Targeted Interventions in Critically Ill Children with Severe Dengue

JOURNAL TITLE: Indian Journal of Critical Care Medicine

Author
1. Suchitra Ranjit
2. Niranjan Kissoon
3. Gokul Ramanathan
ISSN
0972-5229
DOI
10.4103/ijccm.IJCCM_413_17
Volume
22
Issue
3
Publishing Year
2018
Pages
8
Author Affiliations
    1. BC Children’s Hospital BCCH and Global Child Health, Vancouver, British Columbia, Canada
    2. University of British Columbia and BC Children’s Hospital, British Columbia, Vancouver, Canada
    3. UBC and BC Children’s Hospital, Vancouver, British Columbia, Canada
    4. BC Children’s Hospital BCCH and UBC; Vancouver, British Columbia, Canada
    1. Pediatric Intensive Care Unit, Apollo Children\'s Hospital, Chennai, Tamil Nadu, India
    1. Pediatric Intensive Care Unit, Apollo Children\'s Hospital, Chennai, Tamil Nadu, India
  • Article keywords
    Albumin, colloids, fluid overload, intra-abdominal hypertension, plasma leak, resuscitation morbidity, severe dengue, shock

    Abstract

    Background: The World Health Organization guidelines provide suggestions on early recognition and treatment of severe dengue (SD); however, mortality in this group can be high and is related both to disease severity and the treatment complications. Subjects and Methods: In this prospective observational study, we report our results where standard therapy (ST) was enhanced by Intensive Care Unit (ICU) supportive measures that have proven beneficial in other conditions that share similar pathophysiology of capillary leak and fluid overload. These include early albumin for crystalloid-refractory shock, proactive monitoring for symptomatic abdominal compartment syndrome (ACS), application of a high-risk intubation management protocol, and other therapies. We compared outcomes in a matched retrospective cohort who received ST. Results: We found improved outcomes using these interventions in patients with the most devastating forms of dengue (ST+ group). We could demonstrate decreased positive fluid balance on days 1–3 and less symptomatic ACS that necessitated invasive percutaneous drainage (7.7% in ST+ group vs. 30% in ST group, P = 0.025). Other benefits in ST+ group included lower intubation and positive pressure ventilation requirements (18.4% in ST+ vs. 53.3% in ST, P = 0.003), lower incidence of major hemorrhage and acute kidney injury, and reduced pediatric ICU stays and mortality (2.6% in ST+ group vs. 26% in ST group, P = 0.004). Conclusion: Children with SD with refractory shock are at extremely high mortality risk. We describe the proactive application of several targeted ICU supportive interventions in addition to ST and could show that these interventions resulted in decreased resuscitation morbidity and improved outcomes in SD.

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