1 / 77

Fluid Management in DHF Patients

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. Admit No resuscitation. Need Resuscitation. Treat Fever Rest Fluid Specific drugs Warning signs DD

kenny
Download Presentation

Fluid Management in DHF Patients

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Fluid Management in DHF Patients Dr Rasnayaka M Mudiyanse Senior Lecturer in Paediatrics Faculty of Medicine Peradeniya

  2. Short Duration Fever - OPD Treat and send home Admit No resuscitation Need Resuscitation • Treat Fever • Rest • Fluid • Specific drugs • Warning signs DD Dengue ( group A) ( No warning signs ) Viral fevers Other D • Immediate attention • Fluid • Oxygen • Observation • DD • Dengue (group B) • ( with warning signs) • Other infections • Other D 1. Evaluate & ABC care 2. Fluid boluses 3. Oxygen 4. Hand over MO-MO DD Dengue ( group C) (Sever dengue ) Septicemia Diarrhea Anaphylaxis

  3. Classification of Dengue

  4. Dengue Hemorrhagic Fever or Dengue Leaking FeverEssential Feature In DHF is LeakingDF may have bleeding but not leaking

  5. The Cause of Shock in Dengue • Plasma leakage • Bleeding – external and internal • Hypocalcaemia • Vascular involvement • Inadequate fluid intake • Myocarditis

  6. What is the cause of Plasma Leakage Endothelial cell dysfunction rather than destruction

  7. 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%

  8. Evidences of plasma leakage in DHF (Rt. lateral decubitus position) Rt pleural effusion Ascites A. Rising hematocrit ~ 50%

  9. 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

  10. Rising HCT indicate plasma leakage • 20-30% rise  GIT ischemia including liver • 30-40 % rise  Renal and brain ischemia

  11. 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)

  12. Dengue is a Dynamic Disease

  13. Febrile, Critical and Recovery Phase 1 2 3 Incubation period 5-8 days ( 3-14 days) 2-7 days 1-2 days

  14. Rate of Fluid Leakage 1 2 3 M + 5% Optimum volume of fluid …

  15. 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 ) = ?

  16. Fluid Management in DHF patients

  17. Rational Use of Fluid = Management of Dengue Avoid Prolong Shock Avoid Fluid Overload

  18. 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)

  19. DF & DHF in Febrile Phase

  20. 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

  21. 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

  22. 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

  23. Fluid Allocation for Non Shock Patient 10-20 ml/kg 20-10 ml/kg 1 2 3 10-5 ml/kg 5-10 ml/kg 5-3 ml/kg 3-5 ml/kg 3-1 ml/kg 1-3 ml/kg KVO 1.5 ml/kg M + 5% 48 hrs

  24. Fluid Allocation for Non Shock Patient 10-20 ml/kg 20-10 ml/kg 1 2 3 10-5 ml/kg 5-10 ml/kg 5-3 ml/kg 3-5 ml/kg Fluid over load and shock 3-1 ml/kg 1-3 ml/kg KVO 1.5 ml/kg M + 5% 48 hrs

  25. Fluid Allocation for Non Shock Patient 10-20 ml/kg 20-10 ml/kg 1 2 3 10-5 ml/kg Shock and Fluid Over Load 5-10 ml/kg 5-3 ml/kg 3-5 ml/kg 3-1 ml/kg 1-3 ml/kg KVO 1.5 ml/kg M + 5% 48 hrs

  26. Prolonged shock

  27. 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

  28. Prevent Shock – Manage PCV 10-20 ml/kg 20-10 ml/kg 1 2 3 10-5 ml/kg 5-10 ml/kg 5-3 ml/kg 3-5 ml/kg 3-1 ml/kg 1-3 ml/kg KVO 1.5 ml/kg M + 5% 48 hrs

  29. 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 ? Lack of knowledge and training Failures in teaching/training programs WHY ?

  30. (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

  31. Management of DHF Grade 4Severe 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

  32. 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)

  33. Management of DHF Grade 4Severe Dengue with Hypotensive shock • 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 Fluid bolus 10-20 ml/kg Normal Saline / 15 mt Improving , HCT coming down gradually , good UOP No improvement HCT dropping – Blood transfusion No improvement HCT Rising – Colloid transfusion

  34. 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 Rising HCT • 2ndBolus - Colloids • 10 – 20 ml/kg/ ½-1 hr Blood transfusion whole blood 10 -20 ml/kg Packed RBC 5-10 ml/kg • 3rd bolus - Colloids • 10 – 20 ml/kg/1 hr

  35. DHF Grade 3Dengue 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)

  36. Management of DHF grade 3(Severe Dengue with Compensated shock) • 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 Fluid bolus 5-10 ml/kg Normal Saline / 1hr Improving , HCT coming down gradually , good UOP

  37. 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 Blood transfusion Packed RBC 5-10 ml/kg Whole blood 10-20 ml/kg Fluid bolus saline /colloids 10 -20 ml/kg for 1hr However, a rising or persistently high HCT together with stable haemodynamic status and adequate urine output does not require extra intravenous fluid.

  38. Patients not responding to usual fluid boluses • Massive plasma leakage – rising PCV • Concealed hemorrhage – Drop of PCV • Hypocalceamia • Hypoglycaemia • Hyponatremia • Acidosis

  39. 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

  40. Fluid Allocation for shocked Patient 20-10 ml/kg 1 2 3 10-5 ml/kg 5-3 ml/kg 3-1 ml/kg KVO M + 5% 24 hrs

  41. Fluid Allocation for Non Shock Patient 10-20 ml/kg 20-10 ml/kg 1 2 3 10-5 ml/kg 5-10 ml/kg 5-3 ml/kg 3-5 ml/kg 3-1 ml/kg 1-3 ml/kg KVO 1.5 ml/kg M + 5% 48 hrs

  42. 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

  43. Fluid Management in Recovery Phase

  44. 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

  45. 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.

  46. Management of severe bleeding • Probably he has internal bleeding • Manage with • 10 ml/kg whole blood • 5 ml/kg Packed RBC

  47. 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

  48. 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-

  49. Why do you do platelet counts ? • To decide on platelet transfusion - X • To recognize the beginning of critical stage - • As a prognostic indicator-

More Related