Taking the sting off dengue
Early diagnosis and good clinical management are the panacea for preventing dengue-deaths. “This is the only way to battle this strange viral disease where healthy and well-nourished children and adults seem to be more vulnerable,” stressed Consultant Paediatrician Dr. LakKumar Fernando.
Commending his colleagues, both Paediatricians and Physicians, across the country whose efforts have reflected a drastic drop in dengue-deaths over the past few years, he urges constant vigilance. “We have to be alert even if people walk into hospital, as the situation may deteriorate quickly and send the patient into shock, followed by death,” he says, pointing out the importance of the Dengue NS1 Antigen Test which can be performed on Day 1 of fever, after 12 hours of fever.
Guiding people on what to do, Dr. Fernando says that even if the Dengue NS1 Antigen Test is not done on Day 1 and an adult or child has fever for more than two days, “seek medical attention because time is of essence”.
When a child is having fever, parents need to take the following measures:
Check the temperature with a thermometer and record it along with the timings to help the doctor.
Give the correct dosage of paracetamol and no other anti-pyretic drug.
Carry out sponging — between paracetamol doses — with warm water and not cool or iced water.
Rest is very important. A child with fever should not be sent to school and adults with a fever should not go to work.
Focusing on the four strains of dengue — DEN-1, DEN-2, DEN-3 and DEN-4, he says that anyone of these strains can cause both Dengue Fever (DF) and Dengue Haemorrhagic Fever (DHF). “Infection with one strain provides immunity only to that strain, while if a person gets another strain, the antibodies created in the body by the first infection will make the second more severe. The vital need is to differentiate between DF and DHF for they look similar on Days 1 and 2 of illness. Plasma leakage would be the deciding factor between the two.”
The pointers are:
DF will have NO plasma leakage
DF will never end in DHF
The red flag in DHF will be plasma leakage from the blood vessels to body cavities such as the abdominal cavity and the pleural cavity. Beware of leaky capillaries – that is the alert to DHF
A drop in the platelet count will point towards dengue
The haematocrit count and ultrasound or X ray evidence of fluid in the chest (pleural cavity) or abdomen (peritoneal cavity), will be essential tools in catching DHF.
The three phases of dengue are: Febrile, Critical and Recovery
Febrile Phase – The sudden onset of high fever lasting between 2-7 days. There may be flushing of the face, skin redness or rash, muscle and joint pain and headache. Some may also develop a sore throat, infected pharynx and conjunctival (eye) infection. Nausea and vomiting are common. These features will be present in both DF and DHF, with a tender liver indicating a tendency towards DHF. Critical Phase – Lasting between 24 and 48 hours, this phase comes towards the end of the febrile stage.
Almost never occurring in the first two days of the disease, the critical phase could grip the patient any time from Day 3, commonly on Day 4 or 5 or even as late as Day 7. At this stage, the fever may come down rapidly but the patient’s general condition will not improve, unlike in other viral infections. Sometimes he may improve if there has been minimal or no plasma leak. However, the leakage of a large volume of plasma will make the patient critically ill.
Recovery Phase – Lasts 3-5 days but may be longer in adults. The plasma leakage stops and the fluid that leaked out during the critical phase is re-absorbed. The patient’s well-being and appetite improve. The movement of blood stabilizes and urine output starts increasing. May develop a recovery rash which has white areas on a red background along with generalized itching. A rise in the platelet count will be preceded by a rise in the white blood cell count.
Close monitoring is the answer to saving lives, according to Dr. Fernando, not two-hourly but half-hourly during the 24-48 hour ‘critical phase’
The Management Plan:
Day 1 & 2 – The patient should be hydrated, reversing any losses due to vomiting. If there is vomiting, he should be given fluids only to maintain the usual body functions. It is unlikely that the patient will get into the critical phase.
Day 3 – If the patient has DHF, don’t give large amounts of fluid freely to prevent an overload. It is better to restrict fluids to some degree only to maintain a ‘just’ adequate urine output.
CRITICAL STAGE – A platelet count of less than 100,000, an increase of haematocrit (packed red blood cells in a proportion of blood) and/or the presence of fluid in body cavities detected through X-rays and ultrasound scanning will alert the doctors.
The fluid leakage will reach a peak after 24 hours, slowing down thereafter and stopping after 48 hours. Very important to gauge the exact start of the leakage and administer the fluid spread across the 48 hours. Essential to work out the total fluid volume that should be given to each individual patient according to the ideal body weight.
If the patient comes in late after leakage has started and in shock, it may be an indication that leakage has already gone on for about a day. Then fluid intake should be spread across the next 24 hours only.
Electrolyte solutions such as Jeevani should be given orally without sticking to plain water and those in the critical phase put on intravenous fluids at a minimal level as well.*
Close monitoring is essential because as the patient peaks the leakage stage and shock is detected, the fluid infusion rate should be increased rapidly. If not, the patient will die.
As many patients appear conscious and very alert until the last stage of shock, health personnel are lulled into a sense of complacency — to see the early signs of shock, pulse and blood pressure need to be measured frequently.
Shock could come after the patient becomes restless briefly, followed by becoming pulse-less. Then immediate resuscitation has to be performed.
Whenever pulse, blood pressure or urine output drops or haematocrit increases the rate of infusion may have to be increased but once they stabilize the rate should be reduced, preventing a fluid overload.
| Spot DHF The four essential criteria in the clinical definition of DHF are: Fever or recent history of acute fever Haemorrhagic manifestations Low platelet count – 100,000/mm3 or less Objective evidence of leaky capillaries – elevated haematocrit and pleural and other effusions | |
