CPG 2015 - Management of Dengue Infection in Adults (3rd Edition)

Finally, after  some review and finalizing on the initial draft, this has been officially published in Malaysia's MOH site. While most of the content has remain the same, some key changes such as the preference of fluids used in decompensated shock has been reverted to either crystalloid/colloid (The draft mentioned colloid as the first line of fluid resuscitation in dengue decompensated shock).



Management of Dengue Infection in Adults (3rd edition) - Dec 2015
 Full CPG Download Links: Dropbox| Mediafire
Quick Reference Download Links: Dropbox| Mediafire  



For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE
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Draft CPG: Management of Dengue Infection in Adults 2015- 3rd Edition

The draft of Malaysia's MOH 3rd edition clinical practice guidelines (CPG) for dengue management in adults had been launched on the 4th Sept 2015. It had been uploaded on the MOH site and is currently open for feedback and comments to further improvise the CPG. Compared to international publication of similar guidelines, the feedback duration is rather short as it will be opened from 4th Sept to 31st Oct 2015. Therefore, we are uploading a copy here in MedPBL as well. All comments and feedback can be sent to htamalaysia@moh.gov.my.



  
CPG 2015 Draft- Management of Dengue Infection in Adults 2015
1st public draft (3rd Sept 2015): Dropbox | Mediafire

Among the key updates in the latest CPG draft are: 

1.  Inclusion of diarrhea as dengue warnings signs.

While diarrhea is not a warning sign according to the WHO 2009 classification, it may be considered as a compounding factor leading to further fluid loss. Or perhaps it could be a sign of 3rd space loss causing gut edema which may lead to diarrhea(No proven pathophysiology here, just postulation). With many severe dengue and dengue deaths patients initially presenting as fever with gastroenteritis, perhaps there is some truth in it, hence leading to the inclusion of diarrhea in the warning signs. 

2. Inclusion of frequency of vomiting and diarrhea to be considered "persistent" as more than 3 times per day.

Previously, many referrals were made based on patients vomiting once or twice which resolved spontaneously with or without treatment. The word "persistent" had been clearly defined here as more than 3 times, avoiding any further confusion. 

3. Inclusion of median value of normal hematocrit among Malaysians, with the hematocrit above these values now being considered as a warning sign.

---Hematocrit level for males less than 60 years old - 46
---Hematocrit level for males more than 60 years old - 42
---Hematocrit level for female regardless of age - 40 

4.Inclusion of NS1 Antigen and Dengue Rapid Combo Test as part of the recommended tests to diagnose dengue especially during the early phase of dengue infection.

While previous edition mentioned that NS1 Ag was currently under evaluation, the latest draft advocates for the use of NS1 which had a sensitivity between 75-97% during the first 5 day of illness in particular.

The serum NS1 Ag titer peaks at Day 1 to Day 2 of illness and drops subsequently to low levels at D4-D5 of illness, leading to reduced sensitivity of NS1Ag. Therefore, Dengue Rapid Combo Test could be falsely negative during this period of D4-D5 illness if serum NS1 Ag titer drops below detectable level, while serum Dengue IgM levels have not risen above detectable levels as well. These tests should be interpreted in clinical context and a repeat test for Dengue IgM may be considered in recovery phase to determine seroconversion.

5.Inclusion of a dengue assessment checklist for dengue patient

While previous CPG edition advocates for a dengue clerking sheet, this may not be feasible as patients do not walk in with dengue as a chief complain or "dengue" labeled on their forehead. Hence the clerking sheet is only used after the patient has been diagnosed with dengue. While certain centers use a fever clerking sheet instead, some dengue patients do not come with fever as they may be in their critical phase. Therefore, a unified dengue assessment checklist is being introduced instead of re-clerking the patient for dengue using the dengue clerking sheet upon diagnosis. 

6. Changes in the intravenous fluids maintenance regime for dengue management in patients with warning signs but not in shock.

Instead of the Halliday-Segar formula used for calculation of fluid maintenance in dengue patients, a new calculation method is used using 1.2 - 1.5ml/kg/hour, making calculation easier for physicians and medical students alike. This is based on National Clinical Guideline Center (UK) on Intravenous Fluid Therapy in Adults in Hospitals (Dec 2013)

IV Fluid regime for obese and overweight patients are no longer calculated according to ideal body weight (IBW) but using adjusted body weight(ABW) instead.

However, do take note that more emphasis had been put on the judicious use of intravenous fluids as overly prescribed intravenous fluids has higher complication rate compared to those who can take fluids orally.

7. Changes in the algorithm for fluid management in dengue patients with warning signs but not in shock

 While the 2nd edition advocates for fluid resuscitation according to the formula of 5-7cc/kg/hr for 1-2 hours, then reduce to 3cc/kg/hr for 2-4 hours and then reduce to 2-3cc/kg/hr orless, this holds true only for compensated shock and decompensated shock (post fluid resusictation and responding). For dengue patients with only warning signs but not in shock, the lower limit of the regime is being advised, being 5/3/2 cc/kg/hr instead of the 5-7/3-5/2-3 cc/kg/hr to avoid fluid overload.


8. Changes in fluid of choice for fluid management in Decompensated Shock

While previous edition of CPG advocates for crystalloid solution for decompensated shock and the consideration of colloids only in profound shock, the latest edition outlines for the use of COLLOIDS outright from the start. Fluid resuscitation continues with COLLOIDS and subsequently blood products in patients who remained in shock. If there is improvement, then only the fluid of choice can be switched to crystalloid or remain as colloid.

9. Introduction of a new algorithm for fluid management in Decompensated Shock (With presence of bleeding and leaking or other causes of shock)

Previous edition of CPG emphasized on the fluid management towards dengue shock syndrome, however, this draft edition includes addition of this algorithm to guide physicians to look for other causes of shock instead as well and to manage accordingly. This is due to increasing number of dengue mortality where by patient deteriorates into shock despite aggressive fluid management.

OGDS has been put under consideration if the patient has a suspected Upper GI bleed due to peptic ulcer, although routine endoscopy for UGIB in dengue is not advised as it may increase the risk for bleeding.

Continuous renal replacement therapy is a new modality considered in the treatment of dengue for those with liver failure with severe metabolic acidosis from lactic accumulation 

10. Introduction on the section on Management of Complications in Dengue Infection

As there are rising number of incidence of complications due to dengue, a section has been added to guide physicians on the management of such complications. The management is beyond the scope of this post, hence here's the list of the section:

A. Management of Bleeding/Hemostasis in Dengue Infection
i) Hemostatic Abnormalities
ii) Significant Occult Bleed
iii) Upper Gastrointestinal Bleed 

B. Management of Hepatitis in Dengue Infection  

C. Management of Cardiac Complications in Dengue Infection 

D. Management of Neurological Complications in Dengue Infection
i) Dengue Enchephalopathy
ii) Dengue Encephalitis
iii) Acute Transverse Myelitis
iv) Muscle involvement (including rhabdomyolysis, post-dengue Guillane-Barre, etc)
v) Ocular manifestations (maculopathy, retinal edema, retinal hemorrhages, optic neuropathy etc) 

E. Management of Renal Complications in Dengue Infection 

F. Management of Haemophagocytic Syndrome in Dengue Infection

Of course, there are more updates in the latest CPG draft including ED management as well as intensive care management, but I'll leave it for you to read it from the draft. We will try to introduce more updates from time to time. 
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CPG 2014- Management of Neonatal Jaundice (2nd Edition)

The last CPG for management of neonatal jaundice was published in 2003. While it may not have been widely adopted as the TSB level varies slightly between hospitals, it serves as a guide for those new to the field. 11 years later, the second edition is out for all to compare. We hope everyone would benefit from the education served fro each CPG including this one.




Management of Neonatal Jaundice (2nd edition) - Dec 2014
Full CPG Download Links: Dropbox| Mediafire 
Quick Reference Download Links: Dropbox| Mediafire  



For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE

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National Antibiotic Guideline (2nd Edition) - 2014




Since the 2008 National Antibiotic Guideline was more than 5 years ago, it is time for the new guideline to be published. Here it is, the 2nd edition by the Ministry of Health.

FYI, there had been some correction done on the dose for Augmentin has the dose has been rectified. For our Amoxycillin/Clavulanate (500/125) formulation, the dosing should be 625mg t.d.s instead of b.d. This is in line with the amoxycillin dosing of 500mg t.d.s.

Below are the download links for the pdf version as well as the Playstore link for Android. Pretty sorry for those in iOS, but I guess those using iPhone will need to bear with the pdf version for the time being. :) Kudos to the Ministry of Health and the Pharmaceutical division for the initiative to include it in Android.



National Antibiotic Guideline (2nd edition) - 2014
Download Links: Dropbox| Mediafire  

https://lh3.googleusercontent.com/ibJopCmKGoQ57k8Is6IUK9QmHm1KsyS4AdkXxRqGniOseQj2sOMYkm9ttz5vznr2CNqI=w300

Playstore: Android (Supports Android Version 2.2 and up)

 
For a view of the whole collection of Malaysia CPG's available in Medical PBL (Trust me, we do have quite a collection), kindly do refer to: ==> HERE


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Malaysia Clinical Practice Guidelines and Consensus (Last update: 4th Aug 2015)


Below is the subsection for the available CPG in Malaysia. All CPG are valid for 4-5 years unless stated otherwise. Older CPG are stored for archiving and reference purposes and should not be held liable for any differences in management.

For search purposes, it is recommended to use the browser's search function, "Find" through this list of CPG's. For example, Firefox or Chrome users can use the function "Ctrl" + "F" and type in the keywords in the designated search box. This will lead to the targeted keywords/ text on this list.

Pharmacological Guidelines

  • National Antibiotic Guideline (2nd edition) - 2014
    Download Links: Dropbox| Mediafire  
  • Insulin Therapy Guidelines 2011

Cardiovascular CPG:
  • Management of Acute STEMI (3rd Edition) - 2014
    Download Links: Dropbox| Mediafire
  • Management of Heart Failure (3rd Edition) - 2014
    Download Links: Dropbox| Mediafire
  • Management of Hypertension (4th Edition)- 2013
    Download Links: Dropbox| Mediafire 
  • Prevention and Treatment of Venous Thromboembolism- 2013
    Download Links: Box.net | Mediafire
  • Management of Atrial Fibrillation  - 2012
    Download Links: Box.net | Mediafire  
  • Management of Stable Angina Pectoris  - 2012
    Download Links: Box.net | Mediafire 
  • Management of Ischemic Stroke (2nd edition) - 2012
    Download Links: Box.net | Mediafire  
  • Management of Unstable Angina/ Non-STEMI (2nd Edition) - 2011
    Download Links: Box.net | Mediafire  
  • Management of Pulmonary Arterial Hypertension - 2011
    Download Links: Box.net | Mediafire
  • Prevention of Cardiovascular Disease in Women - 2008 (1st Edition)
    Download Links: Box.net | Mediafire
  • Management of Hypertension (3rd edition) - 2008
    Download Links: Box.net | Mediafire
  • Management of Heart Failure - 2007
    Download Links: Box.net | Mediafire
  • Management of Acute STEMI - 2007 (2nd Edition)
    Download Links: Box.net | Mediafire
  • Management of Ischemic Stroke - 2006
    Download Links: Box.net | Mediafire
  • Management of Unstable Angina/ Non-STEMI - 2002
    Download Links: Box.net | Mediafire 

Respiratory CPG:
  • Management of Chronic Obstructive Pulmonary Disease (2nd Edition) - 2009
    Download Links: Box.net | Mediafire
  • Treatment of Tobacco Use and Dependence - 2003
    Download Links: Box.net | Mediafire
  • Management of Adult Asthma -Revised 2002
    Download Links: Box.net | Mediafire

Hematology CPG:
  • Management of Transfusion Dependent  Thalassaemia - 2009
    Download Links: Box.net | Mediafire
  • Management of Anemia in Pregnancy and Chronic Kidney Disease (?Draft) - 2007
    Download Links: Box.net | Mediafire
  • Management of Immune Thrombocytopenic Purpura - 2006
    Download Links: Box.net | Mediafire
  • Diagnosis and Management Chronic Myeloproliferative Disorders - 2004
    Download Links: Box.net | Mediafire

Nephrology CPG:

 Endocrine/ Metabolism Disorder CPG:
  • Management of Dyslipidemia - 2011
    Download Links: Box.net | Mediafire
  • Management of Type 2 Diabetes Mellitus (4th Edition) - 2009
    Download Links: Box.net | Mediafire
  • Management of Diabetic Foot - 2004
    Download Links: Box.net | Mediafire
  • Management of Dyslipidemia - 2004 (The previous 2003 was a draft)
    Download Links: Box.net | Mediafire
  • Management of Obesity - 2003
    Download Links: Box.net | Mediafire
  • Consensus Statement on Androgenetic Alopecia - 2003
    Download Links: Box.net | Mediafire

Dermatology CPG:

Infection CPG:
  • Management of Dengue Infection in Adults (3rd edition) - 2015
    Full CPG Download Links: Dropbox| Mediafire
    Quick Reference Download Links: Dropbox| Mediafire  
  • Management Guidelines of Malaria in Malaysia - 2014
    Download Links: Dropbox| Mediafire
  • Management of Tuberculosis 3rd Edition- 2012
    Download Links: Box.net | Mediafire
  • Guidelines on Management of HIV Infection in Adults with Anti-retroviral Therapy - 2012
    Download Links: Box.net | Mediafire
  • Guidelines for the Diagnosis, Management, Prevention and Control of Leptospirosis in Malaysia - 2011 Download Links: Box.net | Mediafire
  • Guidelines for Clinical and Public Health Management of Melioidosis in Pahang - 2011
    Download Links: Box.net | Mediafire
  • Management of Dengue Infection in Adults (Revised 2nd Edition) - 2010
    Download Links: Box.net | Mediafire
  • Management of HIV Infection in Pregnant Women - 2008
    Download Links: Box.net | Mediafire
  • Management of HIV Infection in Children - 2008
    Download Links: Box.net | Mediafire 
  • Guidelines of Management of Sexually Transmitted Infection - 2008
    Download Links: Box.net | Mediafire Management of Hand, Foot and Mouth Disease - 2007 Download Links: Box.net | Mediafire
  • Management of Dengue Fever in Children - 2004
    Download Links: Box.net | Mediafire
  • Adult Vaccination - 2003
    Download Links: Box.net | Mediafire   
  • Childhood Immunisation - 2004
    Download Links: Box.net | Mediafire
  • Control and Management of Tuberculosis 2nd Edition - 2002
    Download Links: Box.net | Mediafire

Neurology CPG:
  • Consensus Guidelines for Parkinson's Disease (2nd edition) - 2012
    Download Links: Box.net | Mediafire
  • Consensus Guidelines on the Management of Epilepsy- 2010
    Download Links: Box.net | Mediafire

Vascular CPG:
  •  Management of Acute Variceal Bleeding - 2007
    Download Links: Box.net | Mediafire
  • Management of Non-Variceal Upper Gastrointestinal Bleeding - 2003
    Download Links: Box.net | Mediafire
  • Management of Venous Tromboembolism - 2003
    Download Links: Box.net | Mediafire

Orthopedics & Rheumatology CPG:    

Ophthalmology CPG:
  • Screening of Diabetic Retinopathy - 2011
    Download Links: Box.net | Mediafire
  • Management of Primary Open Angle Glaucoma - 2008
    Download Links: Box.net | Mediafire
  • Management of Post-Operative Infectious Endophthalmitis - 2006
    Download Links: Box.net | Mediafire

Otorhinolaryngology (ENT) CPG: 

Women's Health CPG:
  • Hormone Therapy During Menopause in Malaysian Women - 2010 
    Download Links: Box.net | Mediafire
  • Management of Anemia in Pregnancy and Chronic Kidney Disease (?Draft) - 2007 Download Download Links: Box.net | Mediafire
  • Management of Menorrhagia - 2004
    Download Links: Box.net | Mediafire

Pediatrics CPG:
  • Management of Neonatal Jaundice (2nd Edition) - 2014
    Full CPG: Dropbox| Mediafire
    Quick Reference: Dropbox| Mediafire  
  • Management of Otitis Media with Effusion in Children  - 2012
    Download Links: Box.net | Mediafire
  • Guidelines on the management of Cow's Milk Protein Allergy in Children - 2012
    Download Links: Box.net | Mediafire  
  • Management of HIV Infection in Children - 2008
    Download Links: Box.net | Mediafire 
  • Retinopathy of Prematurity - 2005
    Download Links: Box.net | Mediafire
  • Withholding and Withdrawing of Life Support in Children - 2005
    Download Links: Box.net | Mediafire
  • Rational Antibiotic Utilisation in Selected Paediatric Conditions - 2004
    Download Links: Box.net | Mediafire
  • Management of Jaundice in Healthy Newborns - 2003
    Download Links: Box.net | Mediafire
  • Management of Postnatal Corticosteroids For The Prevention of Chronic Lung Disease In Preterm Infants - 2003
    Download Links: Box.net | Mediafire
  • Management of Febrile Fits - 2000
    Download Links: Box.net | Mediafire

Mental Health CPG:
  •  Management of Bipolar Disorder in Adults - 2014
    Download Links: Dropbox| Mediafire
  • Management of Autism Spectrum Disorder in Children and Adoslescents - 2014
    Download Links: Dropbox| Mediafire
  • Management of Schizophrenia in Adults - 2009
    Download Links: Box.net | Mediafire
  • Management of Dementia (2nd Edition) - 2009
    Download Links: Box.net | Mediafire
  • Management of Attention Deficit Hyperactive Disorder in Children and Adolescent - 2008
    Download Links: Box.net | Mediafire
  • Management of Major Depressive Disorder - 2007
    Download Links: Box.net | Mediafire
  • Malaysia Consensus Statement for the Treatment of Bipolar - 2007
    Download Links: Box.net | Mediafire  

Cancer CPG: 
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