Dengue hemorrhagic fever and Dengue shock syndrome Severe

Dengue hemorrhagic fever and Dengue shock syndrome - Severe Dengue Fever 奇美醫學中心 楊俊杰醫師

Outlines Ø Clinical presentations Ø Laboratory examinations Ø Diagnosis Ø Management

Clinical Presentations Before admission Fever Vomiting, watery diarrhea with blood in stool Periumbillical abdominal pain for 1 day After admission Cold peripheral perfusion, mottled skin, shortness of breath Fresh blood from NG tube, mouth, endotracheal tube, anal tube Diffuse petechiae over trunk

Laboratory Examinations (1) WBC (/u. L) 5800 D 1 27700 ↑ D 25 band (%) Platelet (/u. L) 15 ↑ 14000 ↓ D 1 CRP (mg/ml) 88. 8 ↑ D 1 146. 9 ↑ D 8 2. 73 ↑ D 1 23. 15 ↑ D 12 PCT (ng/ml) Dengue NS 1 Ag rapid test (+) D 1

Laboratory Examinations (2) Hb (g/d. L) Hct (%) PT/APTT (Sec) 18. 9 ↑ D 1 7. 9 ↓ D 4 51. 6 ↑ D 1 27. 9 ↓ D 5 14. 4 ↑ /48. 0 ↑ D 1 15. 1 ↑ /59. 6 ↑ D 3 D-Dimer (ng/ml) FDP (ug/ml) Fibrinogen (mg/d. L) 7463. 4 ↑ D 1 27. 6 231 D 1 ↑

Laboratory Examinations (3) Lactate (mmol/L) 4. 1 ↑ /7. 9 ↑ D 1/D 3 PO 2/Fi. O 2 (mm. Hg) 76. 6 ↓/66. 3 ↓ D 2/D 4 (Day 4) CPPV mode, Vt: 360 ml, PEEP: 18 cm. H 2 O, Fi. O 2: 100%, PIP: 42 cm. H 2 O, Pplateau: 40 cm. H 2 O, Fetanyl + Ativan + Nimbex GOT/GPT (U/L) Bil-T/D (mg/d. L) Ammonia (umol/L) 4319 ↑/1366 ↑ D 1 7718 ↑/1257 ↑ D 2 4. 45 ↑/3. 17 ↑ D 1 18. 54 ↑/13. 78 ↑ D 19 135 ↑ D 2

Laboratory Examinations (4) BUN/Cr. (mg/d. L) Amylase (IU/L) Lipase (IU/L) 50 ↑/4. 14 ↑ D 1 194 ↑/12. 46 ↑ D 21 225 ↑ D 2 931 ↑ D 7 594 ↑ D 2 1359 ↑ D 7 Abdominal CT: diffuse mild swelling of pancreas Albumin (g/d. L) 3. 7 D 1 1. 8 ↓ D 3 D 11

Diagnosis Severe Dengue fever (Dengue hemorrhagic fever and Dengue shock syndrome) with acute hepatitis, acute kidney injury, disseminated intravascular coagulation, gastrointestinal bleeding, acute pancreatitis, probable coexisting bacterial infection and severe sepsis acute respiratory failure s/p mechanical ventilation

Management Treat underlying diseases Dengue & coexisting bacterial infection: inflammation, bleeding Hospital acquired infection: VAP, catheter related sepsis Hemodynamic support and Fluid status management Perfusion pressure, perfusion, O 2 delivery, intravascular volume Internal and external fluid status

Underlying diseases (1) Bleeding Diffuse bleeding Platelet ↓ PT/APTT ↑ CNS Hb (g/d. L) D 1: 18. 9 - D 4: 10. 5 Plt: (/u. L) D 1: 14 K - D 4: 55 K PT (Sec) D 1: 14. 4 - D 4: 12 APTT (Sec) D 1: 48 - D 4: 46. 7 Hb ↓ PRBC: 10 U Plt: 7 U Pain, agitation, delirium Fetanyl + Ativan + Nimbex Sedation withdrawal PIP < 35 cm. H 2 O, Fi. O 2≦ 50%, PPEP ≦ 10 cm. H 2 O, GI work FFP: 38 U Cryo. : 20 U Tramadol, Zyprexa zydis, Haldol, Ativan, Etumine, Mesyrel, Inderal

Underlying diseases (2) Circulation Cold peripheral perfusion D 2: cold Elevated lactate level D 4: warm Lac. (mmol/L) D 3: 7. 9 D 5: 2. 0 D 1 -3: + 22600 ml D 2: GEDI/CI (626/4. 27) D 3: GEDI/CI (787/5. 64) D 4: GEDI/CI (766/3. 89) Lung Acute pulmonary edema, PO 2/Fi. O 2 mixed type D 2: 76. 6 D 3: 119

Underlying diseases (3) GI Liver UGI bleeding PPI Ileus Prokinetics: promeran, mopride Gastroparesis NJ tube Acute hepatitis Nutrition support (parenteral and enteral) Jaundice Urso Hyperammonemia

Underlying diseases (4) Kidney Acute oliguric renal failure Fluid (Crystalloid firstly, colloid) Diuretics CVVH H/D Recirculation problem Pancreas Acute pancreatitis Supportive care Pain control + Nutrition support

Underlying diseases (5) Infection Community acquired Antibiotics ? ? ? Hospital acquired Fever (adrenal insufficiency? ) WBC/band% Plt CRP/PCT Endocrine Type 2 DM Relative adrenal insuffiiciency Insulin Steroid

Hemodynamic support & Fluid status management

Everyday in ICU Hemodynamic Status Fluid Status Evaluation hydrostatic pressure/permeability/oncotic pressure Perfusion pressure？ Perfusion ？ (Flow, Cardiac output) ？ Oxygen delivery (C. O, Hb, Sa. O 2) ？ Int. human body Ext. human body Pulmonary edema Sclera Pul. congestion Scalp Pleural effusion Trunk Ascites Limbs Bowel edema？ Inner side of thigh Genital area

Fluid choice: Crystalloid or Colloid? Hydrated status Albumin level Na+ Crystalloid 0. 9% N/S Chemosis Dehydrated Lactated Ringer’s K+ Normal hydrated Peripheral edema Colloid Edematous Permeability？ Cl-

Hemodynamic Status on Day 4 Adequate perfusion pressure BP: 113/75 mm. Hg MAP: 89 mm. Hg Adequate perfusion (cardiac output) Cold to Warm Perfusion SVI: 23 to 41 ml/m 2 CI: 2. 72 to 3. 81 L/min/m 2 Adequate O 2 delivery (Q, Hb, Sa. O 2) Lactate: 7. 9 to 2. 4 mmol/L Adequate Intravascular Volume GEDI: 569 to 766 ml/m 2 (Lactate: 2. 0 mmol/L D 5)

Fluid Status Management (1) Day 1 Day 4 Total body water ↑ Interstitial water ↑ Intravascular volume: adequate

Fluid Status Management (2) Day 4 Day 15 Body weight: D 1 80 Kg to D 15 81 Kg