Management of Patients with Unusual Manifestations

00000000The most importantly encountered are acute hepatic failure and renal failure (which usually follows prolonged shock), which require appropriate treatment. Early exchange transfusion in Reye's syndrome is a life-saving measure, as is haemodialysis in renal failure.

00000000 In most cases of shock without severe bleeding, the prognosis is good. The serious pitfall in management of shock is failure to recognize internal bleeding. Over-transfusion with crystalloid and/or plasma fluid instead of blood in these cases is the major contributory factor to the high mortality rate. The major clinical challenge in management of DHF with prolonged shock is often complicated by clinical DIC and massive bleeding. The benefits of anticoagulant and anti-fibrinolysis therapy remain to be further studied. The role of large doses of corticosteroids (pulse therapy) were studied in a small group of patients with prolonged shock and the results were not conclusive(4,5). There have been , however, many studies on the role of corticosteroids in the treatment of DSS, which have shown that the therapy is not effective(6,7,8).

00000000 With the careful monitoring of patients and appropriate volume replacement as described above, the case-fatality rate of DSS at the Bangkok Children's Hospital is approximately two per cent.

Criteria for discharging inpatients

00000000The following criteria should be met before patients recovering from DHF/DSS are discharged:

• Absence of fever for at lease 24 hours without the use of antifever therapy (cryotherapy or antipyretics)
  
• Retrun of appetite
  
• Visible clinical improvement
  
• Good urine output
  
• Stable haematocrit Passing of at least 2 days after recovery from shock
  
• No respiratory distress from pleural effusion or ascites
  
• Platelet count of more than 50 000 per mm3.

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บทที่2มาจาก " Monograph of Dengue/Dengue Heamorrhagic Fever complied by Prasert Thonchareon, M.D. WHO Regional Office fr South-East Asia, New Delhi 1993"