Dengue Fluids
Dr Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai
Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056. India
Clinical Problem :
A 2 years old boy presented with fever for 7 days, vomiting for 2 days, pain in abdomen for 2 days and oliguria for a day. There was no jaundice, loose motions or altered sensorium. On examination, the child has heart rate of 150, min, respiratory rate of 46, min with minimal distress, some dehydration, B.P. of 80, 60 mm of Hg and an erythematous maculopapular rash. He had a right sided minimal pleural effusion with tender hepatomegaly. Other systems were normal. He was suspected to have dengue hemorrhagic fever {DHF} and was given 2 Normal Saline boluses of 20 cc, kg. Investigations showed leucopenia, hemoconcentration with thrombocytopenia, normal creatinine with elevated BUN, hyperkalemia, elevated liver transaminases, prolonged prothrombin time and partial thromboplastin time with Chest X-Ray showing right sided pleural effusion. Dengue IgM was positive. He was continued on IV fluids of 6 cc, kg, hour to which his hypotension responded and hematocrit decreased. However, he had passed urine of only 0.5 cc, kg, hour in next 12 hours. At the end of 12 hours, he was noticed to have respiratory distress {RR = 46, min} with lower intercostal retractions, deep and not to rapid breathing with puffiness of eyes.
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What is the problem_? How should this child be managed now_?
Discussion :
This child has Dengue Hemorrhagic Fever {DHF}. With fluid resuscitation, his intravascular compartment seems to have restored but the oliguria continues. Thus the child seems to have an additional renal component of the cause of oliguria. Even though serum creatinine is normal, the child does have hyperkalemia. Also the respiration seems to be like an acidotic breathing making one suspect metabolic acidosis. Metabolic acidosis without dehydration also suggests a renal involvement. This child also has puffiness of eyes which may be due to third spacing. The distress of breathing especially with activity of lower intercostals suggests congestion of the bases of lung. Congestion can be the lung parenchyma i.e., pulmonary edema or in the pleural spaces due to third space losses. Pulmonary edema in a DHF may occur either due to volume overload {which should lead to increased urine output} or due to myocardial dysfunction. Thus, there seems to be a heart involvement in this child too. Thus, in this child, there seems to be a multisystem organ problem. The pulmonary edema should be treated with a diuretic which may also help the kidneys to open up. Prior to that the extra fluids should be stopped and child would require ionotropic support to maintain the intravascular volume. This child was given Dopamine, extra fluids were stopped and when blood pressure was around 75th centile, a diuretic was given following which the child passed 400 ml of urine in next 6 hours. His blood gases did show metabolic acidosis Echocardiography showed left ventricular dysfunction. With this treatment, child had a marked improvement.
Hence in a patient with DHF, optimum fluid management is very essential to prevent complications.
E-published: October 2010 Vol 7 Issue 10 Art No. 62
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