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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