Dengue deaths are preventable if proper procedures are followed

No patient who walks into a hospital should go out in a coffin
By Kumudini Hettiarachchi

As rains lash the country, there is grave concern in health circles that a dengue disaster is waiting to happen. There are serious issues with dengue management in State hospitals, the Sunday Times understands, with many an allegation that basics are not being followed.

So far, 150 people have died of dengue this year with two-thirds being adults, it is learnt.
“We will have to brace ourselves for a dengue disaster because no one is interested in the simple procedures which have been told over and over again,” said a senior doctor, pointing an accusing finger not only at the physicians under whose care were the humble dengue victims, but also the hospital administrations for not carrying out a dengue audit and the bureaucrats in the Health Ministry who are only bent on holding meetings.

This is a view echoed by many doctors and healthcare professionals who, however, were reluctant to shout out loud about the situation where patients are dying unnecessarily, as they would draw the ire of colleagues.

The patients then become the double victims, stressed another source, referring to an incident at the most important hospital in Colombo where the dengue audit committee was refused entry into a ward.
“If that was not bad enough, the committee doctors were even allegedly threatened with physical violence,” another source confirmed, explaining that this incident did the rounds for quite some time, but the authorities simply didn’t act.No punitive action was taken, so what is the message being given to senior as well as junior doctors, the source asked, explaining that the message would be that “anything goes” and the culprits will be scot-free.

When there is wilful neglect of dengue patients and those patients die, it may be tantamount to murder, the source said, adding that the relatives of humble patients keep quiet unlike in the West where there would be massive law suits.

With mostly adults dying of dengue, there is evidence to suggest that paediatricians are a lot better in following the guidelines set by the Epidemiology Unit and preventing deaths, said another doctor, asking whether it is lethargy or complacency or negligence on the part of physicians.

It can’t be ignorance because over and over again they have been told what should be done and that is very simple, another pointed out. The first step is to monitor all febrile patients (those coming in with fever) as the first suspect on the diagnosis list should be dengue, the Sunday Times understands, as dengue has become hyper-endemic.

The policy should be to think of all patients with fever as having dengue, unless ruled otherwise, it is learnt. Clinicians should monitor the febrile phase very carefully and then check out whether it is dengue fever (DF) or dengue haemorrhagic fever (DHF) when the fever has continued for more than three days, said a senior doctor who has studied dengue. DF has no plasma leakage, while in DHF there will be evidence of both a plasma leakage and a platelet count equal to or below 100,000/ Many patients with DF and DHF will also have a white blood cell count below 5,000.

The other important factor is that dengue patients do not need to be accommodated in an intensive care unit but can be managed in a ward. However, constant monitoring is the key, another doctor pointed out.
How do you differentiate between DF and DHF? Through clinical features and two simple tests – a Full Blood Count (FBC) and an ultrasound scan, he answers.

Most physicians seem to be fixated with the platelet count and that shouldn’t be, said another. If it is DHF, then the 48-hour “critical phase” needs to be calculated to ascertain plasma leakage. Here is where the scan comes in handy, he said.

Once leakage is confirmed, fluid therapy should begin, according to the guidelines laid down by the Health Ministry, taking into account the ideal body weight. If shock develops, in a majority of cases it would be due to a misdiagnosis or wrong diagnosis or delayed diagnosis, another source said.
The fluid leakage can be deduced by an intelligent analysis of the total and differential white blood cell counts, platelet counts and haematocrit of the entire series of FBCs available from Day 2, a doctor said, laying down in black and white the way of doing it. This would be essential to give fluid therapy.

Calculate the fluid quota for the entire period of plasma leakage i.e. M+5% for 48 hrs. The fluid rate has to be adjusted hour by hour based on the capillary haematocrit and vital signs during this period to match the dynamics of plasma leakage. Do NOT give fluid at a flat rate, stressed the doctor who has pulled many a dengue victim from the brink of death.

Manipulate the use of crystalloids, Dextran and Hetastarch intelligently in relation to the point in the time scale of the disease in the critical phase and the balance of the fluid quota to prevent both shock as well as fluid overload, he said, adding that Dextran should specifically be given as a bolus and NOT as an infusion.

Do not give intravenous fluids or Dextran during convalescence when the leaked fluid is being reabsorbed and tends to augment the risk of fluid overloading, he urged, pointing out that a smooth convalescence should be ensured.

Of course, for all this, the physicians and the staff under their purview should be monitoring the patients very closely and also maintaining charts, it is learnt. Fluid therapy is the important pillar on which dengue management is based, reiterated another source, stressing that timed, specific interventions through fluid therapy can prevent fatalities.

Many asymptomatic patients have DF and will recover, while the few who develop DHF are often slow leakers and even when fluid therapy is less than optimal they too have a high chance of recovery, it is learnt.

The golden rule in dengue management is that dengue deaths are preventable. Dengue is a predictably treatable disease. By and large, no patient who walks into a hospital should go out in a coffin, the Sunday Times understands.

If that happens there has been a failure not only on the part of the doctor and his ward staff but also on the part of the hospital management, was the consensus among doctors.

Another dengue death

A dengue patient passed away at the Matara hospital last morning. A 28-year-old electrician identified as Thushara Vitharana had initially contracted dengue while working in Colombo and was later admitted to the Matara hospital.

He was the father of a 10 month old child and passed away on his birthday. During this year 319 dengue patients have been admitted to the Matara hospital with four deaths for the year. Authorities have now stepped up fumigation and cleaning of drains.

Ban on NSAIDs necessary?

There should be a temporary ban on NSAIDs (non-steroidal anti-inflammatory drugs) such as ibu profen for acute fevers. Although specific instructions have been issued not to use NSAIDs, physicians are still doing so, it is learnt. So a ban may be the only answer, it is understood.

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