eMedinewS Editorial

Health Care 8 Comments

Commonwealth Games Special

Dengue Watch (Part 2)

  1. Retro-orbital pain as mentioned in books is present in only up to 15% of cases admitted in Delhi. The importance of platelet transfusion has been blown out of proportion. Even in cases of dengue hemorrhagic fever (DHF), there has been no bleeding at platelet count 2000 cell/cumm and up to 1000 cell/cumm in other SEA countries. Prophylactic platelet transfusion is not indicated in children at all. It is blood transfusion.
  2. Bleeding can be observed both in DF and DHF. DHF can be differentiated from dengue fever by evidence of plasma leakage.
  3. The platelet count is a less important determinant of bleeding.
  4. Indications for blood/platelet transfusion as recommended in clinical practice guidelines are:
    • In cases with significant clinical bleeding, which require blood transfusion. Usually bleeding is > 10% of total blood volume (> 6-8 ml/kg of ideal body weight)
    • In adults with underlying hypertension or coronary heart diseases and platelet < 10,000 cells/cumm. In children, no prophylaxis platelet transfusion, no matter how low the platelet count.
  5. Risk of bleeding in DHF patients:
    • Vascular fragility: Minimal bleeding, only petechiae
    • Platelet count < 30,000-50,000 cells/cumm: Bleeding is usually associated with trauma, no spontaneous bleeding
    • Prolonged partial thromboplastin time (PTT): Advance DIC usually found in cases with prolonged/ profound shock (DHF grade IV)
    • Prolonged prothrombin time (PT), INR > 1.3-1.5, which is the result of liver failure: Major contributing factor for massive bleeding.

There is no evidence to support the use of blood components such as platelet concentrates, fresh frozen plasma or cryoprecipitate. Its use could contribute to fluid overload.

Important instructions for treatment of DHF as per guidelines:

  • If the patient’s condition becomes worse despite giving 20ml/kg/hr crystalloid solution for one hour, replace crystalloid solution with colloid solution such as Dextran or Plasma. As soon as improvement occurs, replace with crystalloid.
  • In case of severe bleeding; give blood transfusion @ 20ml/kg for two hours. Then give crystalloid IV fluids @ 10 ml/kg/hr for a short time (30 – 60 minutes) and later reduce the speed.
  • If hematocrit falls, give blood transfusion 10 ml/kg and then give crystalloid IV fluids at the rate of 10 ml/kg/hr. The volume of blood administered should be just enough to raise the red blood cell concentration to normal.

(With inputs from Dr. K.N. Tewari, Secretary, World Lung Foundation, South Asia, 9911559234)

Dr KK Aggarwal
Editor in Chief