Triage of Pediatric Dengue Disease Cases at KBNIMS Kalaburagi Outpatient Clinic – A Retrospective Observation Study

Introduction

Dengue is the most rapidly emerging vector-borne viral infection spreading to newer geographical areas in India each year. Recognising the severity of the disease at its early stage is necessary for quick intervention and appropriate management.^1,2 To improve dengue triage and treatment decisions, the World Health Organization (WHO) recommends classifying the disease with or without warning signs or severe dengue.³ The study aimed to define the case severity based on clinical features, a simple tourniquet test,⁴ laboratory parameters (haematocrit) and USG findings, particularly the inferior vena cava (IVC) collapsibility index and form a decision-making algorithm for admission of patients presenting with dengue fever at OPD and to further determine the course of management at home or the hospital.

Vascular leakage is a critical component of the pathophysiology of severe dengue and is detectable by raising haematocrit tourniquet test and bedside ultrasound (POCUS).^5,6 Given the progress of current ultrasound technology, a focused point-of-care ultrasound protocol for early detection of vascular leakage in dengue is needed to generate the evidence required for its implementation in routine care. USG measures the inferior vena cava diameter (IVC) and low vena cava collapsibility index (IVC-CI), which are valuable in assessing intravascular fluid volume.⁷ This study was performed to determine whether ultrasound is an adjunct to clinical and laboratory profiles in predicting the severity of the disease.⁸

Materials and Methods

All the paediatric dengue patients presenting to OPD at Khaja Banda Nawaz Teaching and General Hospital, Kalaburagi, were included in a retrospective observational study from Dec 2019 to July 2021. The sample size was 80.

Inclusion criteria

1. Patients in 0-14 years age group.
2. Clinical features suggestive of dengue fever confirmed by rapid dengue test or ELISA. 
3. Ultrasound finding suggestive of dengue infection.

Exclusion criteria

1. Patients presenting with fever, negative dengue rapid test and dengue serology.
2. Tense ascites.

Results

Eighty medical records were analysed. These included 63.7% males and 36.2% females. Patients were divided into age groups 0-1 year (15%), 1-5 years (30%), 5-10 years (33%), and 10-15 years (21%) (Table 1). The most common presentation mode was fever, headache, myalgia, vomiting, and pain in the abdomen (Table 2). At the time of admission, important indicators included leukopenia, thrombocytopenia, hyponatremia, raised liver enzymes, and a positive tourniquet test (Table 3). Screening for patients with IVC diameter and IVC collapsibility had been undertaken to foresee the patients with dengue fever and dengue haemorrhagic fever who are at risk of developing dengue shock syndrome (DSS) and to predict the severity of patients with DSS.

Based on these features, triaging was done and severity was assessed. Out of 80 patients, majority i.e., 51 (63%) presented with dengue fever, followed by 25 (31%) patients who presented with Dengue Haemorrhagic Fever (DHF) and 4 (5%) patients presented with DSS (Table 4 & Figure 1). Out of 51 patients with dengue fever, 36 (71%) were managed on an OPD basis and 15 (29%) were managed in OPD day-care. The remaining 29 (36%) patients with DHF and DSS were hospitalised.

Discussion

Hemodynamic monitoring is a functional tool to assess the pathophysiological process of a disease.⁹ It is also used to facilitate the diagnosis which enables more effective management and monitor response to therapy.^9,10

The appropriate hemodynamic monitoring modality depends on the availability of techniques in the treating institution, the accuracy of the devices, and the patient’s condition and contraindications.¹¹

We conducted a retrospective observational study involving 80 cases. Children aged 10-15 years had an increased incidence, and males were more affected. In a similar survey by Hussai and colleagues including 93 cases of dengue fever, 71 (76.3%) children were males. The mean age of the children was 5.7 ± 3.07 years. The preponderance of male sex was seen in both the studies. In the present study, 51 (63%) patients presented with dengue fever, followed by 25 (31%) patients with DHF and 4 (5%) patients presented with DSS. Out of 51 patients with dengue fever, 36 (71%) were managed on an OPD basis, and 15 were managed with day care admission. Out of 80 cases, 29 (36%) patients with DHF and DSS were hospitalised. Thus children who required hospitalization were admitted based on clinical signs (warning signs), serial hematocrit monitoring, and tourniquet test. Similar observations have been reported by Narvaezet et al., where the number of pediatric dengue patients transferred to their study hospital had risen from 11-36% to 83%.¹² Similarly, Leo et al., estimated a 2-3- fold increase in workload by adopting a warning sign guiding-guided on policy.¹³ Admitting patients with dengue fever exhibiting warning signs has increased the burden on the hospital and patient care.

Current techniques to identify and monitor leakage rely on surrogate markers of intravascular volume depletion, serial hematocrit, and close monitoring of heart rate and pulse pressure. In the current study, hospitalised patients with warning signs were subjected to bedside ultrasound or point care ultrasound (POCUS) IVC diameter and IVC-CI. 31% of cases had an IVC diameter less than 1cm diet non-collapsing, g and it was collapsible in m e than 50% in 4 % of cases. All cases where the diameter was less than 1 cm were correlated with warning signs and raised hematocrit levels. In a study done at Kanchi Kamakoti hospital by Raman and coworkers (46 children with dengue fever were grouped into dengue shock (n=40) and Dengue fever with warning signs (n=6) to evaluate the relationship among IVC-CI, packed cell volume (PCIn Vin) and fluid requirements. IVC-CI >50% was positively correlated with high PCV; features of DSS, needed for normal saline fluid boluses and colloid requirements; intensive care admission.¹⁴ Additionally, in the study by Thanachartwet t al., 17 (10.5%) patients had dengue shock, patients with dengue shock had a significantly higher proportion of patients with IIVC<1.5 cm and IVIVC50% between days 4 and 5. it has been noted the majority of dengue patients will have IVCd 50% during defervescence subsequently developed DSS.¹⁵ Both cardiogenic and hypovolemic shock appears to have an equal contribution (50%) in the pathogenesis of DSS. Point-of-care ultrasound plays a vital role in patient care in many settings, and its role function is growing with the advent of more portable and affordable equipment.¹⁶ As the role of ultrasound in assessing dengue patients is still being defined, consideration should also be given for developing specific protocols and training.

Dengue is a major worldwide health problem expanding into areas that have not previously dealt with the disease. Recognition of patients at risk for decompensation and close observation is vital for essential outcomes. Point-of-care findings in early suspected dengue patients can predict the need for subtle frequent acute care visits. Its usefulness during dengue outbreaks in endemic, resource-limited settings is promising and warrants further research. Our study investigated the role of point-of-care ultrasound in predicting the early suspected dengue worsening in an ambulatory pediatric population.

Conclusion

Dengue fever with warning signs exhibiting rising hematocrit needs evaluation with bedside ultrasound. Serial measurements of IVC diameter and IVC–CI in hospitalised patients predicts the severity of illness and helps guide the management of patients. Bedside ultrasound being non-invasive is key in managing critical patients with dengue shock and severe dengue.

Financial support

Nil

Conflict of interest

Nil