Ashani Jayamini Thamel, 10, was very ill. She was not only running such a high temperature that her mother could feel the heat through the T-shirt but she was also throwing up blood.
Waiting in line to see a private doctor, people advised the mother that time seemed to be running out and when Ashani collapsed, she decided to rush her to the Gampaha General Hospital.
When she was admitted to hospital on July 30 around noon, this was Ashani's case history: Fever for 5 days, bloodstained vomiting for a day, bleeding from the gums, very low pulse, un-recordable blood pressure and tender liver. A blood test indicated a platelet count of 11,000.
Three days later on August 2, this critically ill child was up even though her platelet count was 8,000
When the Sunday Times met her on August 9, she was fine. She was back home with her mother and had been well after she passed the "critical phase" of this disease that has been plaguing Sri Lanka for two decades and sending many men, women and children to their deaths….this year alone dengue has claimed 186 lives, with many succumbing in hospital Intensive Care Units under the best care and expertise.
Ashani, however, had not been pumped with loads of fluid, packets of platelets or continuous blood transfusions, during the "critical phase".
A different and new type of management had been resorted to by the team of doctors headed by Consultant Paediatrician Dr. A. LakKumar Fernando who has brought back valuable insights from Thailand which has been researching dengue for more than 50 years. He and five other Consultants had been part of a workshop at the WHO Collaborating Centre for Case Management of Dengue Fever (DF), Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS) at the Queen Sirikit National Institute of Child Health in Bangkok in May.
Not only Ashani but other critically ill children stricken with dengue have been brought to the Gampaha Hospital, recovered and left a few days later, like from several other hospitals that now practise the new guidelines learnt from Thailand, it is learnt. The monitoring of such patients has been intense, not two hourly but half-hourly, with charts being meticulously filled out by the team of doctors and nurses under Dr. Fernando and Consultant Paediatrician Dr. Chithra Fernando.
Management is vital, points out Dr. Fernando who interacted in Thailand with Prof. Siripen Kalayanarooj and Prof. Suchitra Nimmannitya, considered to be world experts on dengue, who have revolutionized these techniques.
Differentiation between the look-alikes of DF and DHF is a key factor, he says, adding that they look very similar in the first two days of illness. There is, however, no plasma leakage in DF which however badly managed will not lead to DHF, it is learnt.
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| Lucky to be alive: Ashani |
Stressing that a drop in the platelet count may be a strong pointer that the patient is suffering from dengue, he says that other counts that are important are the haematocrit (packed cell volume) count, the cholesterol count and the albumin count.
"Plasma leakage from the blood vessels to body cavities such as the abdominal cavity and the pleural cavity is another danger signal," he says, adding, "The diagnosis of DHF will depend on objective evidence of leaky capillaries, for there is no plasma leakage in DF."
Dubbing DHF a "dynamic disease", he stresses that it has three important phases - 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 the scales being tipped more 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 grips the patient any time from the 3rd day, commonly on the 4th or 5th day or even as late as the 7th day. 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 increases. 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.
The management of the patient during the 24-48 hour "critical phase" will determine what complications will arise and whether he lives or dies.
Giving a word of advice to parents, he says that if a child is having fever it is important to check the temperature with a thermometer and record it along with the timings to help the doctor. The correct dosage of paracetamol should be given and sponging, between these doses done with tap water and not cool or iced water.
Rest is also very important, he says, adding that if a child has fever he should not be sent to school and if it is an adult he should not go to work.
Detailing the management process, Dr. Fernando explains that as it is unlikely that the patient will get into the critical phase in the first two days of the disease, he should be hydrated, reversing any losses due to vomiting. If there is no loss, the fluid intake of the patient should be just to maintain the usual body functions.
If the patient has DHF, from the 3rd day onwards don't give large amounts of fluid freely to prevent an overload, he cautions, emphasizing that some fluid restriction will be good.
How is the critical stage
identified?
The clinical parameters include a platelet count of less than 100,000, increase of haematocrit (PCV) by 20%, low albumin or cholesterol detected by frequent blood tests and/or the presence of fluid in body cavities detected through X-rays and ultrasound scanning.
Tracing fluid leakage, he reveals that it reaches a peak after 24 hours, slowing down thereafter and stopping after 48 hours.
Urging that if the patient has been in hospital from the beginning it is important to zero in on the exact start of the leakage, he says that the total fluid intake should be worked out according to ideal body weight and then spread across the 48 hours. But 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.
What fluids should be
administered?
Orally don't give just plain water, he advises but electrolyte solutions such as Jeevani, while those in the critical phase should invariably be on intravenous fluids at a minimal level as well. "These patients need to be monitored closely and as they peak the leakage stage, the fluid infusion rate rapidly increased if shock is detected. Otherwise they will die from prolonged shock."
Many patients appear conscious and very alert until the last stage of shock, the Sunday Times understands but pulse and blood pressure need to be measured frequently to catch the early signs of shock.
"When going into shock, the patient may become restless briefly before becoming pulseless, that's why monitoring and being ready to resuscitate him can save his life," says Dr. Fernando.
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.
The guiding factor should be – not too much, not too little but just the right amount of fluid during the critical phase, with constant monitoring, he reiterates, adding that keeping the platelet count up is not a priority in management.
Citing the case of Ashani who did not receive platelet transfusions even though her count dropped to 6,000, Dr. Fernando says the platelet count is only useful in the diagnosis but not in management.
"Platelet transfusions are only needed very rarely and sometimes can do more harm than good. Each platelet packet is about 100-150 ml in volume and is a major cause of fluid overload in those who have died despite being given such treatment."
Referring to claims that papaya juice helps increase the platelet count in dengue, Dr. Fernando points out that there is still very little evidence to indicate so. If by giving papaya juice, a falsely high platelet count is recorded, it will mislead doctors from identifying the time a patient enters the critical phase, he says, adding that this may be worth studying.
The four essential criteria in
the clinical definition
of DHF are:
- ever or recent history of acute fever
- Haemorrhagic manifestations
- Low platelet count – 100,000/mm3 or less
- Objective evidence of leaky capillaries – elevated haematocrit (20% or more over baseline), low albumin/cholesterol and pleural or other effusions
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