Dengue and dengue hemorrhagic fever: management issues in an intensive care unit.

OBJECTIVES: To describe the epidemiology, clinical features and treatment of dengue fever and dengue shock syndrome. SOURCES: To prepare this review, a literature search was made on PubMed and on the World Health Organization (WHO) and PAHO websites using the terms dengue and dengue shock syndrome. This information was complemented with personal practice. SUMMARY OF THE FINDINGS: Dengue is the most important arthropod-borne viral disease of humans. Its presentation is protean and varies from an undifferentiated viral syndrome to hemorrhagic fever and severe shock. Dengue fever is a self-limiting, nonspecific illness characterized by fever, headache, myalgia, and constitutional symptoms. Its severe forms (hemorrhagic fever and shock syndrome) may lead to multisystem involvement and death. Early diagnosis, close monitoring for deterioration and response to treatment are necessary in all cases. WHO has provided a stepwise approach to management that is useful for milder forms and early shock. In the more severe forms aggressive fluid resuscitation and support for failing organs is necessary for the critically ill patient. Research addressing pathophysiological differences between dengue shock and septic shock, choice of fluids, inotropes and techniques of organ support are likely to yield benefits for the critically ill. CONCLUSIONS: There is no specific therapy for dengue infections. Good supportive care may be lifesaving, but ultimately initiatives aimed at vector control and prevention of mosquito bites may provide the greatest benefits.

Dengue e dengue hemorrágico: aspectos do manejo na unidade de terapia intensiva / Dengue and dengue hemorrhagic fever: management issues in an intensive care unit

OBJETIVOS: Descrever a epidemiologia, as características clínicas e o tratamento do dengue e das síndromes do choque associadas ao dengue. FONTES DOS DADOS: Para esta revisão de literatura, foi feita uma pesquisa no Pubmed e nos websites da Organização Mundial da Saúde (OMS) e OPAS usando os termos dengue e síndrome do choque associada ao dengue. A informação foi complementada com a experiência pessoal dos autores. SíNTESE DOS DADOS: O dengue é a mais importante doença viral transmitida por artrópodos em seres humanos. A doença se manifesta de diversas formas, variando desde uma síndrome viral não-diferenciada até febre hemorrágica e choque grave. O dengue é uma enfermidade autolimitada, não específica, caracterizada por febre, cefaléia, mialgia, e sintomas constitucionais. As formas mais graves (febre hemorrágica e síndrome do choque) podem levar a um comprometimento multissistêmico e ao óbito. O diagnóstico precoce e um acompanhamento contínuo do agravamento e da resposta ao tratamento são necessários em todos os casos. A OMS recomenda uma abordagem escalonada para o manejo, adequada para as formas mais leves e para o choque precoce. Nas formas mais graves, é preciso uma abordagem agressiva de reanimação com fluidos e de suporte à falência de órgãos em pacientes em estado crítico. As pesquisas sobre as diferenças fisiopatológicas entre o choque do dengue e o choque séptico, seleção de fluidos, agentes inotrópicos e técnicas de suporte a órgãos podem beneficiar os pacientes em estado crítico. CONCLUSÕES: Não há uma terapia específica para infecções causadas pelo dengue. Um bom tratamento de suporte pode salvar vidas mas, em última análise, as iniciativas de controle do vetor e de prevenção contra picadas do mosquito podem trazer os maiores benefícios.

OBJECTIVES: To describe the epidemiology, clinical features and treatment of dengue fever and dengue shock syndrome. SOURCES: To prepare this review, a literature search was made on Pubmed and on the World Health Organization (WHO) and PAHO websites using the terms dengue and dengue shock syndrome. This information was complemented with personal practice. SUMMARY OF THE FINDINGS: Dengue is the most important arthropod-borne viral disease of humans. Its presentation is protean and varies from an undifferentiated viral syndrome to hemorrhagic fever and severe shock. Dengue fever is a self-limiting, nonspecific illness characterized by fever, headache, myalgia, and constitutional symptoms. Its severe forms (hemorrhagic fever and shock syndrome) may lead to multisystem involvement and death. Early diagnosis, close monitoring for deterioration and response to treatment are necessary in all cases. WHO has provided a stepwise approach to management that is useful for milder forms and early shock. In the more severe forms aggressive fluid resuscitation and support for failing organs is necessary for the critically ill patient. Research addressing pathophysiological differences between dengue shock and septic shock, choice of fluids, inotropes and techniques of organ support are likely to yield benefits for the critically ill. CONCLUSIONS: There is no specific therapy for dengue infections. Good supportive care may be lifesaving, but ultimately initiatives aimed at vector control and prevention of mosquito bites may provide the greatest benefits.

Intrapartum infusion of oxytocin and glucose water and neonatal jaundice

Two hundred and seventy-eight deliveries were studied prospectively to determine the association between the use of oxytocin during labour and the incidence of neonatal jaundice. Jaundice was seen significantly more often in neonates following maternal infusion of oxytocin in dextrose water (OT) or dextrose water alone (DW) as compared to those whose mothers did not receive either. No significant difference was seen in the incidence of jaundice between OT or DW groups. Mean umbilical cord serum sodium levels were significantly lower in the OT and DW group neonates who became jaundiced, as compared to the rest of the neonates in the same group and the control group. Sixty per cent of the jaundiced neonates in the OT as well as the DW group had frank hyponatremia as compared to only 8 percent in the control group. These findings support a probable causative association between hyponatremia at birth and neonatal jaundice in the deliveries following dextrose water and/or oxytocin infusion (AU)

Immunoglobulin and C3 levels in maternal and cord blood in Jamaica

IgG, IgM, IgA and C3 were estimated by radial immunodiffusion (RID) in one hundred paired maternal and cord blood samples. The mean maternal IgG, and IgM, and IgA were 2112 mg/dl, 118 mg/dl and 251 mg/dl, respectively, while in corresponding infants, the mean levels were 2194 mg/dl, 36 mg/dl and 19 mg/dl. Mean cord serum C3 levels was 113 mg/dl, approximately half the maternal level (203 mg/dl). Variation in the gestational age, birth weight, duration of labour and maternal pre-eclamptic toxaemia did not significantly affect the immunoglobulin levels. Seven out of 36 (16 percent) cord blood with IgM level greater than 36 mg/dl showed either fourfold rise or high antibody titres against one of the TORCH (toxoplasma, rubella, cytomegalovirus and herpes simplex virus) agents. Screening of cord serum for IgM levels can be of particular value in detection of newborn infants with clinically apparent or inapparent intrauterine infections (AU)

Plasma arginine vasopressin response to water load during labor

To find out whether plasma vasopressin (PAVP) response to a water load during pregnancy is inappropriately high, as had been speculated, we measured PAVP by radio-immunoassay in 30 women at the time of delivery. Ten women had received infusion of aqueous glucose solution during labor for hydration (GW group); another ten received infusion of glucose solution as a vehicle for oxytocin (OT group), and ten women did not receive any intrapartum intravenous fluid therapy (controls). Serum sodium and osmolality were also determined in all the subjects. PAVP levels were significanty lower in GW (0.70) ñ 0.4 pg/ml)and OT groups (0.7 ñ 0.6 pg/ml) (P< 0.05). Significant negative correlation was seen between the amount of glucose solution infused and levels of PAVP (r = 0.61; P< 0.01). These findings suggest that during labor, the physiological relationship between serum osmolality and PAVP is intact, and that infusion of a water load in the form of aqueous glucose solution is attended by an expected lowering of PAVP. We infer that inappropriate ADH response is not the cause of water retention and hyponatremia often seen in women receiving aqueous glucose solution during labor.(AU)

Roentgenographic skull volume in Jamaican children between the ages of one month and five years

Values for roentgenographic skull volume estimated with the help of McKinnon's formula in 331 black normocephalic children between the ages of one month and five years, using standard anteroposterior and lateral skull films, are presented. Mean skull volume was higher among boys at all ages after the first six months of life. Significant linear correlation was seen between log-age and skull volume for both sexes. The roentgenographic skull volume in Jamaican children was more or less similar to that of British and Indian children (AU)

Intrapartum infusion of aquenous glucose solution, transplacental hyponatraemia and risk of neonatal jaundice

Cord serum sodium levels in three groups of 278 singleton infants, born vaginally at term, were correlated with the incidence of jaundice (serum bilirubin o85æmol/1) in the first 3 days of life. Of the 278 infants, 87 were born to mothers who were given infusions of 5 percent or 10 percent glucose in water during labour (group I), 90 were born to mothers who received glucose solution as a vehicle for oxytocin (group II), and 101 to mothers who did not receive any intravenous fluid therapy (control group). Jaundice was seen significantly more frequently in groups I (28/87, 32 percent) and II infants (30/90, 33 percent) than in the control group (12/101, 12 percent) (P<0.01), but when analysed in relation to cord serum sodium levels, the prevalence of jaundice in the normonatraemic infants (serum sodium o131 mmol/1) was similar in the three groups. On the other hand, in groups I and II jaundice occurred about 3.5 times more frequently in the hyponatraemic infants (group I (17/32, 53 percent) and II (20/39, 51 percent) than in the normonatraemic infants (P<0.01). The difference was not associated with any other perinatal or neonatal characteristic.(AU)

Paired maternal and umbilical cord serum cholesterol and triglyceride levels in Jamaicans: normal values and the influence of some perinatal factors

Serum total cholesterol (TCHO) and tryglyceride (TG) levels were determined in paired maternal and umbilical cord serum from 120 full-term deliveries at the University Hospital of the West Indies. The median cord serum TG level was found toPbe 0.74 mmol/l, which is much higher than the levels of 0.34-0.52 mmol/l in the studies reprted so far. On the other hand, cord serum TCHO levels of 1.91 mmol/l, and maternal TG and TCHO levels of 1.84 mmol/l and 5.60 mmol/l respectively are within the range of values reported in the literature. Cord serum hypertriglyceridaemia was seen in 7 newborns, all of whom had at least one kind of perinatal stress. A significant elevation of cord serum TG was seen in infants who suffered neonatal jaundice. Further studies are needed to confirm our findings to elucidate their significance (AU)

Transplacental hyponatraemia following infusion of electrolyte-free glucose solution during labour and neonatal jaundice - abstract

Umbilical cord serum sodium level in three groups of 278 term, vaginally delivered, singleton infants, were correlated with the incidence of jaundice (serum bilirubin 85 æmols/1) in the first 3 days of life. Eighty-seven infants were born to mothers who were given infusions of 5 percent or 10 percent glucose in water during labour (Group I); ninety were born to mothers who received glucose solution as a vehicle for oxytocin (Group II); and 101 whose mothers did not receive any intravenous fluid therapy served as controls. Jaundice was seen significantly more frequently in groups I (28/87, 31.5 percent) and II (30/90, 33 percent) infants compared with controls (12/101, 12 percent) (p<0.001); but when analysed in relation to umbilical cord serum sodium levels, the incidence of jaundice in normonatraemic infants (serum sodium < 131 mols/l) in the three groups was not different (p>0.1). On the other hand, the incidence of jaundice was about 3.5 times more in the hyponatraemic groups I (17/32, 53 percent) and II (20/39, 51 percent) infants as compared to normonatraemic infants in the same groups (p<0.01). The difference was not attributable to any other perinatal or neonatal characteristic. These findings lend support to our previous suggestion that there is a causative association between transplacental hyponatraemia and neonatal jaundice, and define one more category of infants 'at risk' for jaundice (AU)

Roentgenographic cranial-base and calvarial measurements of Jamaican children between one month and five years

Three hundred and thirty lateral skull films obtained from apparently healthy normocephalic Jamaican children between the age of one month and five years were studied, using bony reference points nasion (N), tuberculum sellae (Ts), internal occipital prominence (IOP), inion (I), bregma (B) and lambda (L). Cranial-base length was measured between N-Ts, Ts-IOP and N-I. Calvarial height was measured between Ts-B, N-Ts and Ts-L and N-I and Ts-L at all the ages and in both sexes. Ratios between lengths of anterior and posterior cranial-base, as well as between cranial-base lengths and anterior cranial heights, were nearly constant at all the ages and in both sexes. These observations support the view that there is definite proportionality between the growth of anterior calvarial height and cranial-base lengths. On the other hand, a significant increase with age was seen in the ratios N-Ts/Ts-L, N-I/Ts/L and Ts/B/Ts-L, suggesting a progressive decrease in growth of posterior calvarial height. A comparison of the data with previously published figures for Indian and Norwegian populations suggests a racial difference in the various cranial-base and calvarial ratios. (AU)

Altered thyroid status: a possible cause of growth retardation in children with congenital heart disease

To investigate the possibility that growth retardation in children suffering from congenital heart disease (CHD) may be due to altered thyroid function, we studied 27 growth-retarded children with CHD (7 cyanotic, 20 acyanotic) and compared the results with thyroid functions of 10 healthy normal-growing children of the same age group (control). Serum tri-iodothyronine (T3) and throxine (T4) levels were significantly lower in cyanotic CHD; however, serum thyrotropin (TSH) levels were not affected. In acyanotic children, thyroid function was essentially normal. These findings suggest that subnormal levels of T3 and T4 with normal TSH might be a homeostatic response to chronic hypoxia in cyanotic CHD and may contribute to growth retardation in these children (AU)