Serum Procalcitonin and Peripheral Venous Lactate for Predicting Dengue Shock and/or Organ Failure: A Prospective Observational Study

Can we predict bleeding at admission in Crimean-Congo hemorrhagic fever?

BACKGROUND

In Crimean-Congo hemorrhagic fever, bleeding has a significant impact on the prognosis of the disease. In our study, we aimed to identify independent risk factors for the development of bleeding in Crimean-Congo hemorrhagic fever and to contribute to the management of the disease.

METHODS

Cases with a definitive diagnosis of Crimean-Congo hemorrhagic fever were divided into two groups: those who developed bleeding and those who did not. Demographic, clinical and laboratory parameters were subjected to logistic regression analysis in terms of risk factors for bleeding development. Cut-off values for numerical variables were determined by receiver operating characteristics.

RESULTS

A total of 74 patients diagnosed with CCHF were included in the study. Bleeding occurred in at least one defined focus in 21 patients. In the multivariate logistic regression model, procalcitonin, days from symptom onset to admission, platelet count, and d-dimer were identified as independent risk factors for bleeding development. Procalcitonin had the most significant effect, with an approximately 5.3-fold increase in bleeding risk for each unit increase in its level. For discriminate bleeding, LDH and ferritin exhibited the highest sensitivity, while procalcitonin showed the highest specificity.

CONCLUSION

This study demonstrates the potential use of specific clinical and laboratory variables to predict bleeding development in CCHF patients. Procalcitonin elevation and the time from symptom onset to hospital admission have a significant effect in predicting bleeding.

A comparison of changes in venous lactate and haematocrit during fluid resuscitation of dengue haemorrhagic fever

BACKGROUND

Judicious fluid resuscitation and stringent monitoring of clinical parameters improve the outcome of dengue haemorrhagic fever (DHF). The usefulness of serum lactate to monitor adequate fluid therapy has not been adequately explored.

METHODS

An observational study was conducted in Sri Lanka, recruiting 162 DHF patients within 12 h of diagnosis of the critical phase. Venous lactate level was measured at each time of performing haematocrit (HCT), using a prevalidated handheld lactate analyser.

RESULTS

The median venous lactate level was 1.3 (range 0.3-6) mmol/L in the study population and 154 (95.2%) patients had median lactate levels of <2 mmol/L. The HCT values in the study participants ranged from 28 to 62, with a median value of 43. There was no statistically significant correlation between the lactate and HCT values obtained at the same time. A significant reduction in venous lactate was not observed following the administration of fluid boluses. The expected reduction in HCT was seen following the administration of dextran and crystalloid/dextran combination. The maximum recorded lactate level positively correlated with the duration of hospital stay.

CONCLUSIONS

This study concludes that venous lactate is not an appropriate parameter with which to monitor the response to fluid therapy in uncomplicated DHF.

In-hospital mortality predictors among hospitalized adults and those with chronic kidney disease with dengue

BACKGROUND

Accurately identifying risk factors that predict fatality in dengue is crucial for patient triage and clinical management. Our objective was to identify predictors of death associated with dengue and investigate the clinical characteristics and risk factors among patients with chronic kidney disease (CKD) who died from dengue.

METHODS

A multicenter longitudinal observation study conducted from 2008 to 2019.

RESULTS

A total of 1272 patients (113 who died and 1186 who recovered) diagnosed with dengue were included. Old age, CKD, and an elevated white blood cell count at hospital presentation were identified as independent predictors of in-hospital mortality among individuals infected with the dengue virus. In a subgroup analysis of 138 patients with CKD infected with dengue virus, 64 (46.3%) patients died, with 46 (33.3%) patients dying within 7 days after symptom onset. Among 64 fatal dengue patients with CKD, 34.4% were in stages 2 and 3 of kidney disease, 51.5% were in stages 4 and 5, and 14.1% had end stage renal disease as per the classification by Kidney Disease Improving Global Outcomes. Multivariate analysis revealed that initial altered consciousness, pulmonary edema, and leukocytosis during hospitalization were independently associated with in-hospital mortality in CKD patients infected with the dengue virus. Leukocytosis during hospitalization and severe hepatitis were independent risk factors for death within 7 days after dengue illness onset in CKD patients.

CONCLUSIONS

This study offers valuable insights into predictors linked to fatality in dengue and reinforces the importance of optimizing patient triage to improve the quality of care.

Association of lactate-to-albumin ratio with in-hospital and intensive care unit mortality in patients with intracerebral hemorrhage

Background

Intracerebral hemorrhage (ICH) is a severe stroke subtype with a high mortality rate; the lactate-to-albumin ratio (LAR) is a new biomarker for predicting clinical outcomes in patients with ICH. However, the relationship between LAR and mortality in patients with ICH treated in the intensive care unit (ICU) remains controversial. Therefore, in this study, we aimed to investigate the association between LAR and in-hospital and ICU mortality in patients with ICH.

Methods

Patients with ICH were selected from the Medical Information Mart for Intensive Care III (MIMIC-III) database; their clinical information, including baseline characteristics, vital signs, comorbidities, laboratory test results, and scoring systems, was extracted. Univariate and multivariate Cox proportional hazards analyses were used to investigate the association of LAR with in-hospital and ICU mortality. The maximum selection statistical method and subgroup analysis were used to investigate these relationships further. Kaplan-Meier (KM) analysis was used to draw survival curves.

Results

This study enrolled 237 patients with ICH whose lactate and albumin levels, with median values of 1.975 and 3.6 mg/dl, respectively, were measured within the first 24 h after ICU admission. LAR had an association with increased risk of in-hospital mortality [unadjusted hazards ratio (HR), 1.79; 95% confidence interval (CI), 1.32-2.42; p < 0.001] and ICU mortality (unadjusted HR, 1.88; 95% CI, 1.38-2.55; p < 0.001). A cut-off value of 0.963 mg/dl was used to classify patients into high LAR (≥0.963) and low LAR (<0.963) groups, and survival curves suggested that those two groups had significant survival differences (p = 0.0058 and 0.0048, respectively). Furthermore, the high LAR group with ICH had a significantly increased risk of in-hospital and ICU mortality compared to the low LAR group.

Conclusion

Our study suggests that a high LAR is associated with an increased risk of in-hospital and ICU mortality in patients with ICH. Thus, the LAR is a useful prognostic predictor of clinical outcomes in patients with ICH.

Lactate-to-albumin ratio is associated with in-hospital mortality in patients with spontaneous subarachnoid hemorrhage and a nomogram model construction

Introduction

Subarachnoid hemorrhage (SAH) is a severe hemorrhagic stroke with high mortality. However, there is a lack of clinical tools for predicting in-hospital mortality in clinical practice. LAR is a novel clinical marker that has demonstrated prognostic significance in a variety of diseases.

Methods

Critically ill patients diagnosed and SAH with their data in the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and the eICU Collaborative Research Database (eICU-CRD) were included in our study. Multivariate logistic regression was utilized to establish the nomogram.

Results

A total of 244 patients with spontaneous SAH in the MIMIC-IV database were eligible for the study as a training set, and 83 patients in eICU-CRD were included for external validation. Data on clinical characteristics, laboratory parameters and outcomes were collected. Univariate and multivariate logistic regression analysis identified age (OR: 1.042, P-value: 0.003), LAR (OR: 2.592, P-value: 0.011), anion gap (OR: 1.134, P-value: 0.036) and APSIII (OR: 1.028, P-value: < 0.001) as independent predictors of in-hospital mortality and we developed a nomogram model based on these factors. The nomogram model incorporated with LAR, APSIII, age and anion gap demonstrated great discrimination and clinical utility both in the training set (accuracy: 77.5%, AUC: 0.811) and validation set (accuracy: 75.9%, AUC: 0.822).

Conclusion

LAR is closely associated with increased in-hospital mortality of patients with spontaneous SAH, which could serve as a novel clinical marker. The nomogram model combined with LAR, APSIII, age, and anion gap presents good predictive performance and clinical practicability.

Antimicrobial Stewardship in Tropical Infectious Diseases: Focusing on Dengue and Malaria

Acute undifferentiated febrile illness (AUFI) is the presenting symptom of various tropical and infectious diseases. Viral infection is generally the most common cause of AUFI, accounting for 8–11.8% of cases; thus, antibiotics might be unnecessary. Dengue and malaria are common tropical infectious diseases requiring effective supportive treatment and antimalarial agents, respectively. The uncertainty of early diagnosis results in widespread empirical antimicrobial treatment in high -income as well as in low-and middle-income countries. Although rapid diagnostic tests (RDTs) have been shown to limit antibiotic prescriptions in dengue and malaria, we observed a wide range of antibiotic prescriptions for 13–92.7% of cases in previous literature, particularly in RDT-negative malaria cases. Given several RDT limitations, antimicrobial stewardship (AMS) appears to be an effective strategy for controlling unnecessary antibiotic use and antimicrobial resistance (AMR) prevention. This program should be endorsed by a multidisciplinary team in tropical diseases to control collateral damage of inappropriate antimicrobial use. Empirical antibiotic treatment should be administered based on clinical judgement, microbiological evidence, and local epidemiological data. Rapid termination of antibiotic therapy, including disease control or elimination, is the mainstay of AMS in tropical diseases. Local and international sectors should implement an AMS programme to reduce AMR in the Tropics.

Rickettsial Infections Are Neglected Causes of Acute Febrile Illness in Teluk Intan, Peninsular Malaysia

Rickettsial infections are among the leading etiologies of acute febrile illness in Southeast Asia. However, recent data from Malaysia are limited. This prospective study was conducted in Teluk Intan, Peninsular Malaysia, during January to December 2016. We recruited 309 hospitalized adult patients with acute febrile illness. Clinical and biochemistry data were obtained, and patients were stratified into mild and severe infections based on the sepsis-related organ failure (qSOFA) scoring system. Diagnostic assays including blood cultures, real-time PCR, and serology (IFA and MAT) were performed. In this study, pathogens were identified in 214 (69%) patients, of which 199 (93%) patients had a single etiology, and 15 (5%) patients had >1 etiologies. The top three causes of febrile illness requiring hospitalization in this Malaysian study were leptospirosis (68 (32%)), dengue (58 (27%)), and rickettsioses (42 (19%)). Fifty-five (18%) patients presented with severe disease with a qSOFA score of ≥2. Mortality was documented in 38 (12%) patients, with the highest seen in leptospirosis (16 (42%)) followed by rickettsiosis (4 (11%)). While the significance of leptospirosis and dengue are recognized, the impact of rickettsial infections in Peninsular Malaysia remains under appreciated. Management guidelines for in-patient care with acute febrile illness in Peninsular Malaysia are needed.

Study of Utility of Basic Arterial Blood Gas Parameters and Lactate as Prognostic Markers in Patients With Severe Dengue

Background

The importance of prognostication in critical care cannot be over-emphasized, especially in the context of diseases like dengue, as their presentation may vary from mild fever to critical life-threatening illness. With the help of prognostic markers, it is possible to identify patients at higher risk and thus improve their outcome with timely intervention. Basic arterial blood gas (ABG) parameters, i.e., potential of hydrogen (pH), partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2) and bicarbonate are useful parameters, especially in critical care medicine as they are known to vary with the severity of illness. Hyperlactatemia is often referred to as a “powerful predictor of mortality”. Basic ABG parameters and lactate have been used as an essential prognostic modality in critically ill patients for decades; however, the evidence remains limited for their role as prognostic markers in patients with severe dengue.

Method

We carried out an observational retrospective cohort study comprising 163 patients with severe dengue, admitted between July 2021 and November 2021 at Medical Intensive Care Unit (MICU) of Shri Ram Murti Smarak Institute of Medical Sciences (SRMS IMS), Bareilly, Uttar Pradesh, India. Basic ABG parameters and lactate levels at the time of admission to MICU were compared between survivor and non-survivor groups of patients with severe dengue in order to evaluate their prognostic utility as predictors of mortality.

Results

pH (p<0.0001), PO2 (p=0.01) and bicarbonate (<0.0001) levels were significantly lower, while PCO2 (p=0.002) and lactate (p<0.0001) levels were significantly higher in non-survivor group as compared to survivor group. Lactate was found to be the best prognostic marker with Area Under the Curve (AUC) of 88.7% on Receiver Operating Characteristics (ROC) analysis.

Conclusion

Basic arterial blood gas parameters and lactate can be used as feasible prognostic markers in patients with severe dengue.

Lactate Albumin Ratio Is Associated With Mortality in Patients With Moderate to Severe Traumatic Brain Injury

Background

Traumatic brain injury (TBI) is a serious public health issue all over the world. This study was designed to evaluate the prognostic value of lactate to albumin ratio (LAR) on patients with moderate to severe TBI.

Methods

Clinical data of 273 moderate to severe TBI patients hospitalized in West China Hospital between May 2015 and January 2018 were collected. Multivariate logistic regression analyses were used to explore risk factors and construct a prognostic model of in-hospital mortality in this cohort. A receiver operating characteristic (ROC) curve was drawn to evaluate the discriminative ability of this model.

Results

Non-survivors had higher LAR than survivors (1.09 vs. 0.53, p < 0.001). Results of multivariate logistic regression analysis showed that Glasgow Coma Scale (GCS; odds ratio [OR] = 0.743, p = 0.001), blood glucose (OR = 1.132, p = 0.005), LAR (OR = 1.698, p = 0.022), subdural hematoma (SDH; OR = 2.889, p = 0.006), intraparenchymal hemorrhage (IPH; OR = 2.395, p = 0.014), and diffuse axonal injury (DAI; OR = 2.183, p = 0.041) were independent risk factors of in-hospital mortality in included patients. These six factors were utilized to construct the prognostic model. The area under the ROC curve (AUC) values of single lactate, albumin, and LAR were 0.733 (95% Cl; 0.673–0.794), 0.740 (95% Cl; 0.683–0.797), and 0.780 (95% Cl; 0.725–0.835), respectively. The AUC value of the prognostic model was 0.857 (95%Cl; 0.812–0.901), which was higher than that of LAR (Z = 2.1250, p < 0.05).

Conclusions

Lactate to albumin ratio is a readily available prognostic marker of moderate to severe TBI patients. A prognostic model incorporating LAR is beneficial for clinicians to evaluate possible progression and make treatment decisions in TBI patients.

Prognostic indicators associated with progresses of severe dengue

Background

Dengue usually progress abnormally, especially in the critical phase. The main causes of death were shock, severe bleeding and organ failure. The aim of our study was to evaluate prognostic indicators of severe dengue according to the phases of the disease progression.

Methods

A cross-sectional study was conducted from July to December 2017 at the National Hospital for Tropical Diseases and the Hospital for Tropical Diseases of Ho Chi Minh City. 326 patients, aged 6 years and over, including 99/326 patients with severe dengue and 227/326 patients with non-severe dengue, hospitalized in the first 3 days of illness, confirmed Dengue virus by the RT-PCR assay have been registered for the study. Clinical manifestations were monitored daily. The hematocrit, white blood cells, platelet, serum albumin, ALT, AST, bilirubin, prothrombin time (PT%, PTs), fibrinogen, aPTT, INR and creatinine were evaluated at two times: febrile phase and critical phase.

Results

Independent factors associated with severe dengue were identified on multivariate logistic regression models. During the first 3 days of the disease, the prognostic indicators were platelet count ≤ 100 G/L (OR = 2.2; 95%CI: 1.2–3.9), or serum albumin < 35 g/L (OR = 3.3; 95%CI: 1.8–6.1). From day 4–6, the indicator were AST > 400 U/L (OR = 3.0; 95%CI: 1.1–7.9), ALT > 400 U/L (OR = 6.6; 95%CI: 1.7–24.6), albumin < 35 g/L (OR = 3.0; 95%CI: 1.5–5.9), and bilirubin total >17 μmol/L (OR = 4.6; 95%CI: 2.0–10.4).

Conclusion

To predict the risk of patients with severe dengue, prognostic laboratory indicators should be indicated consistent with the progression of the disease. During the first 3 days of illness, prognostic indicators should be platelet count, or serum albumin. From the 4th - 6th day of illness, prognostic indicators should be AST, ALT, albumin, or bilirubin total.

Soluble Notch ligand DLL1 is associated with bleeding complication in patients with dengue fever infection

Bleeding associated with endothelial damage is one key feature of severe dengue fever. Here, we investigated whether Notch ligands are associated with bleeding in 115 patients with confirmed dengue infection in Vietnam. Soluble Notch ligands were determined by ELISA. 14.8% (17/115) experienced bleeding manifestations. High soluble DLL1 (sDLL1) plasma levels was associated with bleeding (median 15674 pg/ml vs 7117 pg/ml; p<0.001). ROC analysis demonstrated that sDLL1 had the best test performance (AUC=0.852), with 88% sensitivity and 84% specificity. The combination with ALT/AST slightly increased DLL1 performance. sDLL1 may be useful to guide clinical management of dengue patients in endemic settings.

Predictors of plasma leakage among dengue patients in Thailand: A plasma-leak score analysis

Delayed plasma leakage recognition could lead to improper fluid administration resulting in dengue shock syndrome, subsequently, multi-organ failure, and death. This prospective observational study was conducted in Bangkok, Thailand, between March 2018 and February 2020 to determine predictors of plasma leakage and develop a plasma leakage predictive score among dengue patients aged ≥15 years. Of 667 confirmed dengue patients, 318 (47.7%) developed plasma leakage, and 349 (52.3%) had no plasma leakage. Multivariate analysis showed three independent factors associated with plasma leakage, including body mass index ≥25.0 kg/m2 (odds ratio [OR] = 1.784; 95% confidence interval [CI] = 1.040-3.057; P = 0.035), platelet count <100,000/mm3 on fever days 3 to 4 (OR = 2.151; 95% CI = 1.269-3.647; P = 0.004), and aspartate aminotransferase or alanine aminotransferase ≥100 U/l on fever days 3 to 4 (OR = 2.189; 95% CI = 1.231-3.891; P = 0.008). Because these three parameters had evidence of equality, each independent factor was weighted to give a score of 1 with a total plasma-leak score of 3. Higher scores were associated with increased plasma leakage occurrence, with ORs of 2.017 (95% CI = 1.052-3.869; P = 0.035) for score 1, 6.158 (95% CI = 2.914-13.015; P <0.001) for score 2, and 6.300 (95% CI = 2.419-16.407; P <0.001) for score 3. The area under the receiver operating characteristics curves for predicting plasma leakage was good (0.677 [95% CI = 0.616-0.739]). Patients with a plasma-leak score ≥1 had high sensitivity (88.8%), and those with a plasma-leak score of 3 had high specificity (93.4%) for plasma leakage occurrence. This simple and easily accessible clinical score might help physicians provide early and timely appropriate clinical dengue management in endemic areas.

Procalcitonin (PCT)-guided antibiotic stewardship in Asia-Pacific countries: adaptation based on an expert consensus meeting

Introduction Recently, an expert consensus on optimal use of procalcitonin (PCT)-guided antibiotic stewardship was published focusing mainly on Europe and the United States. However, for Asia-Pacific countries, recommendations may need adaptation due to differences in types of infections, available resources and standard of clinical care. Methods Practical experience with PCT-guided antibiotic stewardship was discussed among experts from different countries, reflecting on the applicability of the proposed Berlin consensus algorithms for Asia-Pacific. Using a Delphi process, the group reached consensus on two PCT algorithms for the critically ill and the non-critically ill patient populations. Results The group agreed that the existing evidence for PCT-guided antibiotic stewardship in patients with acute respiratory infections and sepsis is generally valid also for Asia-Pacific countries, in regard to proposed PCT cut-offs, emphasis on diagnosis, prognosis and antibiotic stewardship, overruling criteria and inevitable adaptations to clinical settings. However, the group noted an insufficient database on patients with tropical diseases currently limiting the clinical utility in these patients. Also, due to lower resource availabilities, biomarker levels may be measured less frequently and only when changes in treatment are highly likely. Conclusions Use of PCT to guide antibiotic stewardship in conjunction with continuous education and regular feedback to all stakeholders has high potential to improve the utilization of antibiotic treatment also in Asia-Pacific countries. However, there is need for adaptations of existing algorithms due to differences in types of infections and routine clinical care. Further research is needed to understand the optimal use of PCT in patients with tropical diseases.

A Rare Case of Dengue Encephalitis with Raised Procalcitonin

BACKGROUND Dengue virus is a common arbovirus with uncertain neurotropism. Dengue encephalitis is a rare but fatal manifestation of severe dengue. Diagnosis requires high clinical suspicion. It should be routinely considered in patients with encephalopathy, especially in countries where dengue virus is endemic. Unlike other forms of severe dengue, the typical warning signs and biochemical derangements are not reliable markers for dengue encephalitis. Alternative biochemical markers of dengue encephalitis are needed. CASE REPORT We present a case of dengue encephalitis with distinctly raised procalcitonin (13.2 μg/L), in the absence of the typical warning signs and biochemical derangements of severe dengue. The patient was a 65-year-old man with fever and sudden loss of consciousness in the absence of other localizing signs/symptoms. Inflammatory markers were raised, with findings of leptomeningeal enhancement on brain computed tomography suggestive of meningoencephalitis. Septic workup was unremarkable (normal renal and liver functions, negative blood and urine cultures). The typical neurotropic microorganisms were not detected in the cerebrospinal fluid. On day 4 of admission, the patient reported abdominal pain and hematuria with a new onset of bicytopenia. Subsequent investigations for dengue infection were positive for serum dengue NS1 antigen and dengue RNA (type 2 strain) in cerebrospinal fluid, confirming the diagnosis of dengue encephalitis. The patient was managed supportively and experienced full clinical recovery. CONCLUSIONS Dengue encephalitis is a rare condition with nonspecific biochemical and imaging abnormalities. We demonstrated that a raised procalcitonin level can occur in the setting of dengue encephalitis. In endemic countries, this finding may prompt further investigations for dengue encephalitis in patients with meningoencephalitis.

Bacterial sepsis in dengue fever - A paediatric perspective

Dengue fever is the most common arthropod borne infection worldwide. Bacterial sepsis in dengue fever is not widely recognised. This is a retrospective cohort study of children who had sepsis coexisting along with Dengue fever. One hundred and twenty-four patients aged between three months and eighteen years admitted in two private hospitals in North India were studied. Thirteen children had concurrent sepsis (13/124, 10.4%). Children between 0 and five years (7/13, 53.8%, p = 0.019), having longer hospital stay (7/13, 53.8%, p = 0.00029), shock (10/13, 76.9%, p = 0.00001), and increased PCT (13/13, 100%, p < 0.001) were some indicators of sepsis in these patients. Blood cultures were positive in five children. It is a matter of speculation as to why these patients of dengue are more susceptible to sepsis. Increased vascular permeability may increase the chances of bacterial contamination. Antibiotics should not be used routinely in dengue fever. However, young children presenting with severe symptoms especially shock should be screened for sepsis, and appropriate antibiotics should be started early.

Risk Factors for Elevated Serum Lipopolysaccharide in Acute Dengue and Association with Clinical Disease Severity

Although serum lipopolysaccharide (LPS) was shown to associate with development of severe dengue, the reasons for high LPS and its subsequent involvement in disease pathogenesis are not known. We assessed serum LPS, C-reactive protein (CRP), and procalcitonin in patients with acute dengue fever (DF = 129) and dengue haemorrhagic fever (DHF = 64) and correlated these observations with the presence of comorbid illnesses, and clinical disease severity. Serum LPS levels were significantly (p = 0.01) higher in patients with DHF, compared to those with DF. In total, 45 (70%) of those with DHF and 63 (49%) of those with DF had detectable LPS and therefore, the presence of LPS was significantly associated with DHF (p = 0.005, OR = 2.48, 95% CI: 1.29 to 4.64). Those with metabolic diseases, 22/29 (75.9%) and those with atopic diseases 17/22 (77.3%) were significantly more likely to have detectable LPS levels (p = 0.025, OR = 2.9, 95% CI-1.17 to 7.59 and p = 0.039, OR = 3.06, 95% CI-1.07 to 7.81 respectively). Those with detectable LPS levels were also more likely to develop shock and severe thrombocytopenia. Patients with detectable LPS were more likely to have elevated CRP levels and were more likely to develop DHF. Procalcitonin levels too were significantly (p = 0.009) higher in those with DHF compared to those with DF and were more likely to be high in those with detectable serum LPS. Since serum LPS levels were higher in patients with DHF and significantly more likely to be present in those with comorbid illnesses, the possible role of LPS in disease pathogenesis should be further investigated.

Combined score based on arterial lactate, aspartate transaminase and prolonged capillary refill time is a useful diagnostic criterion for identifying severe dengue

BACKGROUND

Taking into consideration, the variable performance of WHO's dengue case definition and the magnitude of epidemics in India, a score based on clinical and laboratory parameters is required for the early identification of severe dengue.

METHODS

A retrospective observational study of children (aged ≤12 y) presenting with dengue, defined as per the WHO 2009 classification and NS1 antigen/IgM ELISA positivity, was conducted at a tertiary care hospital from 2013 to 2015. Clinical laboratory parameters were compared between severe/non-severe dengue using univariate and multivariate analysis. Areas under receiver operating characteristic curves (AUROCs), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were obtained for independent and composite markers.

RESULTS

Of 135 dengue patients, 46 (34.1%) had non-severe dengue and 89 (65.9%) had severe dengue. Logistic regression determined prolonged capillary refill time (CRT), lactate ≥2.9 mmol/L and serum aspartate transaminase (AST) ≥135 IU/L as predictive for severe dengue. AUROCs of lactate, AST and combined score incorporating AST, lactate and prolonged CRT for identifying severity were 7.55, 7.23 and 8.5, respectively. The combined score cut-off ≥1 had 87.6% sensitivity, 65.2% specificity, 83% PPV and 73.2% NPV. The combined score cut-off ≥3 had 100% specificity and 100% PPV.  However, AST >135 IU/L and lactate >2.9 mmol/L together had 97.8% specificity and 97.1% PPV for identifying severity.

CONCLUSIONS

The presence of either 'prolonged capillary refill time with one deranged biochemical parameter' or 'both deranged biochemical parameters' is nearly 100% specific for severity of dengue.

Clinical Profile and Outcome of Dengue Fever in Multidisciplinary Intensive Care Unit of a Tertiary Level Hospital in India

Background

India is one of the seven identified countries in South-East Asia region regularly reporting dengue fever (DF)/dengue hemorrhagic fever (DHF) outbreaks. Even though the dengue prodrome and evolution of illness are most often similar in many patients, progress and outcome may differ significantly depending on the severity of illness as well as treatment instituted. We studied the clinical manifestations, outcome and factors predicting mortality of serology confirmed dengue fever cases admitted in Multidisciplinary Intensive Care Unit (MICU) of a high acuity healthcare facility in India.

Methodology

All patients with serology proven dengue fever admitted to MICU between 1st July 2015 and1st December 2015 were included in the study. Clinical presentation, laboratory findings, severity of illness scores and outcome were recorded.

Results

Majority of the patients (58.4%) belonged to 21–40 year age group. Hepatic (96.8%) followed by hematological (79.2%) involvement were the most common findings. CNS involvement observed among 27%. Survival to hospital discharge was 78.9%. Respiratory and gastrointestinal system involvement was associated with increased mortality. Acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and shock were the clinical syndromes associated with mortality. Serum lactate, aspartate transaminase (AST) and alanine transaminase (ALT) were significantly elevated among non survivors. Significant difference in sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation (APACHE) scores was also observed among survivors and non survivors.

Conclusion

Organ system involvement and higher disease severity scores are strong predictors of mortality. High index of suspicion for atypical manifestations of dengue is warranted.

How to cite this article

Padyana M, Karanth S, Vaidya S, Gopaldas JA. Clinical Profile and Outcome of Dengue Fever in Multidisciplinary Intensive Care Unit of a Tertiary Level Hospital in India. Indian J Crit Care Med 2019;23(6):270–273.

Improving Dengue Diagnostics and Management Through Innovative Technology

PURPOSE OF REVIEW

Dengue continues to be a major global public health threat. Symptomatic infections can cause a spectrum of disease ranging from a mild febrile illness to severe and potentially life-threatening manifestations. Management relies on supportive treatment with careful fluid replacement. The purpose of this review is to define the unmet needs and challenges in current dengue diagnostics and patient monitoring and outline potential novel technologies to address these needs.

RECENT FINDINGS

There have been recent advances in molecular and point-of-care (POC) diagnostics as well as technologies including wireless communication, low-power microelectronics, and wearable sensors that have opened up new possibilities for management, clinical monitoring, and real-time surveillance of dengue. Novel platforms utilizing innovative technologies for POC dengue diagnostics and wearable patient monitors have the potential to revolutionize dengue surveillance, outbreak response, and management at population and individual levels. Validation studies of these technologies are urgently required in dengue-endemic areas.

Dengue fever: Report from the task force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine

Dengue is an arbovirus affecting humans and spread by mosquitoes. Severe dengue follows a secondary infection with a different virus serotype. The problem is truly global as it is endemic in over 100 countries. Severe dengue can be a life-threatening because of increased vascular permeability, resulting in leakage of fluid from the intravascular compartment to the extravascular space. When major bleeding does occur, it is almost invariably combined with profound shock since this, in combination with thrombocytopenia, hypoxia, and acidosis, can lead to multiple organ failure and disseminated intravascular coagulation. Dengue hemorrhagic fever and dengue shock syndrome are among the leading causes of morbidity and mortality in patients suffering from Dengue. Commercial rapid tests and ELISA kits are freely available, ensuring early diagnosis. The basis of management of severe dengue is effective fluid replacement. Future directions in management will involve vector control and development of effective vaccination.

Cardio-haemodynamic assessment and venous lactate in severe dengue: Relationship with recurrent shock and respiratory distress

Background

Dengue can cause plasma leakage that may lead to dengue shock syndrome (DSS). In approximately 30% of DSS cases, recurrent episodes of shock occur. These patients have a higher risk of fluid overload, respiratory distress and poor outcomes. We investigated the association of echocardiographically-derived cardiac function and intravascular volume parameters plus lactate levels, with the outcomes of recurrent shock and respiratory distress in severe dengue.

Methods/Principle findings

We performed a prospective observational study in Paediatric and adult ICU, at the Hospital for Tropical Diseases (HTD), Ho Chi Minh City, Vietnam. Patients with dengue were enrolled within 12 hours of admission to paediatric or adult ICU. A haemodynamic assessment and portable echocardiograms were carried out daily for 5 days from enrolment and all interventions recorded.

102 patients were enrolled; 22 patients did not develop DSS, 48 had a single episode of shock and 32 had recurrent shock. Patients with recurrent shock had a higher enrolment pulse than those with 1 episode or no shock (median: 114 vs. 100 vs. 100 b/min, P = 0.002), significantly lower Stroke Volume Index (SVI), (median: 21.6 vs. 22.8 vs. 26.8mls/m², P<0.001) and higher lactate levels (4.2 vs. 2.9 vs. 2.2 mmol/l, P = 0.001). Higher SVI and worse left ventricular function (higher Left Myocardial Performance Index) on study days 3–5 was associated with the secondary endpoint of respiratory distress. There was an association between the total IV fluid administered during the ICU admission and respiratory distress (OR: 1.03, 95% CI 1.01–1.06, P = 0.001). Admission lactate levels predicted patients who subsequently developed recurrent shock (P = 0.004), and correlated positively with the total IV fluid volume received (rho: 0.323, P = 0.001) and also with admission ALT (rho: 0.764, P<0.001) and AST (rho: 0.773, P<0.001).

Conclusions/Significance

Echo-derived intravascular volume assessment and venous lactate levels can help identify dengue patients at high risk of recurrent shock and respiratory distress in ICU. These findings may serve to, not only assist in the management of DSS patients, but also these haemodynamic endpoints could be used in future dengue fluid intervention trials.

Dengue is a viral illness that can lead to severe and potentially fatal complications. The most common complication is fluid leakage from blood vessels, which can cause low blood pressure or dengue shock syndrome (DSS). The majority of patients recover with simple intravenous fluid replacement, however in approximately 30% of DSS cases, recurrent episodes of shock occur, and these patients have a higher risk of fluid overload, respiratory distress and death. We investigated whether using portable echocardiograms (Echo) in the intensive care unit (ICU) to assess cardiac function and intravascular volume parameters as well as blood lactate levels, can help identify these patients. We found patients who developed recurrent shock had higher heart rates and lower Stroke Volume Index (SVI), and higher lactate levels at enrolment than those with 1 episode or no shock. Higher SVI and worse cardiac function after 3 days in ICU was associated with respiratory distress. Admission lactate levels predicted patients who subsequently developed recurrent shock and correlated positively with the total IV fluid volume received. These results demonstrate that Echo-derived intravascular volume assessment and venous lactate levels can help identify dengue patients at high risk of poor outcomes in the ICU, and could assist in the management of severe dengue.