FLUID MANAGEMENT IN DENGUE

FLUID MANAGEMENT IN DENGUE FEVER : 

FLUID MANAGEMENT IN DENGUE FEVER Dr . Nadeem-Ur-Rasool Department Of Pediatrics Lahore General Hospital , Lahore

Introduction : 

Introduction DENGUE FEVER Asymptomatic Symptomatic Undifferentiated febrile illness Dengue Fever (DF) Dengue HemorrhagicFever (DHF) Unusual Dengue

Natural course of the illness : 

Natural course of the illness Dengue Hemorrhagic Fever is a dynamic disease. Its clinical course changes as the disease progresses and consists of three main phases; Febrile phase Critical phase Convalescent phase

Fluid Management of Febrile Phase : 

Fluid Management of Febrile Phase Ensure adequate oral fluid intake. IV fluids If the patient is vomiting or dehydrated and not taking adequate oral. Total fluid requirement depends on the degree of dehydration From the 3rd day onwards, be Cautious as the patients with DHF will be entering the critical phase. Types of Fluids i. 5% dextrose in N/2 for infants below 6 months and N. saline for others. ii. Adequate physical rest +Paracetamol Avoid all NSAIDS and steroids Monitoring : Use monitoring chart

Monitoring during febrile phase : 

Monitoring during febrile phase Temperature four hourly Vital parameters - pulse, blood pressure (both systolic and diastolic), respiratory rate, and capillary refill time - four hourly (may need more) frequent monitoring depending on the clinical situation Intake and output FBC daily (or even twice daily when platelet count is dropping below 1 50 , 000 m ` ) H CT once /twice daily

Fluid Management in the Critical Phase : 

Fluid Management in the Critical Phase Calculation of fluid quota for the critical period Fluid quota is only a guide for management of dengue patients during the critical period of DHF. Patients managed using fluid within this safe quota are less likely to develop fluid overload. When fluid requirement is calculated (both oral and IV), calculate it for the Ideal Body Weight (IBW).

Slide 7: 

The total amount of fluid recommended during the Entire critical phase(irrespective of its length) should be ; M+5% = Maintenance + 5% of body weight

Calculation of Ideal Body Weight : 

Calculation of Ideal Body Weight Weight for height using a growth chart ( 50th centile ) -Best Method Weight for age using a growth chart ( 50th centile) In an emergency situation use these formulae Actual body weight is taken for calculation of fluid if it is lower than IBW

Calculation of total fluid quota for the critical period : 

Calculation of total fluid quota for the critical period M (Maintenance) = 100m1/kg for first 10 kg +50 ml/kg for next 10 kg +20 ml/kg for balance weight 5% of body weight = 50m1 x body weight (kg)

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E. g. Body weight 22 kg M =100 x 10+ 50 x 10+20x2= 1540 ml 5% =50 x 22= 1100 ml M + 5% =1540 + 1100= 2640 ml This is the total fluid quota for the "critical period" (48hr in patients coming without shock and 24 hr in patients coming in shock) The maximum weight for which fluid is calculated in any patient should not exceed 50kg . Accordingly M+ 5% should not exceed 4600 ml in any patient.

Slide 11: 

In patients entering the critical phase start on IV normal saline or Hartmann's solution IV in addition to oral fluid. Initial fluid requirement (oral + IV) is 1.5 ml/kg/hr. Those who can drink well may be given IV fluids as 0.5 ml/kg /hr to 'keep vein open' and the balance as oral. N/2+5% DW for infants & for those not taking orally for long. Calculate the total fluid quota for the patient (M+ 5%) at the beginning of critical phase. Subsequent rate of infusion will depend on the rate of leak judged by pulse, BP, pulse pressure, CRFT, HCT , UOP . hourly urine output is the best guide to decide the rate of infusion.

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Patient who had been in the critical phase for a significant period but not gone into shock, the amount of fluid needed for maintenance could go up to 7ml/hr or more, but would be unlikely to require the same amount for a long period. If a higher rate of maintenance fluid is unable to maintain the pulse pressure, fluid boluses (N. saline or colloids 1o ml/kg/ hr) should be used.

Guide to Rate of Fluid Intake in a patient with SHOCK : 

Guide to Rate of Fluid Intake in a patient with SHOCK Early detection of shock

Guide for the rate of IV fluids in profound shock after initial resuscitation : 

Guide for the rate of IV fluids in profound shock after initial resuscitation 10 9 8 7 6 5 4 3 2 1 0 06 12 18 24 Amount o f fluids (ml / kg / hr) Time ( Hours )

Alogrithm on management of shock in DHF : 

Alogrithm on management of shock in DHF Patient with shock Profound shock or unrecordable BP/Pulse(Grade IV) 0.9% saline (Rapid bolus of 20 ml/kg) Shock with narrow pulse pressure(Grade III DHF) 0.9 % saline. start with 10 ml/kg/hr ( 1-2 boluses ) Response Adjust the rate according to HCT / Pulse / BP / CRFT / UOP No Response Response 0.9% saline 10 ml/kg/hr Adjust rate according to HCT / Pulse / BP / CRFT / UOP No Response Assess ** ABCS,Grouping & DT Colloid 10 ml/kg/hr Dextran 40 or 6% Starch No Response Response 0.9% saline.Adjust the rate according to HCT / Pulse / BP / CRFT / UOP HCT ↑ Repeat Colloid HCT ↓ Blood Transfusion

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Peak of leaking occurs around 24 hours, a patient who has gone into significant shock will be in a stage of leaking that has passed about 24 hours and will only have about a further 4 hours before the leaking stops. Hence, if patient presents with shock ,one would assume that the patient had continued to leak before coming to hospital. Individual patient's fluid rates administered will depend on his/ her rate of leak. The rate of IV fluid administration has to be adjusted all the time depending on vital signs specially pulse rate, BP, pulse pressure, HCT,CRFT, urine output. Total fluid quota M+5% should include the fluid given during resuscitation. There is wide variation in rate of leak from patient to patient.

Indications for Colloids (Dextran and Starch) : 

Indications for Colloids (Dextran and Starch) In the management of shock after 2 crystalloid boluses if the pulse/BP has not picked up. Development of shock when already having fluid overload or the amount of fluid received over a period of time appears to be in the direction of exceeding M+5% deficit

Key points - Colloid administration : 

Key points - Colloid administration Both dextran 40 and 6% Starch (Hydroxy Ethyl Starchy are recommended only during the critical phase (24 to 48h) of DHF. They should only be used as boluses over a maximum period of one hour (10m1/kg /h) at a time and not as infusions unlike saline. (a half bolus could be 5m1/kg given over 30 minutes) Dextran may sometimes interfere with grouping and cross matching of blood. It is advisable to preserve a sample of blood for grouping and cross matching before initiating Dextran. One could use up to 3 doses of Dextran 40 (each as 10mI/kg/hr) during a 24 hour period(6 doses within 48 hours). 6% Starch (HES) could be given up to 5 doses (each as10ml/kg/hour) per 24 hours (10 doses within 48 hours). ~ When Normal saline is given it remains in circulation only for about 1 to 2 hours or less during rapid leaking. Even fluids like fresh frozen plasma (FFP) will readily leak and will not hold blood pressure for long periods. A colloid (dextran or 6% Starch) will remain longer.