Journal Reading

Infection Division

DENGUE HEMORRHAGIC FEVER:

CLINICAL EFFICACY OF VITAMIN K
Vedavyasa Srigade
Departemen of Pediatrics, Niloufer Hospital, Osmania Medical College,
Hyderabad, Telangana, India
 ▸ Background: At present dengue is the most significant viral infection

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affecting public health and survival. Bleeding in dengue due to many
reasons can cause significant anemia and death. Elevation of
prothrombin time (PT) in dengue points to liver failure and consequent
bleeding.
▸ Methods: retrospective review of medical records of children admitted
with confirmed and clinical DHF. Children in the age group of 1 month to
15 years from June to November of 2015 at the Institute of Child Health,
ABSTRACT : Niloufer Hospital, Hyderabad, were included in the study.
▸ Results: Of the 100 patients with confirmed DHF, 26 met the inclusion
criteria, and of the 133 clinical DHF, 27 met the inclusion criteria. The
presentation of bleeding in decreasing order of frequency was malena,
epistaxis, hematuria, hematemesis, gum bleed, ecchymoses, and
hematochezia. Deranged PT was seen in nearly 100% of the patients,
and hepatomegaly was seen in 77% patients, while thrombocytopenia
was seen in 80% patients. Clinical response to vitamin K was seen in
80.8% of confirmed and 92.6% of clinical DHF.
▸ Conclusions: presentation of bleeding suggests coagulation failure as
the main contributor to bleeding rather than thrombocytopenia. Overall
response rate to vitamin K was 86.8% (95% CI: 74-94%). Early institution
of vitamin K in DHF may prevent anemia, and reduce the need for
transfusions.
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Dengue is the most rapidly spreading arthropodborne viral
disease of human beings with significant morbidity and
mortality

The listed causes of bleeding in dengue hemorrhagic fever (DHF)

INTRODUCTION are abnormal coagulation profile, thrombocytopenia, platelet
dysfunction, prothrombin complex deficiency secondary to liver
involvement, endothelial injury, prolonged aPTT and disseminated
intravascular coagulation (decrease in fibrinogen level, increased
level of fibrinogen degradation product, increased level of D-Dimer,
consumptive coagulopathy, activation of mononuclear
phagocytes), sequestration of platelets, acidosis, hemorrhagic
gastritis, and ulceration

There is a paucity of evidence regarding the efficacy of vitamin

K in DHF.
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MATERIALS
• Retrospecti
ve review of
Materials

• Inclusion : Children 1
month -15 years with • Analysis using
AND medical confirmed and clinical DHF. SPSS software
METHODS records • Exclusion : Children with version 24.0. and
dengue and concurrent analysed
infections like leptospirosis statistically with
and Incomplete records chi square test

Methods

Statistic
Analysis
5 Group A. Dengue
fever without
warning signs
• No signs

MATERIALS
AND
METHODS Group B. Dengue • Cases who presented with or developed
fever with warning abdominal pain or tenderness or had vomiting or
signs any bleeding manifestations or edema

Group C. Severe • with shock, plasma leak or any organ

dengue involvement
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MATERIALS
Mild
hyponatremia
• Serum sodium level
between 130-134.9 mEq/L

AND
METHODS Moderate • Serum sodium level
hyponatremia between125-129.9 mEq/L

Severe • Serum sodium level <125

hyponatremia mEq/L
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RESULTS
8
Results
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Results
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Results
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Results

Total 81 100%
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Results
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Results
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Results
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This Study
▸ Neurologic manifestations
0.76 % cases.
DISCUSSION
▸ Serum Sodium was normal in
dengue in group A and group
C whereas mild hyponatremia
in group B in dengue with
warning signs
▸ Neurologic manifestations
0.76 % cases.
Other Studies
▸ Kamath SR et al, neurological
manifestations in 20% cases
▸ Many studies revealed mild
hyponatremia is common in
dengue confirmed patients
▸ Similar to Varavithya et al, 
hyponatremia common
among dengue patients
▸ Pancharoen et al, 
hyponatremia in dengue
patients can cause
convulsions, especially in
infants
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DISCUSSION
Limitation
• The present study had not taken the serum
Sodium at different stages of dengue.
• 35.9% of cases was not taken sodium serum.
• In previous studies, the alteration in serum
Sodium levels in dengue was not influenced by
sex and incidence of dengue associated
complications.

• Further studies should include serum Sodium

level in dengue fever, GHF grade I, II, III, IV in
phase of febrile, critical, and recovery. Careful
Recommendation monitoring of electrolytes, acid-base status and
renal function are necessary.
• Careful monitoring of electrolytes, acid-base
status, and renal function are necessary.
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CONCLUSION
▸ Mild hyponatremia in dengue infected children
dengue with warning signs.
▸ Serum Sodium helps to determine the severity of
dengue infection.
18
A. Validity
▸ 1. Apakah awal penelitian didefinisikan dengan jelas ? Ya. untuk
menentukan kadar natrium pada pasien virus dengue
▸ 2. Apakah menyatakan desain penelitian dengan jelas ? Ya. studi cross-
sectional pada 128 anak umur 0-15 tahun dengan demam dengue dari Juni
2014 sampai Mei 2016
TELAAH
KRITIS
▸ 3. Apakah pembanding dinyatakan dengan jelas ? Ya. Grup A (demam
dengue tanpa warning sign), Grup B (Demam dengue dengan warning sign),
JURNAL dan Grup C (demam berdarah dengue/dengue syock sindrom)
“ EBM/
▸
Buki klinis ”
4. Apakah faktor kausal dikemukakan ? Ya. hiponatremia sering pada DBD,
terutama DSS.
oleh Maya
Susanty
▸ 5. Apakah kelompok yang dibandingkan sebanding pada tahap awal ? Ya,
sebanding antara usia, jenis kelamin, dan epidemiologi
▸ 6. Apakah follow up dilakukan secara memadai ? Tidak , penelitian ini
adalah cross sectional study
▸ Note: penelitian ini Valid
▸
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B. Important (clinical important)
▸ 1.Apakah hasil dipaparkan secara jelas dengan hasil nilai
P? Ya , uji statistic X2 dengan nilai P.

TELAAH
KRITIS
JURNAL

▸ Note: penelitian ini mempunyai kepentingan klinis

penanganan pasien dengue
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C. Aplicability ( penerapan klinis pada pasien kita)
▸ 1. Apakah karakteristik pasien mirip dengan subyek yang
diteliti ? Ya, DBD juga dirawat di perawatan Anak RS Wahidin
Sudirohusod
▸ 2. Apakah bukti ini mempunyai pengaruh penting secara
TELAAH klinis terhadap kesembuhan pasien kita ? Ya, hasil
KRITIS penelitian ini menunjukkan bahwa hiponatremia ditemukan
JURNAL pada demam berdarah dengan tanda peringatan (warning
signs). Oleh karena itu, pemantauan yang cermat kadar
natrium serum membantu untuk menentukan tingkat
keparahan infeksi dengue.
▸ Note : penelitian ini dpat diterapkan pada pasien kta.
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▸ Penelitian ini valid, penting dan
dapat diterapkan pada pasien kita
di RSWS
Aplikasi
Bukti klinis ▸ Rekomendasi:
 Pada pasien dengue perlu diperiksa kadar
narium secara serial untuk menentukan
keparahan dan agresi tindakan:
 Berdasarkan bukti penelitian: Raj R, Alva R: serum sodium
level in dengue nfected children; a retrospective study. Int J
Contemp Peduatr. 22018:5(5):1801-04. - level of evidence: 3 .
Recomenndation: C
22 THANK
YOU