Association of Nursing Service

Administrators of the Philippines, Inc.

(ANSAP)

INTRAVENOUS FLUID THERAPY

FOR PATIENT WITH
“DENGUE CLASSIFICATION”
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

DESCRIPTION:

This module focuses on how the I.V. nurse therapist enables to manage Dengue
according to its classification.

OBJECTIVES:

1. Define Dengue and pathophysiology according to its classification.

2. Utilize nursing process techniques for patients with Dengue.
3. Discuss the infusion therapy though computations associated to Dengue
classification.
4. Discuss documentation on the management of patients with Dengue.

Duration of the Topic:

Eight (8) hours

Participants:

IV Therapists

Course Materials:

Whiteboard
Markers
LCD Projector

Methods/Activities:

Lecture
Discussion
Interactive Participation
Computation drills
Demonstration
WORKSHOP
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

Contents:

Definition of Dengue
History of Dengue Infection
Pathophysiology
Dengue Case Classification
Dengue Case Management according to Classification.
IV FLUID THERAPY
Interpretation of Hematocrit
Documentation
Discharge Criteria
Home Care for Dengue
Real Time Dengue Detection
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

DENGUE – an acute infection disease that in characterized by headache, severe joint

pain, and rashes that is caused by a single stranded RNA virus of the genus flea virus
(species Dengue Virus) transmitted by mosquitoes of the genus aedes.

Breakbone Fever
Dandy Fever
Dengue Fever
Dengue Hemorrhagic Fever

HISTORY OF DENGUE INFECTION

Dr. Benjamin Rush reported the outbreak of dengue fever in 1780 from
Philadelphia which he called “Break-bone Fever”

WHO/DOH National Consensus Definition fever of 2-7 days with any 2 of the ff:
 Aches/pains, nausea/vomiting, abdominal pain, leucopenia, (+) TT
 DF- absence of plasma leakage
 DHF- Plasma leakage, Plt Ct <100,000, Bleeding tendency
 DSS: DHF III- signs of circulatory failure
 DHF IV- profound shock

PATHOPHYSIOLOGY

Etiologic Agent – Dengue virus 1, 2, 3 & 4 and Chikungunya virus.

Cases peaks in the months of July to November and lowes during the month of
February to April. It usually affects preschool and school age (5-9 years old).

Transmission – Bite of Aedes aegypti (day biting female mosquitoes that breeds in
household or standing clean water)

Pathophysiology – Increased vascular permeability and abnormal hemostasis

(vasculopathy, thrombocytopenia and coagulapathy); with an incubation period of
6 days to 1 week.

Diagnostic Test – Tourniquet Test (Capillary fragility test or Rumpel Leads Test), a
presumptive test which is positive in the presence of more the 20 petechaie
within an inch square, after 5 minutes of test.
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

CLASSIFICATION

I. Dengue without warning signs

 Group A – May be sent home.
II. Dengue with warning signs
 Group B – Referred for in-hospital care
III. Severe Dengue
 Group C – Require emergency treatment

DENGUE CASE MANAGEMENT: A STEPWISE APPROACH

STEP 1:

Assessment – History

• Date of onset of fever/ illness

• Quantity of oral intake
• Assess for warning signs
• Diarrhoea
• Change in mental state/seizure/dizziness
• Urine output (frequency, volume and time of last voiding)
• Family or neighbourhood dengue, or travel to dengue endemic areas
• Co-existing conditions such as infancy, pregnancy, obesity, diabetes mellitus,
hypertension, etc

Assessment – Physical Examination

• Assess mental state and GCS score

• Assess hydration status
• Assess haemodynamic status
• Look out for tachypnoea/ acidotic breathing/ pleural effusion
• Check for abdominal tenderness/ hepatomegaly/ ascites
• Examine for rash and bleeding manifestations
• Tourniquet test (repeat if previously negative or if there is no bleeding
manifestation)
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

Overall Assessment – Investigation

• Full Blood Count (FBC) and Haematocrit (HCT)

– A full blood count should be done at the first visit
• Dengue diagnostic tests
– Laboratory tests should be performed to confirm the diagnosis
– It is not necessary for the acute management of patients except in cases
with unusual manifestations

STEP 2:

Diagnosis, Assessment of Disease phase and Severity

• Is it dengue?
• Which phase of dengue? (febrile/critical/recovery)
• Are there warning signs?
• What is the hydration and haemodynamic status?
• Does the patient require admission?

STEP 3:

Management

• Disease notification
• Management decisions: depending on the clinical manifestations and other
circumstances, patients may:
• Be sent home – Group A
• Be referred for in-hospital management – Group B
• Require emergency treatment and urgent referral – Group C

Group A – Who can be sent home?

• Able to tolerate adequate volumes of oral fluids
• Pass urine at least once every 6 hours
• Do not have any of the warning signs, particularly when fever subsides
• Stable haematocrit
• No other co-existing conditions
Ambulatory patients should be reviewed daily for disease progression and
development of warning signs until they are out of the critical period.
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

Group B – Who should be referred for in-hospital care?

Patients with any of the following feature:
• Warning Signs
• Co-existing conditions such as pregnancy, infancy and old age, obesity, diabetes
mellitus, renal failure, chronic haemolytic diseases, etc
• Social circumstances such as living alone or living far from health facility or
without a reliable means of transport.

Group C: Who requires emergency treatment and urgent referral?

Severe dengue
1. Severe plasma leakage with shock and/or fluid accumulation with respiratory
distress.
2. Severe bleeding as evaluated by clinician
3. Severe organ impairment
– Severe liver involvement with AST >= 1000 or ALT >= 1000
– Impaired consciousness with GCS < 15 or BCS < 5

DENGUE CASE MANAGEMENT: RECOMMENDATIONS FOR TREATMENT

GROUP A – Patients who may be sent home

• Should be reviewed daily with full blood count and HCT until they are out of the
critical period
• What to monitor?
– Disease progression
• Defervescence
• Rising HCT with concurrent rapid fall in WBC and platelet count
– Development of warning signs
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

HOME CARE FOR DENGUE

What should be done?

• Adequate bed rest
• Adequate fluid intake (> 5 glasses for average-sized adult & accordingly in
children)
– Milk, fruit juice (caution with diabetes patient) and isotonic electrolyte
solution (ORS) and barley/rice water/clear soup
– Plain water alone may cause electrolyte imbalance
• Take Paracetamol
• Tepid sponging
• Look for mosquito breeding places in and around the home and eliminate them
• Do not take steroids or NSAIDS e.g. Acetyl-salicylic acid (aspirin), Mefenemic
acid (Ponstan), Voltaren tablets, injections or suppositories

Calculation of Oral Rehydration Fluids Using Weight (Barnes and Young Method
Body Weight (kg) ORS to be given
> 3 – 10 100 ml/kg/day
> 10 – 20 75 ml/kg/day
> 20 – 30 50 – 60 ml/kg/day
> 30 – 60 40 – 50 ml/kg/day

If any of these are observed, seek medical attention immediately

• Bleeding:
– Red spots or patches on the skin
– Bleeding from nose or gums
– Vomiting blood
– Black coloured stools
– Heavy menstruation / vaginal bleeding
• Frequent vomiting
• Severe abdominal pain
• Drowsiness, mental confusion or seizures
• Pale, cold or clammy hands and feet
• Difficulty in breathing
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

GROUP B

Referred for In-Hospital Management (1)

Dengue with warning signs:
• Obtain a reference HCT before fluid therapy
• Give only isotonic solutions such as 0.9% saline, Ringer's lactate, Hartmann's
solution
– Start with 5-7 ml/kg/hr for 1-2 hrs, then
– reduce to 3-5 ml/kg/hr for 2-4 hrs, then
– reduce to 2-3 ml/kg/hr or less according to clinical response
• Reassess the clinical status and repeat the HCT

Referred for In-Hospital Management (2)

Dengue with warning signs:
• If the HCT remains the same or rises only minimally, continue with the same
rate (2-3 ml/kg/hr) for another 2-4 hours.
• If there are worsening of vital signs and rapidly rising HCT, increase the rate to
5-10 ml/kg/hour for 1-2 hours.
• Reassess the clinical status, repeat HCT and review fluid infusion rates
accordingly.

Referred for In-Hospital Management (3)

• Give the minimum intravenous (i.v.) fluids required to maintain good perfusion
and urine output of at least 0.5 ml/kg/hr.
• I.V. fluids are usually needed for only 24 – 48 hr.
• Reduce i.v. fluids gradually when the rate of plasma leakage decreases towards
the end of the critical phase. Indicated by:
– the urine output and /or oral fluid intake is/are adequate or
– the HCT decreases below the baseline value in a stable patient.

Referred for In-Hospital Management (4)

Monitoring by healthcare providers:
• Patients with warning signs should be monitored until the at risk period is over.
• A detailed fluid balance should be maintained.
• Parameters that should be monitored include:
– Vital signs and peripheral perfusion (1-4 hourly until the patient is out of
critical phase)
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

Referred for In-Hospital Management (4)

– Urine output (4-6 hourly)

– HCT (before & after fluid replacement, then 6-12 hourly)
– Blood glucose
– Other organ functions as indicated

Referred for In-Hospital Management (5)

Dengue without warning signs:
• Encourage oral fluids.
• If not tolerated, start i.v. fluid therapy of 0.9% saline or Ringer Lactate w/ or w/o
dextrose at maintenance rate
• Patients may be able to take oral fluids after a few hours of i.v. fluid therapy.
• Monitoring by healthcare providers:
- Temperature pattern
- Volume of fluid intake and losses
- Urine output – volume and frequency
- Warning signs
- HCT white blood cell and platelet counts

FLUID MANAGEMENT

 B. Fluid Management for patients who are admitted (Dengue w/o Warning Signs
GROUP B)
◦ Isotonic solutions (D5LRS, D5 Acetate Ringers, D5 NSS or 0.9 NaCl).
Maintenance IVF computed using the caloric expenditure method
(Holliday Segar Method) or calculation based on Weight (Barnes & Young
Method)
Body Weight (Kg) Total Fluid Requirement (mL/day)
0-10 100 mL/kg
> 10-20 1000 mL + 50mL/kg for each kg > 10kg
> 20 1000 mL + 50mL/kg for each kg > 20kg

 If the patient shows signs of mild dehydration, the volume needed for mild
dehydration is added to maintenance fluids over the next 6-8 hours.
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

Maintenance IVF + Fluids as for Mild Dehydration

 Where volume of fluids for mild dehydration is computed as follows (to be added
to the maintenance fluid volume):
Infant 50ml/kg/6-8 hours
Older Child or Adult 30 mL/kg/6-8 hours

GROUP C: Emergency Treatment

Compensated shock(1)
• Start I.V. fluid resuscitation with isotonic crystalloid solutions at 5-10 ml/kg/hr
over 1 hour,
• Then reassess the patient’s condition (vital signs, capillary refill time, HCT,
urine output) and decide depending on the situation:
1. If the patient’s condition improves, IV fluids should be gradually reduced
- to 5-7 ml/kg/hr for 1-2 hr, then reduce
- to 3-5 ml/kg/hr for 2-4 hr, then
- to 2-3 ml/kg/hr for 2-4 hr, and then
- to reduce further depending on haemodynamic status, which can be
maintained for up to 24 – 48 hr.

Compensated shock (2)

2. If vital signs are still unstable (shock persists), check the HCT after the first
bolus:
• If HCT increases or is still high (> 50%),
– Repeat a second bolus of crystalloid solution at 10-20 ml/kg/hr for 1 hour.
– After this second bolus, if there is improvement, then reduce the rate to 7-
10
ml/kg/hr for 1-2 hours, and then continue to reduce as above
• Further boluses of crystalloid or colloidal solutions may need to be given
during the next 24 to 48 hours.

Compensated shock (3)

• If HCT decreases compared to the initial reference HCT
this indicates bleeding and the need to cross-match and transfuse blood
as soon as possible
• Further boluses of crystalloid or colloidal solutions may need to be given
during the next 24 to 48 hours.
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

Hypotensive shock (1)

• Patients with hypotensive shock should be managed more vigorously.
• Initiate IV Fluid resuscitation with crystalloid or colloid solution (if available) at
20 ml/kg as a bolus given over 15 minutes to bring the patient out of shock as
quickly as possible.

Hypotensive shock (2)

1. If the patient’s condition improves,
• Give a crystalloid/colloid infusion of 10 ml/kg/hr for 1 hour,
• Then continue with crystalloid infusion and gradually reduce
- to 5-7 ml/kg/hr for 1-2 hours, then
- to 3-5 ml/kg/hr for 2-4 hours and then
- to 2-3 ml/kg/hr or less, which can be maintained for up to 24 to 48 hours

Hypotensive shock (3)

2. If vital signs are still unstable (shock persists), check HCT after the first bolus:
• If HCT increases compared to the previous value or remains very high (>
50%), administer colloid solutions at 10-20 ml/kg/hr over ½ to 1 hour.
– After this dose, reduce the rate to 7-10 ml/kg/hr for 1-2 hours, then change
back to crystalloid solution and
– Reduce rate of infusion when the patient’s condition improves.
• If HCT decreases way below the reference value this indicates bleeding
– cross-match and transfuse blood as soon as possible (refer to treatment for
haemorrhagic complications)

Hypotensive shock (4)

• Further boluses of fluids may need to be given during the next 24 hours.
• Rate and volume of each bolus infusion should be titrated to the clinical
response.
• Patients with severe dengue should be admitted to the high dependency or
intensive care areas.
• Monitoring:
– Frequent monitoring, until the danger period is over.
– A detailed fluid balance of all input and output should be maintained.
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

Interpretation of Hematocrit (1)

Changes in the HCT are a useful guide to treatment.
Must be interpreted together with haemodynamic status, the clinical response to
fluid therapy and the acid-base balance.

• A rising or persistently high HCT:

• Together with unstable vital signs (particularly narrowing of the pulse pressure)
indicates active plasma leakage and the need for a further bolus of fluid
replacement
• With stable haemodynamic status and adequate urine output do not
require extra intravenous fluid.
• Continue to monitor closely and it is likely that the HCT will start to fall
within the next 24 hours as the plasma leakage stops.

Interpretation of Hematocrit (2)

A decrease in haematocrit:
• together with unstable vital signs (particularly narrowing of the pulse pressure,
tachycardia, metabolic acidosis, poor urine output) indicates major
haemorrhage and the need for urgent blood transfusion
• together with stable hemodynamic status and adequate urine output indicates
haemodilution and/or reabsorption of extravasated fluids; i.v. fluids must be
discontinued immediately to avoid pulmonary oedema.

Hemorrhagic Complications (1)

Mucosal bleeding may occur in any dengue patient but if stable after fluid
resuscitation, it should be considered as minor.
• Patients with profound thrombocytopenia, ensure strict bed rest and protection
from trauma to reduce the risk of bleeding.
• Do not give i.m. injections to avoid haematoma.
• Note: Prophylactic platelet transfusions for severe thrombocytopenia in
otherwise haemodynamically stable patients are not necessary.

Hemorrhagic Complications (2)

• If major bleeding occurs it is usually from the gastrointestinal tract and/or per
vagina in adult females.
• Internal bleeding may not become apparent for many hours until the first black
stool is passed.
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

Hemorrhagic Complications (3)

Who are at risk of major bleeding?
• Prolonged/refractory shock
• Hypotensive shock and renal or liver failure and/or severe and persistent
metabolic acidosis
• Given non-steroidal anti-inflammatory agents
• Pre-existing peptic ulcer disease
• On anticoagulant therapy
• Any form of trauma, including intra-muscular injection
Note: Patients with hemolytic conditions will be at risk for acute hemolysis with
hemoglobinuria and will require blood transfusion.

How to recognize severe bleeding? (4)

Unstable haemodynamic status + any of below:
• Persistent and/or severe overt bleeding, regardless of the HCT level
• A decreased HCT after fluid resuscitation
• Hypotensive shock with low/normal HCT before fluid resuscitation
• Shock is refractory if isotonic fluid of > 40-60mL/kg has been administered.
• Persistent metabolic acidosis ± a normal systolic blood pressure

Treatment of Hemorrhagic Complications (5)

• Give 5-10 ml/kg of fresh packed red cells or 10-20 ml/kg of fresh whole blood at
appropriate rate and observe the clinical response.
– A good clinical response includes improving hemodynamic status and acid-
base balance
– Consider repeating the blood transfusion if
• there is further blood loss or
• no appropriate rise in HCT after blood transfusion
• Little evidence to support the practice of platelet concentrates and/or fresh
frozen plasma transfusion for severe bleeding. But, it is being practised and
may exacerbate the fluid overload.

DISCHARGE CRITERIA

• No fever for 24 – 48 hours

• Improvement in clinical status (general well being, appetite, hemodynamic status,
urine output, no respiratory distress)
• Increasing trend of platelet count (usually preceded by rising WBC)
• Stable hematocrit without intravenous fluids
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

Modes of Reporting of Suspected Dengue Cases to CHD-NCR

Telephone
531-0013
531-0015
531-0017
531-0021
531-0027
531-0034
531-0037
535-4521
535-4537
535-4556
E-mail: No2dengue_ncr@yahoo.com.ph

Note to access the revised dengue clinical case management guidelines 2011 follow the
following steps:
a. Log on to www.doh.gov.ph
b. Click Information Resource Tab
c. Click Non-Serial
d. Click Modules, Manuals, Guidelines Tab
e. Click Revised Dengue Clinical Case Management Guidelines 2011
 INTRAVENOUS FLUID THERAPY FOR PATIENT WITH
“DENGUE CLASSIFICATION”

REFERENCES

1. DOH, Dengue Health Information Center Lectured by

EFREN M. DIMAANO, MD, FPSMID
Chairman, Clinical Division,
San Lazaro Hospital

2. DOH
Dr. Enrique A. Tayag
Assistant Secretary of Health Support to Service Delivery Technical

3. Medical Dictionary, 2005

Merriam-Webster, Incorporated

4. Principles and Practice of Intravenous Therapy 6th Edition, 1997

Sharron M. Weinstein, Plummer’s

5. IV Therapy
Terry Shaylor Rudd and Lana W. Van Sani, 2009

6. Incredibly Easy, 2006

Lippincott Williams and Wilkins