Transcript Clinical Practice Guideline Postoperative Infectious

DISEASE MONITORING
Dr Mahiran Mustafa
Chairman of CPG
Development Committee
CONTENTS
• Brief review on different phases in dengue
infection
• Issues at different phases
• Clinical monitoring for each phase
• Laboratory monitoring for each phase
INTRODUCTION
• Monitoring dengue cases require the understanding
that dengue infection is a systemic and dynamic
disease.
• Its clinical, haematological and serological profiles
changing from day to day and accelerate by the
hour during the critical phase, particularly in those
with plasma leakage
• Failure in recognising and interpreting the clinical
and laboratory manifestations can lead to delay in
appropriate management thus cause intractable
shock and death
CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS
OUTPATIENT MONITORING
Symptoms:
1. Warning signals
2. Bleeding manifestations
3. Inability to tolerate oral
fluids
4. Reduced urine output
5. Seizure
Signs:
1. Dehydration
2. Shock
3. Bleeding
4. Any organ failure
Laboratory:
1. HCT
2. Hb
3. Platelet
DISEASE MONITORING CARD
DENGUE DISEASE PROGRESSION CARD
Patient’s name: ________________________________
I/C No.
: _______________________________
Date of onset of fever : __________________________
Date
Temp
°C
BP
PR
PCV/
HCT
WBC
Platelet
Attending Clinic/
phone no.
Next Appointment
CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS
• Clinical deterioration often occurs during
the critical phase because of marked
plasma leakage
 Evidence of plasma leakage includes:
raised HCT
haemodynamic instability
fluid accumulation in extravascular space
Pathophysiology
• Vascular permeability
leads to leakage
• Haemoconcentration
• Hypovolaemia leads
to reflex tachycardia
and vasoconstriction
• Inadequate perfusion
of the tissue leads to
increased anaerobic
glycolysis and
resultant lactic
acidosis
• Shock that leads to
DIC and bleeding
WARNING SIGNALS
•
•
•
•
•
Vomiting
Abdominal pain
Restlessness or altered mental state
Mucosal Bleed
Sudden change of temperature to
subnormal
• Raising HCT with rapid drop in platelet
CLINICAL ISSUES IN DIFFERENT PHASES OF DENGUE ILLNESS
SEVERE MANIFESTATIONS
•
•
•
•
Acute abdomen
Hepatitis and hepatic failure
CNS manifestations
Carditis or cardiomyopathy
Pathophysiological changes from normal circulation
to compensated and decompensated shock
Normal Circulation
Compensated shock
Decompensated /
Hypotensive shock
Clear consciousness
Clear consciousness
Change of mental state –
restless, combative
or lethargy
Brisk capillary refill time
(<2 sec)
Prolonged capillary refill
time (>2 sec)
Mottled skin, very
prolonged capillary refill
time
Warm and pink extremities
Cool extremities
Cold, clammy extremities
Good volume
peripheral pulses
Weak & thready
peripheral pulses
Feeble or absent
peripheral pulses
Normal heart rate for age
Tachycardia
Severe tachycardia with
bradycardia in late shock
Normal blood pressure for age
Normal systolic pressure
with raised diastolic pressure
Postural hypotension
Hypotension/ unrecordable
BP
Normal pulse pressure
for age
Narrowing pulse pressure
Narrowed pulse
pressure (<20 mmHg)
Normal respiratory rate
for age
Tachypnoea
Metabolic acidosis/
hyperpnoea
Fluid Guidelines
Fluid Therapy: Non Shock
Recommendation
• Encourage adequate oral fluid intake. (Grade C)
• IV fluid is indicated in patients who are vomiting
or unable to tolerate oral fluids. (Grade C)
• IV fluid is also indicated in patients with
increasing HCT (indicating on-going plasma
leakage) despite increased oral intake. (Grade
C)
• Crystalloid is the fluid of choice for non shock
patients. (Grade C)
Indications for referral to
Intensive
•
•
•
•
Recurrent or persistent shock
Requirement of respiratory support
(non-invasive and invasive ventilation)
Significant bleeding
Encephalopathy or encephalitis
DISCHARGE CRITERIA
•
•
•
•
•
•
Afebrile for 48 hours
Improved general condition
Improved appetite
Stable haematocrit
Rising platelet count
No dyspnoea or respiratory distress from pleural
effusion or ascites
• Resolved bleeding episodes
• Resolution/recovery of organ dysfunction
Summary:
Principles of disease monitoring
1.Dengue is a systemic and dynamic disease. Therefore
disease monitoring is governed by different phases of
the disease.
2. The critical phase (plasma leakage) may last for 24-48
hours. Monitoring needs to be intensified and frequent
adjustments in the fluid regime may be required.
3. Recognition of onset of reabsorption phase is also
important because intravenous fluid regime needs to be
progressively reduced/ discontinued