Abstract
Few previous studies have monitored hemodynamic parameters to determine the physiological process of dengue or examined inferior vena cava (IVC) parameters to assess cardiac preload during the clinical phase of dengue. From January 2013 to July 2015, we prospectively studied 162 hospitalized adults with confirmed dengue viral infection using non-invasive cardiac output monitoring and bedside ultrasonography to determine changes in hemodynamic and IVC parameters and identify the types of circulatory shock that occur in patients with dengue. Of 162 patients with dengue, 17 (10.5%) experienced dengue shock and 145 (89.5%) did not. In patients with shock, the mean arterial pressure was significantly lower on day 6 after fever onset (P = 0.045) and the pulse pressure was significantly lower between days 4 and 7 (P<0.05). The stroke volume index and cardiac index were significantly decreased between days 4 and 15 and between days 5 and 8 after fever onset (P<0.05), respectively. A significant proportion of patients with dengue shock had an IVC diameter <1.5 cm and IVC collapsibility index >50% between days 4 and 5 (P<0.05). Hypovolemic shock was observed in 9 (52.9%) patients and cardiogenic shock in 8 (47.1%), with a median (interquartile range) time to shock onset of 6.0 (5.0–6.5) days after fever onset, which was the median day of defervescence. Intravascular hypovolemia occurred before defervescence, whereas myocardial dysfunction occurred on the day of defervescence until 2 weeks after fever onset. Hypovolemic shock and cardiogenic shock each occurred in approximately half of the patients with dengue shock. Therefore, dynamic measures to estimate changes in hemodynamic parameters and preload should be monitored to ensure adequate fluid therapy among patients with dengue, particularly patients with dengue shock.
Highlights
Dengue is a mosquito-borne viral disease in humans caused by one of four dengue virus (DENV) serotypes [1]
Of 250 patients with suspected dengue admitted to our hospital during the study period, 88 patients were excluded due to a history of underlying medical illness (N = 38), including hypertension (N = 11, 28.9%), diabetes mellitus (N = 8, 21.0%), lung diseases (N = 5, 13.2%), kidney diseases (N = 5, 13.2%), cardiovascular diseases (N = 4, 10.5%), liver diseases (N = 3, 7.9%), autoimmune diseases (N = 3, 7.9%) and human immunodeficiency virus (HIV) infection (N = 2, 5.3%); mixed infection (N = 31); negative results for dengue reverse-transcriptase polymerase chain reaction (RT-PCR), micro-neutralization test, and anti-dengue virus IgM/IgG antibodies using enzyme-linked immunosorbent assays (ELISA) (N = 14); and age
Hemodynamic monitoring is a functional tool used for assessing the pathophysiological process of a disease, and proper monitoring can alert health care teams to an impending cardiovascular crisis before the development of organ injury [12]
Summary
Dengue is a mosquito-borne viral disease in humans caused by one of four dengue virus (DENV) serotypes [1]. Dengue is rapidly becoming widespread across the globe [1]. 500,000 people with severe dengue require hospitalization, and 2.5% of those affected die annually [2]. There was an epidemic shift in the age pattern of dengue, from children to adults, accompanied by an increase in severity [3,4,5]. The common complications of dengue in adults are bleeding and organ impairment [6], but severe plasma leakage leading to circulatory shock is a common cause of death [7]. Circulatory shock in dengue occasionally occurs during the critical phase or defervescence period [1, 3]. Previous reports showed cardiac involvement in adults with dengue, including myocardial dysfunction (42–47%), arrhythmias (29–63%), and myocarditis (15–29%) [8,9,10,11]
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