Thanyanat Bunnag1, Siripen Kalayanarooj. 1. Department of Pediatrics, Queen Sirikit National Institute of Child Health, College of Medicines, Rangsit University, Bangkok, Thailand. thanyanat@childrenhospital.go.th
Abstract
BACKGROUND: Dengue virus infection is an important mosquito-borne disease with the reported 40,000-100,000 cases per year in Thailand. Shock is one of the common presentations at the emergency room (ER) and dengue shock syndrome (DSS) is among the common causes of shock. Proper and timely management of DSS determines the outcomes and prognosis of DSS patients. OBJECTIVE: To find the prevalence of DSS at the ER and evaluate the medical management and risk factors associated with the outcome of DSS patients. MATERIAL AND METHOD: A retrospective study on patients who presented with shock, including DSS patients at the ER of Queen Sirikit National Institute of Child Health (QSNICH), Bangkok, Thailand, from 1st January 2008 to 31st December 2009 was done. The prevalence of patients who presented with shock at the ER was retrieved from the Statistical and Information Technology Departments. Out-patient cards and In-patient charts of DSS patients were reviewed. Clinical and laboratory data were compared between recovered and death cases. Statistical analysis was done by using SPSS version 14.0. RESULTS: There were 109 shock patients seen at the ER during the present study period with 59 DSS (54.1%), 30 septic shock (27.5%), 13 hypovolemic shock (11.9%), 1 cardiogenic shock (0.9%) and 6 other non-specific shock (5.5%). DSS cases were found all year round with the peak prevalence from June to August which is the rainy season. Twenty-six of DSS (44.1%) were referred cases and 5 of them died, case fatality rate was 8.8%. All death cases had prolonged shock, massive bleeding and liver failure at presentation while these findings were found in 2 (4.4%), 16 (35.6%) and 10 (22.2%) cases of recovered cases. Encephalopathy, renal failure and respiratory failure were found in 80, 60 and 60% of the death cases while in recovered cases they were found in 11.1, 4.4 and 2.2%. Acidosis was found higher in the death group (60%) than in recovered group (8.9%). Other common presenting findings in death and recovered groups were bleeding (35.6 vs 100.0%), fluid over load (31.1 vs. 80%), hyponatremia (40% for both groups) and hypocalcemia (83.3 vs. 80%). Among the 45 recovered cases; 3 cases were misdiagnosed and another 8 cases (17.8%) received no i.v. fluid at the ER. Cross matching was done in 32 cases (64%) and blood was transfused in 16 cases (50% of the cross matching). CONCLUSION: DSS is the most common shock found at the ER especially during June to August. ER physicians should be alert for making the correct diagnosis of DSS with proper intravenous fluid resuscitation and correction of the common complications/laboratory abnormalities, i.e. acidosis, hyponatremia, hypocalcemia and cross matching for massive bleeding. A referred case with liver failure together with renal and respiratory failure was likely associated with mortality while fluid overload and significant bleeding do not if they are managed properly. Early signs of shock should be detected in walk in cases to prevent later shock after admission.
BACKGROUND:Dengue virus infection is an important mosquito-borne disease with the reported 40,000-100,000 cases per year in Thailand. Shock is one of the common presentations at the emergency room (ER) and dengue shock syndrome (DSS) is among the common causes of shock. Proper and timely management of DSS determines the outcomes and prognosis of DSS patients. OBJECTIVE: To find the prevalence of DSS at the ER and evaluate the medical management and risk factors associated with the outcome of DSS patients. MATERIAL AND METHOD: A retrospective study on patients who presented with shock, including DSS patients at the ER of Queen Sirikit National Institute of Child Health (QSNICH), Bangkok, Thailand, from 1st January 2008 to 31st December 2009 was done. The prevalence of patients who presented with shock at the ER was retrieved from the Statistical and Information Technology Departments. Out-patient cards and In-patient charts of DSS patients were reviewed. Clinical and laboratory data were compared between recovered and death cases. Statistical analysis was done by using SPSS version 14.0. RESULTS: There were 109 shock patients seen at the ER during the present study period with 59 DSS (54.1%), 30 septic shock (27.5%), 13 hypovolemic shock (11.9%), 1 cardiogenic shock (0.9%) and 6 other non-specific shock (5.5%). DSS cases were found all year round with the peak prevalence from June to August which is the rainy season. Twenty-six of DSS (44.1%) were referred cases and 5 of them died, case fatality rate was 8.8%. All death cases had prolonged shock, massive bleeding and liver failure at presentation while these findings were found in 2 (4.4%), 16 (35.6%) and 10 (22.2%) cases of recovered cases. Encephalopathy, renal failure and respiratory failure were found in 80, 60 and 60% of the death cases while in recovered cases they were found in 11.1, 4.4 and 2.2%. Acidosis was found higher in the death group (60%) than in recovered group (8.9%). Other common presenting findings in death and recovered groups were bleeding (35.6 vs 100.0%), fluid over load (31.1 vs. 80%), hyponatremia (40% for both groups) and hypocalcemia (83.3 vs. 80%). Among the 45 recovered cases; 3 cases were misdiagnosed and another 8 cases (17.8%) received no i.v. fluid at the ER. Cross matching was done in 32 cases (64%) and blood was transfused in 16 cases (50% of the cross matching). CONCLUSION: DSS is the most common shock found at the ER especially during June to August. ER physicians should be alert for making the correct diagnosis of DSS with proper intravenous fluid resuscitation and correction of the common complications/laboratory abnormalities, i.e. acidosis, hyponatremia, hypocalcemia and cross matching for massive bleeding. A referred case with liver failure together with renal and respiratory failure was likely associated with mortality while fluid overload and significant bleeding do not if they are managed properly. Early signs of shock should be detected in walk in cases to prevent later shock after admission.