4.5 Some Important Notes

Role of steroid

Basis of DHF pathogenesis is hypothesized to be immunologic that is tempting for immunomodulatory drugs for therapy most common of which is steroid. Currently there is no specific recommendation of steroids for patients with dengue syndrome.

But steroid has been used in Dengue Encephalopathy and Hemophagocytic Syndrome empirically with anecdotal benefits.

There has been used of different formulation of steroids in severe dengue with refractory shock case in different regions of globe, but there is lack of sufficient conclusive evidence.

Well-designed Randomized Control Trial for steroids in severe dengue should be completed before strong recommendation can be solicited.

Special Concerns

Older patients, particularly those with congestive heart failure, must not be given excessive amounts of intravenous fluids.

Rare cases of vertical dengue transmission have been reported. Dengue should be suspected in pregnant patients with compatible clinical features. The potential for a neonate to be born with signs and symptoms of dengue fever should be anticipated.

Pitfalls

Failure to suspect dengue infection in febrile patients with a history of travel to dengue endemic areas within 2 weeks of the onset of illness.
Failures to suspect, identify, and treat other possible diseases such as meningitis or malaria.
Failure to admit patients with signs and symptoms of intravascular volume loss for intravenous hydration.
Failure to administer appropriate fluids to patients with dengue hemorrhagic fever or dengue shock syndrome (moderate and severe) in proper rate.
Failure to refer or transfer potentially critical or critical patients to better facility in time.
Failure to notify public health authorities about suspected cases of dengue infection.

Check list

Cases of DHF should be observed every hour.
Serial platelet and HcT determinations for drop in platelets and rise in HcT are essential for early diagnosis of DHF
Timely intravenous therapy with isotonic crystalloid solution may prevent shock and or lessen the severity. Be careful about the temperature of fluid to avoid chills and rigors.
If patient's condition becomes worse despite giving 10 ml/kg/hour, replace crystalloid solution with colloid solution such as Dextran or plasma. As soon as improvement occurs replace with crystalloid.
Preferred dose of colloid is 10 ml/kg (maximum dose 30 ml/kg/day).
If improvement occurs, reduce the speed from 10 ml to 7 ml, then 5 ml, then 3ml and finally to 1.5 ml/kg.
If HcT falls, give blood transfusion 10 ml/kg and then give crystalloid IV fluids at the rate of 10 ml/kg/hour.
In case of severe bleeding, give blood transfusion about 10 ml/kg over 1 - 2 hours. Then give crystalloid at 10 ml/kg/hour for a short time (30-60 minutes) and later reduce the speed.
In case of shock, give oxygen.
For correction of acidosis, use sodium bicarbonate. Acidosis should be partially corrected if base deficit is more than 6 mmol/L. Half of the calculated based deficit should be administered as 1-2 mmol/kg of Sodibicarbonate IV over 20 minutes. Available Sodibicarbonate solution in Bangladesh is of the strength 7.5% i.e. 1 ml contains 2 mmol/ml. So, 50 - 100 ml of Sodibicarbonate is to be added to make up to one liter of IV fluid of glucose containing crystalloid.
Check for any concomitant other medical or surgical condition and or any maintenance therapy.

Don't

Do not give aspirin or NSAID for the treatment of fever.
Avoid giving blood transfusion or platelet concentrate unless there is hemorrhage and bleeding, fall in HcT or severe bleeding.
Do not use antibiotics per see for dengue syndromes.
Do not change the infusion rate of fluid rapidly or abruptly i.e., avoid rapidly increasing or rapidly slowing the infusion rate of fluids.
Insertion of nasogastric tube to determine concealed bleeding or to stop bleeding (by cold lavage) is not recommended since it is hazardous.
Avoid IM injections.
Avoid tooth brushing in presence of gum bleeding.

Good Medical Practice for IV Therapy

Always collect and check necessary appliances before proceeding to IV puncture.
Use gloves to protect yourself and mask to protect the patient. Wash hands with antiseptic before handling cannula/needle. Always use disposable items. Be careful about needle stick injury.
For IV choose a vein at a site having the following criteria: Distal, relatively less mobile and inactive, away from joint with overlying healthy skin and after shaving hairs. If necessary, immobilize the part with sprint. Keep proximal sites reserve for future puncture if necessary.
Preferably use cannula having wider bore (18G or wider), which may allow high flow rate and blood transfusion if necessity arises for avoiding further puncture. Properly fix the cannula with adhesive tape. Put date and time of infusion/transfusion beginning on bag and on adhesive tape.
Insert the cannula or needle along the lengths of vein appropriately to avoid extravasation and check the site frequently for it. Avoid multiple punctures.
Don't keep the cannula/needle in a same site for more than 48 hours to avoid phlebitis.
If extravasation occurs immediately remove the cannula/needle and keep the part elevated.
Always check the fluid bag for deposits, puncture, leaking, proper seals in the port, dirt and labels. In such cases discard the bag. Similarly check the infusion/transfusion sets and cannula. Never reuse any disposables and remaining fluid in bag.
For high flow rate never use cold fluid to avoid chills and discomfort. Warm the fluid near to body temperature by placing on the cover of the sterilizer and not immersing in that.
Always dispose the disposables and sharps in a bin to be managed properly.
Hang the fluid bag at appropriate height and check for proper fluid flow.