Blood and blood products

Haemostatic changes in dengue

Vasculopathy Thrombocytopenia Coagulations abnormalities

Haemostatic changes in dengue Vasculopathy

Due to the direct effect of the virus on the capillaries Hesss test is positive Early sign preceding thrombocytopenia and increased vascular permeability

Thrombocytopaenia Thrombocytopenia
Platelet count begins to fall towards the end of febrile stage
Lowest during critical phase

Main mechanism: platelet activation and utilization

Coagulation Abnormalities
Prolonged APTT: 54.6% Prolonged PT: 33.3% Variable but no significant reduction in coagulation factors II, V, VII, VIII, IX, XII and X

Thrombocytopenia and Thrombocytopenia and Coagulation coagulation abnormalities Abnormalities

Thrombocytopenia and coagulation abnormalities do not reliably predict bleeding in dengue infection
In general, bleeding is mild and improves after fluid replacement or cease spontaneously after recovery of illness

No role for prophylactic transfusion of platelets or FFP

Do not produce sustained changes in the coagulation status and platelet count in patients with DHF/DSS
Do not change or reduce the bleeding outcome in DHF Inappropriate transfusion of blood products increases the risk of pulmonary oedema and respiratory embarrassment

Risk factors for significant bleeding

Prolonged/Refractory shock due to plasma leakage Renal or liver failure with persistent metabolic acidosis Given NSAID Pre existing peptic ulcer disease Are on anticoagulant therapy

Prevention of significant bleeding

Early recognition of shock
Adequate fluid resuscitation to prevent patient from protracted shock

Avoiding NSAID/Aspirin

Management of bleeding in dengue

Mild bleeding eg. gums, vagina, epistaxis or petechiae usually cease spontaneously and do not require blood or platelet transfusion Transfusion of blood and/or blood products in dengue is indicated only when there is evidence of significant bleeding (occult or overt)

Significant occult bleeding

Haematocrit not as high as expected for the degree of shock to be explained by plasma leakage alone
A drop in HCT without clinical improvement despite adequate fluid replacement (40-60 ml/kg)

Persistent metabolic acidosis and end-organ dysfunction despite adequate fluid replacement

Significant bleeding- management

Blood transfusion with fresh whole blood ( 10 to 20mls/kg) or fresh packed cell( 5 to 10mls/kg)
Consider repeating the blood transfusion if there is further blood loss or no appropriate increase in HCT blood products if in DIC or uncontrolled bleeding

Management of UGIT bleed

Endoscopy and endoscopic injection therapy in upper GIT haemorrhage increases the risk of bleeding and should be avoided Blood transfusion if significant bleeding Use proton pump inhibitors

Adjunctive therapy
Insufficient evidence to support use in dengue of Recombinant activated factor VII (rFVIIa) in significant bleeding

The coagulation system is activated in dengue and infusion of activated factor concentrates may increase the risk of thrombosis

Pitfalls in the management of DHF

Focus on platelet count instead of hematocrit
Late recognition of shock and inadequate resuscitation Too much emphasis on lab results rather than the clinical condition of the patient

Pitfalls in the management of DHF

Not recognising that HCT does not drop to low levels even in significant bleed Transfusion of blood only when the HCT falls to a low level may be too late Too much reliance on platelet and FFP transfusion to control bleeding

Thank you