Revised guideline for severe dengue averts death, but not organ failure

Following the revised guideline for severe dengue (SD), which includes intensive monitoring of vital signs among others, helps prevent death of patients with multiorgan failure and/or abdominal compartment syndrome (ACS), but not organ failure, a study has shown.

“[W]e believe that our revised SD guideline will help decrease the mortality rates of patients with multiorgan failure and/or ACS and could be useful for other institutions in dengue-endemic areas who are also trying to reduce their dengue mortality rates,” the researchers said.

Medical records of SD patients aged <15 years who were hospitalized during 1998‒2020 were reviewed to compare the mortality rates before and after the implementation of a revised SD guideline.

The revised guidelines were employed in 2016 and included intensive monitoring of vital signs and intra-abdominal pressure, the release of intra-abdominal pressure in cases of ACS, and the use of N-acetyl cysteine in patients with acute liver failure.

On initial admission, no significant difference in organ failure including severe bleeding, acute respiratory failure (ARF), acute kidney injury, and acute liver failure was noted between 78 and 23 patients treated in the pre- and postrevised guideline periods, respectively. [Pediatr Infect Dis J 2022;41:211-216]

Likewise, there were no significant differences in the proportions of patients who developed profound shock (68.8 percent vs 41.2 percent), multiorgan failures (60.4 percent vs 73.3 percent), ACS (37.2 percent vs 26.1 percent), and fatal outcome (33.3 percent vs 13.0 percent) between pre- and postrevised guideline periods, respectively, after hospitalization.

Subgroup analysis revealed significantly higher rates of mortality in patients with multiorgan failure (44.1 percent vs 15.8 percent), ARF and active bleeding (78.1 percent vs 37.5 precent), and ACS (82.8 percent vs 33.3 percent) in the pre- than the postrevised guideline periods, respectively.

Moreover, the “durations of time before liver function tests returned to normal levels, and the mortality rates in acute liver failure patients treated with and without N-acetyl cysteine were not significantly different,” according to the researchers.

Comparisons to other studies

Earlier studies found ACS to be rare in SD, but the current study confirmed ACS in six of 23 (26.1 percent) patients and probable ACS in 29 of 78 (37.2 percent) patients with SD. [BMJ Case Rep 2018;doi:10.1136/bcr-2018-225936; Indian J Pediatr 2012;79:386-388; Indian J Pediatr 2006;73:889-895]

Another study by Ranjit and colleagues found ACS in 30 percent of SD patients prior to the implementation of a new guideline similar to the one used in this study. Ranjit’s findings revealed a significant decrease in the proportions of patients with ARF, severe bleeding, and AKI after implementation of their guideline. [Indian J Crit Care Med 2018;22:154-161]

“In [the current] study, after implementation of the revised SD guideline, the proportion of patients who developed profound shock decreased from 68.8 percent to 41.2 percent (p=0.06). However, the proportions of patients who developed multiorgan failure and who finally had organ failure did not decrease,” the researchers said.

“This could be explained by not only hypotension but also narrowing of capillary vessels from endothelial cell oedema and perivascular oedema causing inadequate tissue perfusion leading to organ failure,” they added. [Semin Immunopathol 2017;39:563-574]

The present study was limited by the involvement of different time periods, which made comparisons difficult, and by its retrospective design, which could have resulted in some missing information.