Fluid bolus 5-10 ml/kg Normal Saline / 1hr
Rpt fuid bolus 5-10 ml/kg Normal Saline / 1hr
NO IMPROVEMENT
HCT rising
If HCT is dropping
< 40 for Children and female < 45 for adult male
Fluid bolus saline /colloids
10 -20 ml/kg for 1hr
Blood transfusion
Packed RBC 5-10 ml/kg
Whole blood 10-20 ml/kg
However, a rising or persistently high HCT together with
stable haemodynamic status and adequate urine output
does not require extra intravenous fluid.
Patients not responding to usual
fluid boluses
•
•
•
•
•
•
Massive plasma leakage – rising PCV
Concealed hemorrhage – Drop of PCV
Hypocalceamia
Hypoglycaemia
Hyponatremia
Acidosis
Fluid Management During Critical Phase
DON’T OVER LOAD LEAKING VESSELES
• Manage PCV and shock; use monitoring chart
• Fluid quota for leaking phase is M+5%
– Pre shock in 48 hours , Grade 3& 4 in 24 hours
• Use colloids to retain longer
• UOP – 0.5 ml/kg /hr is OK (Void volume chart)
• Cut down fluid at recovery phase
– Eg - 10ml/kg/hr  1.5 ml/kg/hr
• Give blood when indicated
Fluid Allocation for shocked Patient
20-10 ml/kg
1
10-5 ml/kg
2
53
3
105
51
5-3 ml/kg
104
140
103
47
3-1 ml/kg
102
120
101
45
43
100
100
KVO
99
80
M + 5%
24 hrs
2
3
4
41
39
98
1
49
37
35
60
5
6
7
8
Fluid Allocation for Non Shock Patient
10-20
20-10 ml/kg
1 5-10 ml/kg
10-5 ml/kg
2
53
3
105
3-5 ml/kg
104
51
5-3 ml/kg
140
103
47
3-1 ml/kg
102
1-3 ml/kg
101
120
100
KVO
1.5 ml/kg
80
M + 5%
48 hrs
2
3
4
41
39
98
1
45
43
100
99
49
37
35
60
5
6
7
8
What is M+5%
in management of DHF (MCQ)
• Fluid volume to be given during critical period
after excluding boluses
• Fluid volume to be given during critical period
after including boluses
• Upper limit of fluid volume for critical period
• Upper limit that should never be exceeded
M + 5% is only a guide to understand the risk for fluid over load
Fluid Management in Recovery Phase
Fluid Management in Recovery Phase
Dengue patients have accumulated fluid within
his/her body
• Cut down fluid
• Give oral fluid if tolerating
• Dropping HCT is not bleeding
• Rising HCT in stable child manage with oral
fluid
DHF grade 3 recovery phase; nurse inform that child has massive meleana
HCT dropped to 35 !
Don’t panic if the child is stable, hematocrit 35 is because he is recovering
child is passing what he bled yesterday
6 yr old boy DHF grade 4 recovered after 3 fluid
boluses. His HCT dropped from 48 to 39.
However he again developed circulatory failure
with reduced pulse pressure.
Management of severe bleeding
• Probably he has internal bleeding
• Manage with
–10 ml/kg whole blood
–5 ml/kg Packed RBC
Indications for Blood Transfusions
only 10-15% patients need blood
• Overt bleeding ( more than 10% or 6-8ml/kg)
• Significant drop of HCT < 40 ( < 45 for males)
after fluid resuscitation
• Hypotensive shock + low/normal HCT
• Persistent or worsening metabolic acidosis
• Refractory shock after fluid 40-60 ml/kg
Circulatory failure with high HCT should be managed with
colloids ( + Lasix if fluid overloaded) before blood
Why do you do platelet counts ?
(Answer this MCQ)
• To decide on platelet transfusion
• To recognize the beginning of critical
stage • As a prognostic indicator-
Why do you do platelet counts ?
• To decide on platelet transfusion - X
• To recognize the beginning of critical
stage • As a prognostic indicator-
Fluid Over Load
Causes of Fluid Over Load
•
•
•
•
•
•
•
Too much fluids in febrile phase
Excessive and/or too rapid IV fluids
Use of hypotonic crystalloid solutions
Inappropriate IV fluids for “severe bleeding”
Inappropriate - FFP, platelet & cryo
Continuation of IV fluids after Critical phase
Co-morbid conditions
– congenital or ischaemic heart disease
– chronic lung and renal diseases
– Obesity – Fluid not calculated for IBW
Early Clinical Features of Fluid Overload
• Respiratory distress
– Difficulty in breathing
– Rapid breathing
– Chest wall in-drawing
– Wheezing (rather than crepitations)
• Large pleural effusions &/or Tense ascites
• Increased jugular venous pressure (JVP)
Management of Fluid over load
• Minimize fluid
– Stop if in recovery phase
– Minimize in critical phase
•
•
•
•
•
Nurse in the R lateral position
Maintain oxygen saturation above 95%
IV Furosemide +10% Dextran (40) 10 ml/kg ?
Correct hypokalaemia
Assess ABCS
How to prevent fluid over load
Leaking Blood vessels ! – Give only minimal & essential
• Try to manage within the fluid quota (M+5%)
– For 48 hrs for non shock patients
– For 24 hrs for shocked patients
• Expected Urine out put is only 0.5 ml/kg/hr
• Calculate oral fluid also
• Monitor fluid intake regularly during critical
period – Use a fluid monitor
What to do in practice
3 yr old mucus diarrhea mild dehydration had HCT 55%
8 year old 30 kg girl
Fluid for 48 hrs
30 kg
IBW - 25 kg
M
1700
1600
M+5%
3200
2850
5 ml/kg
7200
6000
3 ml/kg
4320
3600
1.5 ml/kg
2160
1800
Fluid balance in health and dengue
Health
Ml/kg/hr
Dengue
Ml/kg/hr
Total intake
3
3
UOP
2
1
Insensible loss
1
1
Leaking
0
1
(+ ve balance)
Water for growth was not taken in to consideration
Fluid balance in health and dengue
Health
Ml/kg/hr
Dengue
Ml/kg/hr
Total intake
3
5
UOP
2
2
Insensible loss
1
1
Leaking
0
2
(+ ve balance)
Water for growth was not taken in to consideration
Fluid balance in health and dengue
Health
Ml/kg/hr
Dengue
Ml/kg/hr
Total intake
3
1.5
UOP
2
0.5
Insensible loss
1
1
Leaking
0
0.25
(+ ve balance)
Water for growth was not taken in to consideration
Monitoring Charts
22 kg
HCT/
plt
HR
BP
RR
UOP
CRFT
Cold
ness
Fluid
Ml/kg
11.00
am
38
146
90/80
47
5 ml
8
Mid
calf
10 ml/kg bld
12.00
noon
48
100
110/8
0
49
SOB
10
2
ankle 10 ml/kg
HS + Laxis 20 mg
1.00 pm
41
100
100/7
0
40
100
Acitis
effus
ions
2
-
3 ml/kg
NS
110
100/7
0
38
Effus
ions
2
-
1.5 ml/kg
2.00 pm
1
2
3
3
4
5
5
6
7
7
?
3 ml/kg NS /one hr
2222/2640
1
60
8
9
9
1
0
11
1
1
13
1
2
1
3
15
1
4
1
5
17
1
6
19
1
7
1
8
21
1
9
2
0
23
2
1
25
2
2
2
3
27
2
4
2
5
29
2
6
31
2
7
2
8
33
2
9
35
3
0
3
1
37
3
2
3
3
39
3
4
41
3
5
3
6
43
3
7
3
8
45
3
9
47
4
0
35
35
35
30
38
32
34
38
45
35
35
30
25
25
25
20
20
20
20
20
20
20
90/80
95/70
95/70
95/65
80/70
90/80
90/80
65/50
100/70
95/70
100/75
95/70
95/70
95/70
95/70
95/70
100/70
100/70
95/70
95/70
95/70
100/70
50
42
*
46
98
40
42
*
44
100
40
100 100
*
100 100
38
85
*
100
36
60
*
100
34
45
*
110
32
45
*
100
30
60
*
110
28
75
*
100
35
26
60
*
100
24
60
48
40
*
100
95
10
10
22
110
100
160
65
65
49
*
120
120
15
30
*
160
110
30
8 10 12 14 16 18 20
46
*
110
45
6
51
*
110
20
4
45
52
*
140
140
00
00
1
30
140
PCV
*
90/80
R
3R5
UOP
10
9
8
7
6
5
4
3
2
1
0
90/80
BP
HR
*
*
*
*
*
*
*
48
Fluid over load
Why?
Causes of fluid over load
• Clinicians gave too much fluid - eg 3-5 ml/kg/hr
• Clinicians thought that extra fluid in the febrile
can prevent shock
• Clinicians thought giving blood can be dangerous
Personal opinion with no proof
WHY ?
Lack of knowledge and training
Interpretation of HCT
Condition of
the patient
Deteriorating
Improving
HCT Rising
HCT Dropping
Colloids
Blood
transfusion
Observe
Increase fluid rate during
early critical phase
Improving !
Encourage
normal feeding
Use Void Volume Chart
7 year old (20 kg ) boy passed 100
ml of urine at 12 MN. He passed
urine at 5 pm soon after coming to
the ward. Interpret his UOP
• UOP is 0.74 ml/kg/hr
He was given 100 ml/hr of
Hartmann solution from MN up 6
am when he passed 400 ml of
urine.
• UOP is 3.3 ml/kg/hr
• ?
His blood counts done on admission
total 5.6 , Platelets 50 000/dl, PCV 45
Same fluid rate was continued. At
12 noon he passed 40 ml of urine.
• UOP is 0.3 ml/kg/hr
• ?
Blood counts done at 6 am – Platelets 50 , HCT 42
Circulation – HR 120, cold limbs CRFT 5 sec
Patient develop massive fluid over
load. After 30 hours in critical
phase, he is on fluid 15 ml/kg/hr.
He passed 300 ml of urine in 4 hrs.
• UOP is 3.75 ml/kg/hr
• ?
Blood counts done at 6 am – Platelets 60 , HCT 36
Circulation – HR 98, no cold limbs CRFT 3 sec
Use monitoring chart
• Chart one – Suspected dengue patient not in
critical stage
• Chart two – Start once patient enter the
critical stage
Knowing the stage of the illness by everybody
in the team is very important
in management of dengue patients
Unusual Manifestations of Dengue
• Encephalopathy
• Hepatic failure
• Renal Failure
• Dual infections
• Underline conditions
Ward round presentation by ho/sho
• This 7 yr old IBW 20 kg child came to the ward 3
days ago, entered the critical phase yesterday
morning. Now 24 hrs in critical phase. On 5
ml/kg/hr of Hartmann.
• Stable circulation. Warm limbs, CRFT 2 sec, BP
100/60
• UOP for last six hours 0.8 ml/kg/hr
• Last HCT 48 ( it has gone up from 42)
• So far We have given 1200 ml out of 2500 ml 48 hr
fluid quota
• We thought of increasing fluid to 7 ml/kg/hr
Diagnosis Card of DHF Patient
Diagnosis
Dengue Hemorrhagic Fever Grade 4
(Severe Dengue with hypotensive shock)
• Patient entered critical phase 24 hrs
after admission to ward
• HCT - Maximu – 52, minimum – 32
• Platelets – Max – 120, Mini – 40
• Blood pressure – min – 40/ ?
Management
• Total fluid during critical period
1850 / 1900
• Crystalloid boluses – 3
• Colloid boluses – 1
• Blood – 10ml/kg x1
Complications –
• Fluid over load – Wheezing, Pleural effusions and ascites. Lasix 20 mg x2
• Bleeding ( HCT 32, need blood 10ml/kg)
• Hypocalcaemia – Serum Ca – 1.8 ( treated with 10 ml 10% ca Gluconate)
Initial fluid for following DHF patients
• DHF with no palpable pulse
– 10-20 ml/kg/15 mt normal saline
• DHF palpable pulse but low BP
– 10ml/kg/15 mt NSS or colloids
• DHF normal BP, cold limbs+ CRFT 4 sec
– 10ml/kg/hr NSS + 10% Dextrose
• DHF no shock just entered the critical phase
– 1.5 ml/kg/hr
• DF/DHF in febrile phase – Oral fluid ?5 ml/kg/hr
Thank You