It was about four weeks back that Mr. A. Fernando whom I never knew phoned me. He was upset and it did not take long for me to realize the gravity of what he was talking about. He wanted help to save his grand-daughter. Seyarra who had been transferred to the Medical Intensive Care Unit of [...]

The Sundaytimes Sri Lanka

Lessons from Seyarra


It was about four weeks back that Mr. A. Fernando whom I never knew phoned me. He was upset and it did not take long for me to realize the gravity of what he was talking about. He wanted help to save his grand-daughter. Seyarra who had been transferred to the Medical Intensive Care Unit of the Lady Ridgeway Hospital, Colombo, from a private hospital had already developed two episodes of dengue shock.

She had been successfully resuscitated and was in the dedicated hands of the MICU staff comprising Consultant Paediatric Intensivist, Dr. Nalin C. Kitulwatte, Consultant Paediatrician Dr. Sri Lal De Silva, Consultant Haematologist Dr. Mala Jayathilaka, Consultant Paediatric Surgeon Dr. Dharmasri Jayawardena, Consultant Anaesthetist Dr. Lakmali Samaraweera, Consultant Paediatric Nephrologist Dr. Vindya Gunasekara, Medical Officers, nursing officers and minor staff.

When I spoke to Dr. Nalin on behalf of Mr. Fernando, he replied softly but with confidence that “Seyarra had two episodes of shock. We managed to resuscitate her, but never know what will happen during the next few hours as she is already beyond the calculated fluid quota”.

Knowing about dengue and dengue shock syndrome, there was nothing else to do, I knew. The same afternoon, it was quite good news.
“Seyarra is quite stable so far,” I was told, but the news the following day was not that good. Seyarra had developed yet another blood pressure drop, this time due to bleeding.

She was bleeding from somewhere. The only option at this stage was to transfuse blood until she became stable. Her blood-clotting parameters and platelets were within acceptable range. However, she continued to bleed into her small tummy. By that time she had already received several pints of blood to meet the required stability in her vital parameters.

I knew that the chances were slim. But the MICU team was determined. Nalin’s answer was clear, “We are not giving up”. When I phoned him in the evening, the team was still struggling with the patient. “The child is still bleeding. She has received more than the total blood in her body. We are wondering how to proceed. She is likely to develop complications of massive blood transfusions”.
Dr. Mala, however, was very confident based on the blood results. It should be internal bleeding from an internal organ. Repeated scans were not helpful. Thereafter, with the clear guidance of Dr. Mala, they took the brave decision – a decision never taken in the history of dengue.

“We have determined to open up this child. We want to find the bleeder and stop it, this is all what is left for us,” Nalin said. I could not believe my ears. I told him that they would be very brave to operate on a sick child with dengue. However, I realised that there were no other options.

As advised by Dr. Mala and under her close observation, with the consent of the parents, the child’s tummy was opened up and they found the bleeder. It was from the spleen. There was a rupture of the spleen, without any trauma. It was in the history of dengue that a ruptured spleen had been found. In such a situation, there are only two options left — either to remove the spleen altogether or to pack it to stop the bleeding. They opted for the latter as they did not want to go ahead with prolonged surgery on a child who was already very ill. They packed the spleen with gauze and then monitored the child.

Seyarra improved. I was overwhelmed with happiness, but the team was sceptical. They were expecting problems with blood transfusions. Seyarra was kept under very close monitoring and she was doing well over the next 24 hours. Then the surgeons decided to remove the packs, as she would run the risk of sepsis. She underwent the second successful surgery after 24 hours and by that time the bleeding had stopped and she was quite stable. It was a positive sign.

However, 24 hours later, her oxygen saturation started to drop and her chest X-ray was all white. She was developing acute lung injury, most probably due to all the stresses she underwent. She was connected to the ventilator and was closely observed. She was quite stable for the next four days and the lungs were gradually improving. Her dengue status had now almost improved and now she had to recover from the effects of secondary stress and massive blood transfusions.

The seventh night had not been very peaceful. Nalin said, “Her blood pressure and pulse are fluctuating.” This was not good news and I felt she was not going to make it. The team, however, was still determined. When I asked Nalin what their plans were I could not believe what he told me.

The decision was to do an exchange transfusion to remove all toxic material from Seyarra’s blood. I have not heard of such an intervention in dengue. In an exchange transfusion, Seyarra’s blood would be removed in small amounts at a time and replaced with fresh blood.

They did it and there had been amazing success. She was quite stable in her blood pressure and pulse. She remained stable for the next three days, although she was now battling with the diseased lungs. The dedicated LRH team was working hard, day and night to save Seyarra’s life. I am sure some of the doctors may have not slept a minute during this period.

However, after another four days, Seyarra’s pendulum swung away from all expectations and it was not good news. Her kidneys showed some degree of packing up and the urine output was dropping. This could well be as a consequence of massive blood transfusions and the stress Seyarra was undergoing all throughout. She was free of sepsis throughout.

There was no other option, but to do some form of dialysis on her. Her recent abdominal surgery prevented her from undergoing peritoneal dialysis. Therefore, it was decided to do haemofiltration, but there was no machine. They got a machine and other appropriate equipment from the National Hospital and carried out the haemofiltration.

Although it was successful on the first day, later in the evening she started to bleed from her injured lungs. This was mostly due to heparin that she was receiving to thin her blood to undergo haemofiltration. They had managed to reverse the bleeding as advised by Dr. Mala.

At this point Dr. Mala had left the country on an official overseas visit but she advised the team every now and then over the phone. Seyarra developed a complication which made her not fit for dialysis, without which her life was in great danger and the team was helpless.

Seyarra has left behind many lessons and questions. Are patients with dengue at risk of splenic rupture? Is this the cause for unrevealed bleeding in dengue patients? Do we need to explore this possibility in such patients and take certain decisions to avoid massive blood transfusions? What is the value of exchange transfusion? Etc.

There were many new things to learn, to try out, all beyond the guidelines, in the fight against this deadly disease, until it is eradicated from Sri Lanka. Although it was a sad ending, it however highlights the tremendous dedication of a committed staff, we should be proud of. But it is dengue, which needs to be eradicated if we need to avoid similar sad stories and it is the responsibility of each and every citizen of this country to do so.

The writer is a Professor at the Faculty of Medicine, Ragama

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