Thầy thuốc tận tâm Chăm mầm đất nước Vietnam MOH Guideline update on DHFtreatment Dr Bạch Văn Cam CH1 Contents I VN MOH DHF 2019 GUIDELINE II DIAGNOSIS AND CLASSIFICATION III PEDIATRIC DHF TREATMENT IV SEVERE DHF WITH MODS TREATMENT V CONCLUSION I VN MOH DHF 2019 GUIDELINE SỐT XUẤT HUYẾT DENGUE VIETNAM CURRENT STATUS DHF TREATMENT RESULTS SURVIVAL CMV & CRRT implemented FATAL CAUSES ON DHF • PROLONGED/ SEVERE DSS • Severe heamorrhagic bleeding • ARDS/ACS with poor lung compliance • MODS: ARF, ALF, … • Unrecognized • Low compliance to guideline • Unsafe patient transfer • Nocosomial inf Early recognition Decrease mortality Better life quality PAHOWHO 2016 HƯỚNG DẪN CHẨN ĐOÁN, ĐIỀU TRỊ SỐT XUẤT HUYẾT DENGUE WHO 2009 HƯỚNG DẪNCHẨN ĐOÁN, ĐIỀU TRỊ SỐT XUẤT HUYẾT DENGUE số 458/QĐ-BYT ngày 16 /02/2011 số 3705/QĐ-BYT ngày 22/08/2019 (2 nam soan thao PHÁC ĐỒ SXHD) World Health Organization 2012 IBW for obesity children Age (ys) 10 11 12 13 14 15 male (kg) 13 14 16 18 21 23 26 29 32 36 40 45 51 56 (CDC 2014) Female (kg) 12 14 16 18 20 23 26 29 33 37 42 46 49 52 More affordable than BMI calculations ➔ Ideal for fluid resuscitation in the first hours, but CVP is needed for later continuing II DIAGNOSIS AND CLASSIFICATIONS Albumine 5% IN SEVERE DSS collioid • > 60 ml/kg • Cann’t < 5ml/kg/hrs + Albumine • Albumine 24h Normal Hct or ↓ Plasma leak stage Hct ↑ nCPAP Stop IV fluid (±)Furosemide 0,5mg/kg IV → 0.1 mg/kg/hrs 1.↓ fluid rate NO Diuretics RC transfusion 5ml/kg/hrs Warning: APE Closed vital signs monitor Albumin/ colloids 10ml/kg/1-2 HEPATIC DYSFUNCTION HEPATIC DYSFUNCTION/ DHF AST, ALT MILD 120 - < 400U/L MODERATE 400 - < 1000U/L SEVERE OR ALF ≥ 1000U/L, HE (±) Ringer Acetate is preferable ALF: n-Acetyl cysteine with/ without CRRT/ MARS EXPERT CONSULTATION Senior consultant CONSULTATION Hospital Liaison Committee EXPERT TRANSFER AI, TELE MEDICINE, … DHF REPORT FORM Risks of severe DSS ▪ Day 3rd, 4th ▪ Severe/prolonged/ refractory/ relapsed shock, ▪ Too high/low Hct ▪ Shock with fever persistence ▪ ALF • • • • • • GI bleeding Effusion MODS Over nutrition/ obesity Infant Persistent chronic diseases SENIOR CONSULTATION - Critical DSS - Relapsed DSS - Uncontrolled DHF with warnings - Failure after 1h with DSS requiring IV fluid - Respiratory distress - Hematocrit ≥ 50% or ≤ 35% - GI bleeding - Liver impairment (AST ror ALT ≥ 400U/l) - Altered mental status - Sepsis differentiation - Infant or nutrition disorders - Chronic diseases - Physician confusion CONSULTATION Hospital Liaison Committee Fluid> 100ml/kg + failure with inotropes - Relapsed shock (>2 times) - Uncontrolled RDS - MODS - Seizure/ coma - Significant GI bledding - CRRT indication - According to boarding comments Consultation with tertiary referral hospital should be performed before patient transfers!!! DHF IN INFANT • Difficult BP measuring→ late recognition/ detection • Hct may not as high as adult • Overload • IVC diameter echography should be performed to evaluate the intravascular volume DHF VACCINATION • Dengvaxia (Sanofi Pasteur): VN engaged from 2011 • 2018: 54 countries licensed V CONCLUSION New key points on 2019 DHF guideline Items Clasifications Warning signs Pulse pressure ≤ 25 → DSS Pulse pressure ≤ 15 → Critical DSS Overnutrition condition IBW = weight with age (CDC 2014) Colloids HES 200 / Dextran DHF with warnings Normal BP with poor perfusion →LR 10ml/kg/hr Unresponded + Hct : colloids (LR>60ml/kg) DSS treatment After LR 20 ml/kg first hour: recheck Hct After 1st hr, if failure:HES (Hct>40), RBC (hct60ml/kg Treatment for disorders Early CMV CVP measuring Ultrasound guided Technique CVL insertion, IVC diameter evaluation Albumin compensation Unresopnded shock with HES ≥ 5ml/kg/h + Albumine