Yash Chopra’s death should not cause treatment panic: Not all dengue is serious

10:21 am Health Care, Medicine

The mortality of dengue is less than 1% and that too only in selected cases said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal President Heart Care Foundation of India. Dr Aggarwal said that the forthcoming MTNL Perfect Health Mela will focus on identification, prevention and treatment of severe dengue.

There are three groups of patients with dengue, who need attention.

  • Patients with coexisting medical conditions, such as pregnancy, infancy, old age, obesity, diabetes mellitus, renal failure, and chronic hemolytic diseases, may increase the risk of severe dengue and/or complicate management. Referral for hospitalization is recommended for such patients regardless of other findings. Hospitalization should also be considered for patients who may have difficulties with outpatient follow-up or with timely self-referral should complications develop (e.g., patients who live alone or who live far from a health care facility without a reliable means of transport).
  • Patients with “alarm signs” i.e. severe abdominal pain or tenderness, persistent vomiting, abrupt change from fever to hypothermia, mucosal bleeding, liver enlargement on physical exam, or abnormal mental status, such as disorientation.
  • Patients with blood pressure <90/60 mmHg or fall in blood pressure by 20, hematocrit >50% or rise in hematocrit by more than 20, difference between upper and lower blood pressure less than 20, evidence of bleeding other than petechiae,  true platelet count less than 20000, rise in pulse by 20.

Not all dengue is serious

  • The current strains 1 and 3 are not serious.
  • First attack of dengue is usually not serious.
  • Dengue is not serious if one can maintain the difference between upper and lower blood pressure more than 40
  • Dengue is not serious if one can maintain blood volume and avoid intravascular dehydration.

Facts about dengue

• Dengue is a febrile illness that is caused by any one of four serotypes of this flavivirus (DEN-1, DEN-2, DEN-3, and DEN-4).

• It is endemic in more than 100 countries in tropical and subtropical regions of the world and causes an estimated 50 million infections annually worldwide.

• The greatest risk factor for the development of dengue hemorrhagic fever (DHF) or dengue shock syndrome is secondary infection with a different dengue serotype from the original infecting virus. Thus, severe disease occurs primarily in patients who reside in hyperendemic areas where multiple serotypes circulate simultaneously.

• Mosquito control is the most effective approach to the prevention of dengue transmission. There is no licensed vaccine available for preventing dengue.

• Patients with dengue fever should be cautioned to maintain their fluid intake to avoid dehydration and to take paracetamol as needed for fevers and myalgias. Aspirin or nonsteroidal antiinflammatory agents should generally be avoided.

• It is important to manage plasma leakage in dengue hemorrhagic fever with aggressive intravascular volume repletion to prevent or reverse hypovolemic shock. Blood transfusion is appropriate only in patients with significant bleeding. The adequacy of fluid repletion should be assessed by serial determination of hematocrit, blood pressure, pulse, and urine output.

• Prophylactic platelet transfusion has no role.

• Early identification of patients at higher risk for shock and other complications of dengue are important. Patients with suspected dengue who have none of the warning signs for more severe illness and can maintain their fluid intake can be managed as outpatients, but may need daily re-evaluation.

• Duration of illness – The period of maximum risk for shock is between the third and seventh day of illness. This tends to coincide with resolution of fever. Plasma leakage generally first becomes evident between 24 hours before and 24 hours after defervescence.

Insecticide spraying does not help

  • Insecticide spraying in response to dengue outbreaks is not highly effective against A. aegypti mosquitoes, which frequently breed inside houses.
  • Community-based approaches involving education of the population in efforts to reduce breeding sites, such as discarded tires and other containers that accumulate standing water, have shown some promise.

Treatment

  • Exclude other treatable diagnoses. Patients at risk for dengue can acquire other diseases with similar clinical features, such as malaria, typhoid fever, and leptospirosis. Symptoms in patients with dengue virus infections resolve in 5 to 7 days.
  • Patients with dengue fever should be cautioned to maintain their intake of oral fluid to avoid dehydration. Fever and myalgias can be managed as needed with paracetamol. Aspirin or nonsteroidal antiinflammatory agents should generally be avoided because of the risk of bleeding complications and in children because of the potential risk of Reye’s syndrome.
  • Gastrointestinal bleeding or menorrhagia in patients with DHF, and occasionally in patients with dengue fever as well, can be severe enough to require blood transfusion.
  • Platelet transfusions have not been shown to be effective at preventing or controlling hemorrhage, but may be warranted only in patients with severe thrombocytopenia (<10,000/mm3) and active bleeding.
  • Prophylactic platelet transfusions in patients with severe thrombocytopenia but without active bleeding are generally not recommended.
  • Administration of intravenous vitamin K1 is recommended for patients with severe liver dysfunction or prolonged prothrombin time.
  • Use of a histamine H2 receptor antagonist or proton pump inhibitor is reasonable in patients with gastrointestinal bleeding, although there is no evidence of benefit.
  • Plasma leakage in DHF is important to manage with aggressive intravascular volume repletion to prevent or reverse hypovolemic shock
  • In mild cases, oral rehydration may be sufficient. However, in patients with established intravascular fluid loss, intravenous fluid administration is recommended. Blood transfusion is appropriate in patients with significant bleeding; subsequent hematocrit measurements must be interpreted with caution since it is also critical to assess the adequacy of fluid repletion.
  • For patients with hypotensive shock, an initial bolus of 5% dextrose in normal saline or Ringer’s lactate (20 mL per kg of body weight) infused over 15 minutes is recommended, followed by continuous infusion (10 to 20 mL/kg per hour depending on the clinical response) until vital signs and urine output normalize. For patients who improve, the infusion rate should then be gradually reduced until it matches plasma fluid losses.
  • The adequacy of fluid repletion should be assessed by serial determination of hematocrit, blood pressure, pulse and urine output. Patients with shock on presentation should initially have vital signs measured at least every 30 minutes and hematocrit measured every two to four hours.
  • Narrowing of the pulse pressure is an indication of hypovolemia in children even with a normal systolic blood pressure.
  • Normalization of the hematocrit is an important goal of early fluid repletion
  • Patients can develop shock for one to two days after initial fluid resuscitation, which represents the period of increased vascular permeability in DHF.
  • Most patients who present for medical attention before profound shock develops and who receive appropriate fluid therapy will recover quickly.
  • Usually no more than 48 hours of intravenous fluid therapy are required.
  • Discharge from the hospital is appropriate when patients have been afebrile for at least 24 hours and have normal oral intake, urine output, and hematocrit.

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