DENGUE SHOCK SYNDROME :

This most dreaded complication which occurs when the fever resolves on 3rd. or 4th.day. due to plasma leakage in to pleural & peritoneal cavities.

The period of maximum risk for shock is between the third and seventh day of illness. This tends to coincide with resolution of fever. Plasma leakage generally first becomes evident between 24 hours before and 24 hours after fever is over.

Often people insist on a discharge from the hospital when the fever is over or do not want to get admitted once the fever is over.
SO,DONT DISCHARGE THE PATIENT WHEN THE FEVER RESOLVES BUT OBSERVE CAREFULLY WITH ALL SUPPORTIVE BACKUP FOR ANOTHER 2 DAYS.

Plasma leakage is the most specific and life-threatening feature of dengue hemorrhagic fever. This increase in vascular permeability develops rapidly, over a period of hours and thus a person can become worse over hours and die as in patients with marked plasma leakage, shock may develop, especially if supportive treatment is delayed.

Once a person develops clinical shock or low blood pressure (dengue shock syndrome) the case-fatality rate is 12 percent even with aggressive therapy.

Plasma leakage also coincides with severe low platelet counts and elevation of SGOT liver enzyme test. Abdominal pain also precedes the onset of plasma leakage in approximately 60 percent of patients. The presence of intense abdominal pain, persistent vomiting, sudden change from fever to hypothermia and marked restlessness or lethargy should alert the clinician to possible impending dengue shock syndrome.

A doctor can diagnose increased vascular permeability (plasma leakage syndrome) by demonstrating hemoconcentration (20 percent or greater rise in hematocrit above baseline value) or by presence of fluid in the lungs cavity (pleural effusion) or in the abdominal cavity (ascites).

All such case will have a pallet count of lower than one lac, fever lasting 2-7 days and a hemorrhagic tendency (as demonstrated by a positive tourniquet test by the doctor) or spontaneous bleeding.

Another bed side easily done test is to demonstrate a lower pulse pressure or the difference between upper and lower blood pressure of less than 20 mm Hg.

Formulas in dengue management ---- Formula of 20:
· A rise of pulse by 20
· A fall of BP by 20
· Pulse pressure lower than 20
· Platelet counts in thousands lower than 20
· A rise in hematocrit by more than 20%
· A positive tourniquet with more than 20 hges in one inch
(Source: Dr KK Aggarwal)
What is the treatment for plasma leakage in DHF?
A: To prevent or reverse hypovolumic shock fluid resuscitation is required. In patients with established intravascular fluid loss IV fluid, transfusion is recommended. As per WHO guidelines, the patient should receive 20 ml of DNS per kg body weight per hour until the pulse pressure is more than 20 and the urine output normalizes. (Formula of20)
What is the best test for dengue hemorrhage fever?
A: SGOT. Elevated SGOT levels are noted earlier than other tests. A Thailand study showed that normal SGOT levels for first three days of illness is a strong negative predictor of dengue hemorrhage fever.
Should a dengue pt receive platelets? or WHOLE PLASMA ?
BETTER TO GIVE WHOLE PLASMA.
Gastrointestinal bleeding or menorrhagia in patients with DHF, and occasionally in patients with dengue fever as well, can be severe enough to require blood transfusion. Factors that contribute to bleeding include thrombocytopenia due to decreased platelet survival and, in severe cases, frank disseminated intravascular coagulation.

Platelet transfusions are rarely given, but may be warranted in patients with severe thrombocytopenia (<10,000/mm3) and active bleeding.