Clinical mismanagement blamed for dengue deaths

Clinical mismanagement of dengue fever has been leading to an increased mortality of cases in the State, especially as most of the suspected dengue deaths are being reported from small and medium private hospitals in the periphery.

Experts have cautioned that all doctors, especially those in the periphery and in the private sector, be advised to treat fever cases strictly as per the short febrile illnesses management guidelines issued by the Health Department (available on the website of the Directorate of Health Services - DHS) and to avoid unnecessary transfusion of platelets and intravenous fluids.

Senior officials said an analysis of the suspected dengue deaths reported this season had revealed that clinical mismanagement during the critical and recovery phase of the fever was the main cause of increased mortality.

‘‘Kottayam district has reported two confirmed and 12 suspected dengue deaths so far, out of which more than eight cases were reported from small private hospitals. The cause of death in most of these cases was pulmonary edema, resulting from fluid overload. These deaths could have been avoided if the dengue management protocols (issued by the WHO, Centres for Disease Control (CDC) or the combined version brought out by the Health Department) had been followed,” an official said.

Dengue fever has three phases — the febrile phase, the critical phase, and the recovery phase. As dengue is a viral disease, the treatment is mostly supportive care, with plenty of oral fluids and rest in the febrile phase, when the patient will have high temperature.

The next is the critical phase, after the third day when about the time the fever is subsiding; the patient could develop sudden warning symptoms such as vomiting, abdominal pain or altered mental status or confusion. During this phase, the patient should be closely monitored in hospital for signs of haemorrhage, plasma leakage, which should be corrected through intravenous rehydration. According to the dengue management guidelines of WHO, the CDC, and Mayo clinic, ‘‘it is very important to note that the prevention of fluid overload during the recovery phase is critical, as this is a preventable cause of death in severe dengue.’’

S. Ashwini Kumar, Professor of Medicine, Thiruvananthapuram Medical College, said that unnecessary fluid therapy, in the case of children, was a significant cause of mortality in dengue fever.

‘‘An overload of fluids and unnecessary platelets transfusion can pose a risk by itself. Just because platelets are down does not mean that the patient has bleeding and platelets transfusion is not required in every case of dengue fever,” Dr. Kumar said.

“What is required is a close monitoring of the clinical signs and symptoms of the patient and not the lab report which says that the platelet count has gone down. For any fever, platelets may go down.’’ Doctors should focus on the general condition of the patient, watching out for any bleeding signs, change in breathing and proper fluid management, Dr. Ashwini Kumar said. There should be a wider dissemination of dengue management protocols, he said.