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Management of dengue , explain three types with warning , without warning symptoms, and dengue shock syndrome and management of each in detail with fluid and other medications dosage for pediatrics refer IAP, and i have uploaded some pictures refer from that add the flow chart if possible

Reading File
Your request covers several separate topics, so I'll map it first and then go deep on the one you pick. Your uploaded IAP flowcharts (classification, Group B, Group C, discharge criteria, supportive investigations) will be the base for each section.
Topic map
  1. Classification: Group A (dengue without warning signs), Group B (warning signs or high-risk comorbidity), Group C (severe dengue and dengue shock syndrome), plus the phases of illness
  2. Group A: outpatient management of dengue without warning signs (paracetamol dosing, oral fluids, home-care advice, review schedule)
  3. Group B: inpatient management of dengue with warning signs (IV isotonic crystalloid step-down rates, hematocrit monitoring, Flowchart 2)
  4. Group C: dengue shock syndrome (rapid boluses, colloid, blood transfusion, inotropes, Flowchart 3)
  5. Supportive investigations, platelet and blood product use, and discharge criteria
Overview
  • Group A children have fever for 2 to 7 days with nausea, vomiting, rash, headache, retro-orbital pain, myalgia, arthralgia or leukopenia. They are managed as outpatients.
    • Give paracetamol for fever and encourage oral fluids.
    • Watch for dehydration and warning signs.
    • Fever defervescence marks the start of the critical phase, so these children need close review then.
    • Avoid NSAIDs and aspirin.
  • Group B children are those with warning signs, or with high-risk conditions such as infancy, immunosuppression, anticoagulant or antiplatelet use, chronic infections or coagulation disorders. They are admitted.
    • Send a baseline CBC and monitor fluid intake and output.
    • Check vital signs every 4 hours or more often.
    • If oral intake is inadequate, check hematocrit and start isotonic crystalloid (normal saline or Ringer's lactate).
    • The usual stepwise rates are 5 to 7 mL/kg/hr for 1 to 2 hours, then 3 to 5 mL/kg/hr for 2 to 4 hours, then 2 to 3 mL/kg/hr. Titrate these to repeat hematocrit and clinical status.
    • If vitals worsen or hematocrit keeps rising, increase to 5 to 10 mL/kg/hr for 1 to 2 hours. If there is still no improvement, follow the Group C pathway.
  • Group C is dengue shock syndrome, either compensated or hypotensive. It needs ICU-level care.
    • Give oxygen and a rapid bolus of 10 to 20 mL/kg crystalloid or colloid over 30 minutes. Use 20 mL/kg for hypotension and 10 mL/kg may suffice for compensated shock.
    • If the child improves, step the IV rate down from 10 to 7, then 5 to 3, then 3 to 1.5 mL/kg/hr. Stop IV fluids at 24 to 48 hours.
    • If there is no improvement, repeat a 10 to 20 mL/kg bolus, preferably colloid.
    • A rising hematocrit (above 45%) means more fluid. A falling hematocrit suggests bleeding, so give whole blood 10 mL/kg or packed red cells 5 mL/kg.
    • If shock persists, correct acidosis, hypoglycemia and electrolytes, do an echocardiogram, and start inotropes.
  • Discharge requires all of these:
    • no fever for 24 hours without antipyretics
    • improving appetite
    • stable hematocrit
    • no effusion distress
    • platelets above 50,000/mm³
    • normal organ function
I'll verify exact drug doses against IAP when you pick a topic.
Asking for Preferences

Which topic should I cover in detail first?

Your request covers several separate topics, so I'll map it first and then go deep on the one you pick. Your uploaded IAP flowcharts (classification, Group B, Group C, discharge criteria, supportive investigations) will be the base for each section.
Topic map
  1. Classification: Group A (dengue without warning signs), Group B (warning signs or high-risk comorbidity), Group C (severe dengue and dengue shock syndrome), plus the phases of illness
  2. Group A: outpatient management of dengue without warning signs (paracetamol dosing, oral fluids, home-care advice, review schedule)
  3. Group B: inpatient management of dengue with warning signs (IV isotonic crystalloid step-down rates, hematocrit monitoring, Flowchart 2)
  4. Group C: dengue shock syndrome (rapid boluses, colloid, blood transfusion, inotropes, Flowchart 3)
  5. Supportive investigations, platelet and blood product use, and discharge criteria
Overview
  • Group A children have fever for 2 to 7 days with nausea, vomiting, rash, headache, retro-orbital pain, myalgia, arthralgia or leukopenia. They are managed as outpatients.
    • Give paracetamol for fever and encourage oral fluids.
    • Watch for dehydration and warning signs.
    • Fever defervescence marks the start of the critical phase, so these children need close review then.
    • Avoid NSAIDs and aspirin.
  • Group B children are those with warning signs, or with high-risk conditions such as infancy, immunosuppression, anticoagulant or antiplatelet use, chronic infections or coagulation disorders. They are admitted.
    • Send a baseline CBC and monitor fluid intake and output.
    • Check vital signs every 4 hours or more often.
    • If oral intake is inadequate, check hematocrit and start isotonic crystalloid (normal saline or Ringer's lactate).
    • The usual stepwise rates are 5 to 7 mL/kg/hr for 1 to 2 hours, then 3 to 5 mL/kg/hr for 2 to 4 hours, then 2 to 3 mL/kg/hr. Titrate these to repeat hematocrit and clinical status.
    • If vitals worsen or hematocrit keeps rising, increase to 5 to 10 mL/kg/hr for 1 to 2 hours. If there is still no improvement, follow the Group C pathway.
  • Group C is dengue shock syndrome, either compensated or hypotensive. It needs ICU-level care.
    • Give oxygen and a rapid bolus of 10 to 20 mL/kg crystalloid or colloid over 30 minutes. Use 20 mL/kg for hypotension and 10 mL/kg may suffice for compensated shock.
    • If the child improves, step the IV rate down from 10 to 7, then 5 to 3, then 3 to 1.5 mL/kg/hr. Stop IV fluids at 24 to 48 hours.
    • If there is no improvement, repeat a 10 to 20 mL/kg bolus, preferably colloid.
    • A rising hematocrit (above 45%) means more fluid. A falling hematocrit suggests bleeding, so give whole blood 10 mL/kg or packed red cells 5 mL/kg.
    • If shock persists, correct acidosis, hypoglycemia and electrolytes, do an echocardiogram, and start inotropes.
  • Discharge requires all of these:
    • no fever for 24 hours without antipyretics
    • improving appetite
    • stable hematocrit
    • no effusion distress
    • platelets above 50,000/mm³
    • normal organ function
I'll verify exact drug doses against IAP when you pick a topic.
Finding Sources
Searching the Web

IAP guidelines dengue children 2024 management paracetamol dose 10-15 mg/kg fluid dengue shock syndrome Indian Academy of Pediatrics

Searching PubMed

"dengue"[MeSH Terms] AND "child"[MeSH Terms] AND "fluid therapy"[MeSH Terms]

Let me extract the IAP guideline itself to verify the doses.
Reading Web Page

https://iapindia.org/pdf/Ch-138-Dengue-in-Children.pdf

Running Command

mkdir -p /tmp/workspace/dengue && cd /tmp/workspace/dengue && curl -sL -m 60 -o iap.pdf https://iapindia.org/pdf/Ch-138-Dengue-in-Children.pdf; ls -la; python3 -c " import pdfplumber with pdfplumber.open('iap.pdf') as p: t='\n'.join((pg.extract_text() or '') for pg in p.pages) open('iap.txt','w').write(t); print(len(t)) "

Reading File
Running Command

sed -n 139,330p /tmp/workspace/dengue/iap.txt

Running Command

sed -n 330,420p /tmp/workspace/dengue/iap.txt; ls /tmp/workspace/attachments/*/

Dengue in children: IAP management of Group A, Group B and Group C (dengue shock syndrome)

This follows the IAP Standard Treatment Guidelines 2022, Dengue in Children and your five uploaded pages. Those pages are Flowcharts 1 to 3, the supportive investigations and the discharge criteria.
  • Not in the IAP chapter: The chapter does not give oral drug doses, inotrope doses or the blood product volumes beyond those in Flowchart 3. I took paracetamol and antiemetic doses from the WHO case management guide. I took inotrope and glucose doses from standard PICU practice, and I mark them below. Check them against your hospital protocol.
  • Recent evidence: A quick PubMed check for recent systematic reviews found nothing that contradicts these fluid pathways.
  • Your uploaded images: I couldn't load them into my sandbox, so I can't paste the originals into a file. I rebuilt each flowchart below in text with identical content.

1. Classification (Flowchart 1)

GroupCategoryWhere treated
ADengue without warning signs. Fever for 2 to 7 days plus nausea, vomiting, rash, headache, retro-orbital pain, myalgia, arthralgia or leukopenia.Outpatient
BDengue with warning signs, or high-risk comorbidity (infants, children on immunosuppressants, NSAIDs, antiplatelets or anticoagulants, chronic TB or HIV, any coagulation disorder).Inpatient ward
CSevere dengue: shock (DSS), fluid accumulation with respiratory distress, severe bleeding, or severe organ involvement.PICU
Warning signs (IAP):
  • Abdominal pain or tenderness
  • Persistent vomiting
  • Clinical fluid accumulation
  • Mucosal bleed
  • Lethargy or restlessness
  • Liver enlargement >2 cm
  • Rising HCT with a rapid fall in platelets
Severe organ involvement:
  • AST or ALT ≥1,000
  • Impaired consciousness
  • Myocardial dysfunction
  • Acute kidney injury
  • HLH
Phases of illness:
  • Febrile: 2 to 5 days.
  • Critical: starts after 3 to 4 days of fever, usually at defervescence. This is when plasma leakage, hemoconcentration and shock occur.
  • Convalescent: from day 6 to 7, lasting 2 to 3 days. Reabsorbed fluid returns to the circulation, so there is a risk of overload.
                     DENGUE INFECTION
              ┌──────────┴───────────┐
        Asymptomatic            Symptomatic
                       ┌──────────┼───────────┐
                     Mild      Moderate      Severe
                       │      ┌────┴─────┐      │
                       │  High-risk   Warning   │
                       │  comorbidity  signs    │
                   GROUP A      GROUP B      GROUP C
                 Outpatient    Inpatient    Inpatient ICU

2. Group A: dengue without warning signs (outpatient)

Aims: control fever, keep the child hydrated, and pick up warning signs early.
Medications and doses
  • Paracetamol only: 10 mg/kg every 6 hours, or 15 mg/kg every 8 hours. The maximum is 60 mg/kg/day (WHO).
  • Fever above 38.5 °C: add tepid sponging for 15 minutes at a time. Stop if the child shivers.
  • Vomiting: WHO lists domperidone 0.2 to 0.4 mg/kg/dose, up to 3 to 4 times a day, for children under 35 kg. Many Indian units use ondansetron 0.1 to 0.15 mg/kg/dose instead. This is my addition, not from IAP or WHO.
  • Avoid: aspirin, ibuprofen, mefenamic acid, diclofenac and steroids. Also avoid IM injections, which risk hematoma.
Fluids
  • Give oral fluids freely: ORS, milk, coconut water, soups, fruit juice and plain water.
  • Avoid red or brown colored fluids, which can be mistaken for hematemesis or melena.
IAP monitoring points (from Flowchart 1)
  • Watch for dehydration.
  • Watch for clinical and laboratory warning signs.
  • Watch for defervescence, which marks the start of the critical phase.
  • Do a CBC when clinically indicated.
Review: Send the child home with a daily review during days 3 to 7 of illness, with a CBC and HCT where needed. Tell parents to return immediately for any of these:
  • Persistent vomiting
  • Abdominal pain
  • Bleeding
  • Drowsiness or irritability
  • Cold extremities
  • Reduced urine output (<4 to 6 hours without urine)
  • Difficulty breathing

3. Group B: dengue with warning signs (inpatient, Flowchart 2)

Admission: all children with warning signs, and those with high-risk comorbidity even if they have no warning signs.
On admission
  1. Obtain a baseline CBC with HCT.
  2. Monitor fluid intake and output, and encourage oral fluids.
  3. Record vital signs every 4 hours or more often.
  4. Give paracetamol as above. Do not give NSAIDs or steroids.
Flowchart 2, recreated
Child with warning signs
        │
Baseline CBC + monitor I/O + vitals q4h (or more often)
        │
Does the child have adequate oral fluid intake?
   │YES                                   │NO
Continue monitoring vitals,         Check HCT, then give IV isotonic
watch for early signs and           crystalloid (NS or Ringer lactate):
for warning signs of                   5-7 mL/kg/hr for 1-2 h
severe dengue                          3-5 mL/kg/hr for 2-4 h
                                       Recheck HCT + reassess clinically
                                              │
              Clinically stable and no change/minimal change in HCT?
                 │YES                                  │NO
   Continue crystalloid 2-3 mL/kg/hr      Worsening vitals / rising HCT:
   for 2-4 h                              increase to 5-10 mL/kg/hr for 1-2 h
        │                                 Recheck HCT + reassess
   Recheck HCT + reassess                        │
        │                                   Improving?
   Good intake + urine output,           │YES                │NO
   HCT falls to baseline                 Step down:          GROUP C
   → reduce IV fluids                    5-10 mL/kg/hr x1-2h  emergency
                                         3-5 mL/kg/hr x2-4h   management
                                         2-3 mL/kg/hr x2-4h
                                         (reassess before each reduction)
Fluid rates (IAP Flowchart 2)
StepRateDuration
Start (inadequate oral intake)5-7 mL/kg/hr1 to 2 hours
Then3-5 mL/kg/hr2 to 4 hours
Then2-3 mL/kg/hr2 to 4 hours
Worsening vitals or rising HCT5-10 mL/kg/hr1 to 2 hours, then reassess
Practical points
  • Fluid type: isotonic crystalloid, either normal saline or Ringer lactate.
  • Duration: continue IV fluids only for the critical phase, about 24 to 48 hours. Give the minimum volume that keeps perfusion adequate.
  • Fluid overload: the IAP warns that "fluid creep" can worsen respiratory status as leakage progresses. Fluid resuscitation at the cost of respiratory worsening does not give a good outcome. Use lung ultrasound (B lines) where available.
  • HCT: a 20% rise over baseline is clinically significant. Repeat HCT before each rate change.
  • Other microbiology: peripheral smear for malaria, blood cultures, chikungunya, scrub typhus and COVID-19 tests are useful only if you suspect coinfection.
Supportive investigations (from your uploaded page)
  • HCT: normal in uncomplicated disease, rises when capillary leak begins.
  • WBC: low, with atypical lymphocytes. A rise in WBC precedes the rise in platelets in recovery.
  • Platelets: fall rapidly in the critical phase. A rising count signals recovery.
  • CRP: normal or mildly raised.
  • LFT: SGOT is higher than SGPT. Low albumin, low fibrinogen and a prolonged PT or PTT indicate severe disease.
  • Ferritin: very high in severe disease and dengue-associated HLH. Interpret it with the clinical picture.
  • Renal: raised creatinine, proteinuria and hyponatremia indicate severe disease. Metabolic acidosis and raised lactate indicate shock.

4. Group C: dengue shock syndrome (PICU, Flowchart 3)

The IAP says a child in compensated or hypotensive shock should preferably be managed in the PICU. The course over the next 24 hours is unpredictable.
Indications for PICU:
  • Severe plasma leakage with hypoperfusion and hypotension
  • Fluid accumulation with respiratory distress
  • Severe bleeding
  • Severe organ impairment (myocardial dysfunction, AKI, CNS dysfunction, ALT or AST >1,000, HLH)
Recognizing shock: poor peripheral perfusion, narrow pulse pressure (<20 mm Hg), hypotension, or unrecordable BP.
Flowchart 3, recreated
DSS (compensated or hypotensive)
Poor perfusion / hypotension / BP not recordable
        │
   Oxygen + IV access
        │
IMMEDIATE RAPID VOLUME REPLACEMENT
10-20 mL/kg crystalloid or colloid as rapid bolus over 30 min
(20 mL/kg for hypotension; 10 mL/kg may suffice for compensated shock)
        │
 ┌──────┴────────────────────────────────┐
IMPROVEMENT                          NO IMPROVEMENT
 │                                        │
IV crystalloid, titrated down:      Repeat 10-20 mL/kg bolus
 10 → 7 mL/kg/hr  x 2-4 h           (preferably colloid) over 30 min
  5 → 3 mL/kg/hr  x 2-4 h                 │
  3 → 1.5 mL/kg/hr x 2-4 h        ┌───────┼──────────────────┐
 │                            Improvement  HCT rising/>45%   HCT FALLS
Further improvement                │       (no improvement)  (no improvement)
 │                           10-20 mL/kg        │                │
Stop IV fluids at            over 1 h       Repeat colloid   Suspect bleeding
24-48 h                      (colloid)      bolus           Blood transfusion:
                                                             whole blood 10 mL/kg
                                                             or packed RBC 5 mL/kg
        Still no improvement ──────────────────────┘
                    │
   Look for myocardial dysfunction; correct acidosis,
   hypoglycemia, electrolyte abnormalities
                    │
               Echocardiography
                    │
      IV inotropes with fluid replacement therapy
Definitions used in the flowchart
  • Improvement: HCT falls, pulse and BP are stable, and urine output is 0.5 to 1.0 mL/kg/hr.
  • No improvement: HCT or pulse rate rises, pulse pressure falls below 20 mm Hg, or urine output falls.
  • Crystalloid: normal saline or Ringer lactate.
  • Colloid: dextran 40 or degraded gelatin polymer (polygeline).
  • Acidosis: avoid hyperosmolar solutions and Ringer lactate.
Fluid doses summary
SituationFluidDose
Compensated shockCrystalloid or colloid10 mL/kg over 30 min
Hypotensive shockCrystalloid or colloid20 mL/kg over 30 min
No improvement after first bolusRepeat bolus, preferably colloid10-20 mL/kg over 30 min
Improved after second bolusColloid10-20 mL/kg over 1 hour
ImprovementCrystalloid infusion10 → 7 mL/kg/hr (2 to 4 h), 5 → 3 mL/kg/hr (2 to 4 h), 3 → 1.5 mL/kg/hr (2 to 4 h)
Suspected bleeding with falling HCTWhole blood or packed RBC10 mL/kg or 5 mL/kg
The IAP advises a lung-safe approach:
  • After 20 mL/kg of crystalloid or colloid, assess hemodynamics by echocardiography where available.
  • Where advanced monitoring is not available, rely on continuous clinical monitoring when you scale up fluids.
  • Watch for liver enlargement, respiratory distress and falling SpO₂. These are early signs of overload.
Adjuncts (standard practice, not in the IAP text)
  • Hypoglycemia: give 2 mL/kg of 10% dextrose, then a maintenance infusion.
  • Hypocalcemia: give 10% calcium gluconate 0.5 to 1 mL/kg slowly (WHO and PICU practice).
  • Inotropes: adrenaline 0.05 to 0.3 mcg/kg/min or dopamine 5 to 10 mcg/kg/min. Dobutamine can be added if there is myocardial dysfunction. Use these only after the echocardiogram, and titrate in the PICU.
  • Platelet transfusion: not recommended for a low count alone. Reserve it for significant bleeding.
  • Respiratory distress with overload: reduce or stop IV fluids, give oxygen, and consider diuretics once the child is out of shock. Consider ventilation if needed.
  • Avoid: steroids, IVIG and NSAIDs. None is proven to help.

5. Discharge criteria (your uploaded page)

All of these must be met:
  • No fever for at least 24 hours without antipyretics
  • Good general condition with improving appetite
  • HCT back to baseline, or about 38 to 40% if the baseline is unknown
  • No distress from pleural effusion and no ascites
  • Normal organ function tests
  • Platelet count above 50,000/mm³
  • No other complications

Quick comparison

Group AGroup BGroup C
SettingHome or OPDWardPICU
FluidsOralIV isotonic crystalloid, 5-7 then 3-5 then 2-3 mL/kg/hrBolus 10-20 mL/kg, then 10 → 1.5 mL/kg/hr
AntipyreticParacetamolParacetamolParacetamol
MonitoringDaily reviewVitals q4h, HCT, I/OContinuous, HCT, urine, echo
Blood productsNoNoOnly if bleeding (10 mL/kg whole blood or 5 mL/kg packed RBC)
I can turn this into a Word or PDF handout with the flowcharts redrawn as images. I can also trim it to a one-page exam summary.

Make a PPT on pediatric dengue management with flowcharts

Reading File
Browsing Directory

~/

Reading File
Running Command

mkdir -p /tmp/workspace/dengue-ppt && cat > /tmp/workspace/dengue-ppt/build.py <<'EOF' from pptx import Presentation from pptx.util import Inches, Pt from pptx.dml.color import RGBColor from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.oxml.ns import qn from lxml import etree def C(h): return RGBColor.from_string(h) NAVY="1F3A5F"; TEAL="1B7F8C"; GREEN="2E8B57"; AMBER="E69F00"; RED="C0392B"; GREY="5F6B7A" LBLUE="DCEBF7"; LGREEN="DFF1E6"; LAMBER="FDEFD2"; LRED="F9DAD6"; BG="F5F8FB"; DARK="1E2A38"; WHITE="FFFFFF" prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5) BL=prs.slide_layouts[6] def new_slide(title, color=NAVY): s=prs.slides.add_slide(BL) bg=s.background.fill; bg.solid(); bg.fore_color.rgb=C(BG) r=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,0,0,prs.slide_width,Inches(0.85)) r.fill.solid(); r.fill.fore_color.rgb=C(color); r.line.fill.background() tb(s,0.5,0.1,12.3,0.65,title,26,True,WHITE,anchor=MSO_ANCHOR.MIDDLE) return s def tb(s,x,y,w,h,text,size=14,bold=False,color=DARK,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP,italic=False): t=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h)); tf=t.text_frame; tf.word_wrap=True tf.vertical_anchor=anchor tf.margin_left=tf.margin_right=Inches(0.05); tf.margin_top=tf.margin_bottom=Inches(0.03) lines=text if isinstance(text,list) else [text] for i,l in enumerate(lines): p=tf.paragraphs[0] if i==0 else tf.add_paragraph() p.alignment=align r=p.add_run(); r.text=l; r.font.size=Pt(size); r.font.bold=bold; r.font.italic=italic r.font.color.rgb=C(color); r.font.name="Calibri" return t def box(s,x,y,w,h,text,fill=LBLUE,line=TEAL,size=11,color=DARK,bold=False,shape=MSO_SHAPE.ROUNDED_RECTANGLE,head=None): b=s.shapes.add_shape(shape,Inches(x),Inches(y),Inches(w),Inches(h)) b.fill.solid(); b.fill.fore_color.rgb=C(fill); b.line.color.rgb=C(line); b.line.width=Pt(1.5) b.shadow.inherit=False if shape==MSO_SHAPE.ROUNDED_RECTANGLE: b.adjustments[0]=0.12 tf=b.text_frame; tf.word_wrap=True; tf.vertical_anchor=MSO_ANCHOR.MIDDLE tf.margin_left=tf.margin_right=Inches(0.06); tf.margin_top=tf.margin_bottom=Inches(0.03) lines=text if isinstance(text,list) else [text] first=True if head: p=tf.paragraphs[0]; p.alignment=PP_ALIGN.CENTER r=p.add_run(); r.text=head; r.font.size=Pt(size); r.font.bold=True; r.font.color.rgb=C(color); r.font.name="Calibri" first=False for l in lines: p=tf.paragraphs[0] if first else tf.add_paragraph(); first=False p.alignment=PP_ALIGN.CENTER r=p.add_run(); r.text=l; r.font.size=Pt(size); r.font.bold=bold; r.font.color.rgb=C(color); r.font.name="Calibri" return b def line(s,x1,y1,x2,y2,arrow=False,color=GREY,w=1.75): c=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2)) c.line.color.rgb=C(color); c.line.width=Pt(w) if arrow: ln=c.line._get_or_add_ln(); t=etree.SubElement(ln,qn('a:tailEnd')); t.set('type','triangle'); t.set('w','med'); t.set('len','med') return c def lab(s,x,y,t,color=DARK): tb(s,x,y,0.6,0.3,t,11,True,color,align=PP_ALIGN.CENTER) def card(s,x,y,w,h,title,bullets,color=TEAL,size=13,fill=WHITE): b=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE,Inches(x),Inches(y),Inches(w),Inches(h)) b.adjustments[0]=0.04; b.fill.solid(); b.fill.fore_color.rgb=C(fill); b.line.color.rgb=C(color); b.line.width=Pt(1.5); b.shadow.inherit=False hd=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE,Inches(x),Inches(y),Inches(w),Inches(0.5)) hd.adjustments[0]=0.2; hd.fill.solid(); hd.fill.fore_color.rgb=C(color); hd.line.fill.background(); hd.shadow.inherit=False tf=hd.text_frame; tf.vertical_anchor=MSO_ANCHOR.MIDDLE p=tf.paragraphs[0]; p.alignment=PP_ALIGN.CENTER r=p.add_run(); r.text=title; r.font.size=Pt(15); r.font.bold=True; r.font.color.rgb=C(WHITE); r.font.name="Calibri" t=s.shapes.add_textbox(Inches(x+0.1),Inches(y+0.6),Inches(w-0.2),Inches(h-0.7)); tf=t.text_frame; tf.word_wrap=True for i,l in enumerate(bullets): p=tf.paragraphs[0] if i==0 else tf.add_paragraph() p.space_after=Pt(5) r=p.add_run(); r.text="• "+l; r.font.size=Pt(size); r.font.color.rgb=C(DARK); r.font.name="Calibri" def table(s,x,y,colw,rows,size=12,rowh=0.42,hfill=NAVY,first_bold=True): n=len(rows); m=len(colw) gs=s.shapes.add_table(n,m,Inches(x),Inches(y),Inches(sum(colw)),Inches(rowh*n)) t=gs.table tblPr=gs._element.graphic.graphicData.tbl.tblPr # remove style banding effects for i,wd in enumerate(colw): t.columns[i].width=Inches(wd) for ri,row in enumerate(rows): t.rows[ri].height=Inches(rowh) for ci,val in enumerate(row): c=t.cell(ri,ci); c.text=""; c.vertical_anchor=MSO_ANCHOR.MIDDLE c.margin_left=c.margin_right=Inches(0.08); c.margin_top=c.margin_bottom=Inches(0.03) p=c.text_frame.paragraphs[0]; r=p.add_run(); r.text=val; r.font.size=Pt(size); r.font.name="Calibri" c.fill.solid() if ri==0: c.fill.fore_color.rgb=C(hfill); r.font.bold=True; r.font.color.rgb=C(WHITE) else: c.fill.fore_color.rgb=C(WHITE if ri%2 else "EAF1F8"); r.font.color.rgb=C(DARK) if ci==0 and first_bold: r.font.bold=True return t def note(s,text,y=7.05): tb(s,0.5,y,12.3,0.35,text,10.5,False,GREY,italic=True) # ---------- 1 Title s=prs.slides.add_slide(BL) bg=s.background.fill; bg.solid(); bg.fore_color.rgb=C(NAVY) r=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,0,Inches(5.2),prs.slide_width,Inches(0.08)); r.fill.solid(); r.fill.fore_color.rgb=C(AMBER); r.line.fill.background() tb(s,0.8,1.8,11.7,1.2,"Management of Dengue in Children",44,True,WHITE) tb(s,0.8,3.1,11.7,1.5,["Group A, Group B and Group C (dengue shock syndrome)","Fluid regimens, drug doses and flowcharts"],24,False,"CFE3F5") tb(s,0.8,5.5,11.7,1.2,["Based on IAP Standard Treatment Guidelines 2022: Dengue in Children","Supplemented with WHO case management guidance where the IAP chapter gives no dose"],16,False,"CFE3F5") # ---------- 2 Classification flowchart s=new_slide("Flowchart 1: Classification by severity (IAP)") box(s,5.57,1.15,2.2,0.5,"Dengue infection",NAVY,NAVY,15,WHITE,True) line(s,6.67,1.65,6.67,1.95); line(s,3.0,1.95,9.0,1.95) line(s,3.0,1.95,3.0,2.3,True); line(s,9.0,1.95,9.0,2.3,True) box(s,2.0,2.3,2.0,0.5,"Asymptomatic",LAMBER,AMBER,13,DARK,True) box(s,7.9,2.3,2.2,0.5,"Symptomatic",LAMBER,AMBER,13,DARK,True) line(s,9.0,2.8,9.0,3.05); line(s,2.2,3.05,11.9,3.05) for cx in (2.2,7.6,11.9): line(s,cx,3.05,cx,3.3,True) box(s,1.3,3.3,1.8,0.5,"Mild","D5DAE0",GREY,14,DARK,True) box(s,6.7,3.3,1.8,0.5,"Moderate","D5DAE0",GREY,14,DARK,True) box(s,11.0,3.3,1.8,0.5,"Severe","D5DAE0",GREY,14,DARK,True) line(s,2.2,3.8,2.2,4.3,True) line(s,7.6,3.8,7.6,4.05); line(s,5.85,4.05,9.25,4.05); line(s,5.85,4.05,5.85,4.3,True); line(s,9.25,4.05,9.25,4.3,True) line(s,11.9,3.8,11.9,4.3,True) box(s,0.4,4.3,3.6,1.3,["Fever 2-7 days plus any one of: nausea, vomiting, rash, headache, retro-orbital pain, myalgia, arthralgia, leukopenia"],LBLUE,TEAL,11) box(s,4.55,4.3,2.6,1.3,["Dengue with high-risk comorbidity: infants, immunosuppressants, NSAIDs, antiplatelet or anticoagulant use, TB, HIV, coagulation disorder"],LAMBER,AMBER,10) box(s,7.9,4.3,2.7,1.3,["Dengue with warning signs and symptoms"],LAMBER,AMBER,12,DARK,True) box(s,10.7,4.3,2.5,1.3,["Shock (DSS), fluid accumulation with respiratory distress, severe bleeding, severe organ involvement"],LRED,RED,10.5) line(s,2.2,5.6,2.2,5.95,True); line(s,5.85,5.6,5.85,5.95,True); line(s,9.25,5.6,9.25,5.95,True); line(s,11.9,5.6,11.9,5.95,True) box(s,0.9,5.95,2.6,0.95,"Outpatient management",GREEN,GREEN,13,WHITE,True,head="GROUP A") box(s,5.4,5.95,4.0,0.95,"Inpatient management (ward)",NAVY,NAVY,13,WHITE,True,head="GROUP B") box(s,10.6,5.95,2.6,0.95,"Inpatient ICU management",RED,RED,13,WHITE,True,head="GROUP C") note(s,"Source: IAP Standard Treatment Guidelines 2022, Dengue in Children (Flowchart 1). ICU: intensive care unit; TB: tuberculosis; HIV: human immunodeficiency virus.") # ---------- 3 Warning signs, severe dengue, phases s=new_slide("Warning signs, severe dengue and phases of illness") card(s,0.4,1.1,4.1,5.8,"Warning signs",["Abdominal pain or tenderness","Persistent vomiting","Clinical fluid accumulation","Mucosal bleed","Lethargy or restlessness","Liver enlargement >2 cm","Lab: rising HCT with rapid fall in platelet count"],AMBER) card(s,4.62,1.1,4.1,5.8,"Severe dengue",["Severe plasma leakage: shock (DSS) or fluid accumulation with respiratory distress","Severe bleeding, as judged by the clinician","Liver: AST or ALT ≥1,000","CNS: impaired consciousness","Heart and other organ involvement","Also: AKI, HLH"],RED) card(s,8.84,1.1,4.1,5.8,"Three phases",["Febrile: 2-5 days, may be biphasic. Treat fever, watch for dehydration and warning signs","Critical: starts 3-4 days after fever onset, usually at defervescence. Plasma leakage, hemoconcentration, shock","Convalescent: from day 6-7, lasts 2-3 days. Reabsorbed fluid returns, so watch for overload"],TEAL) note(s,"Source: IAP Standard Treatment Guidelines 2022, Dengue in Children.",7.0) # ---------- 4 Group A s=new_slide("Group A: dengue without warning signs (outpatient)",GREEN) card(s,0.4,1.1,4.1,5.7,"Medications",["Paracetamol only: 10 mg/kg every 6 h, or 15 mg/kg every 8 h. Maximum 60 mg/kg/day","Fever above 38.5 °C: tepid sponging for 15 min at a time; stop if shivering","Vomiting: domperidone 0.2-0.4 mg/kg/dose, up to 3-4 times a day (WHO), or ondansetron 0.1-0.15 mg/kg/dose","Avoid aspirin, ibuprofen, mefenamic acid, diclofenac, steroids and IM injections"],GREEN,12.5) card(s,4.62,1.1,4.1,5.7,"Fluids and home care",["Oral fluids freely: ORS, milk, coconut water, soups, fruit juice, plain water","Avoid red or brown fluids, which can mimic hematemesis or melena","Rest at home; protect the child from mosquito bites","Parents to record fluid intake and urine output"],GREEN,12.5) card(s,8.84,1.1,4.1,5.7,"Monitoring and review",["IAP: watch for dehydration, clinical and lab warning signs, and defervescence (start of critical phase)","CBC when clinically indicated","Daily review during days 3-7 of illness","Return at once for: persistent vomiting, abdominal pain, bleeding, drowsiness, cold extremities, little or no urine for 4-6 h, breathing difficulty"],GREEN,12.5) note(s,"IAP chapter lists paracetamol and the monitoring points. Doses and home-care advice are from the WHO case management guide.",6.95) # ---------- 5 Group B summary s=new_slide("Group B: dengue with warning signs (inpatient)",AMBER) card(s,0.4,1.1,5.2,4.4,"Admission and baseline care",["Admit all children with warning signs, and those with high-risk comorbidity","Baseline CBC with HCT","Monitor fluid intake and output; encourage oral fluids","Vital signs every 4 h or more often","Paracetamol for fever. No NSAIDs, no steroids","Coinfection tests (smear for MP, cultures, chikungunya, scrub typhus, COVID-19) only if suspected"],AMBER,12.5) tb(s,5.9,1.1,7,0.4,"IV isotonic crystalloid (normal saline or Ringer lactate)",15,True,NAVY) table(s,5.9,1.55,[3.6,1.7,1.7],[["Step","Rate","Duration"],["Start (poor oral intake)","5-7 mL/kg/hr","1-2 hours"],["Then","3-5 mL/kg/hr","2-4 hours"],["Then","2-3 mL/kg/hr","2-4 hours"],["Worsening vitals or rising HCT","5-10 mL/kg/hr","1-2 hours, reassess"],["Improving: step down","5-10 → 3-5 → 2-3","1-2 h, 2-4 h, 2-4 h"]],12,0.5) box(s,5.9,4.7,7.0,0.8,"Recheck HCT and clinical status before every rate change. A 20% rise in HCT over baseline is clinically significant.",LBLUE,TEAL,12.5) box(s,0.4,5.75,12.5,1.1,["Give the minimum fluid that keeps perfusion adequate, usually for 24-48 h of the critical phase. Fluid creep and respiratory worsening signal overload: reduce fluids and consider lung ultrasound (B lines)."],LAMBER,AMBER,13,DARK,True) note(s,"Source: IAP Standard Treatment Guidelines 2022 (Flowchart 2, adapted from CDC 2015).",7.0) # ---------- 6 Group B flowchart s=new_slide("Flowchart 2: Group B inpatient management",AMBER) box(s,5.35,1.0,2.6,0.45,"Child with warning signs",LGREEN,GREEN,12,DARK,True,MSO_SHAPE.FLOWCHART_TERMINATOR) line(s,6.65,1.45,6.65,1.58); line(s,2.65,1.58,10.65,1.58) for cx in (2.65,6.65,10.65): line(s,cx,1.58,cx,1.7,True) box(s,1.0,1.7,3.3,0.6,"Obtain baseline CBC",LGREEN,GREEN,11.5) box(s,5.0,1.7,3.3,0.6,"Monitor fluid intake/output; encourage oral fluids",LGREEN,GREEN,11) box(s,9.0,1.7,3.3,0.6,"Vital signs every 4 h or more often",LGREEN,GREEN,11.5) line(s,2.65,2.3,2.65,2.42); line(s,10.65,2.3,10.65,2.42); line(s,2.65,2.42,10.65,2.42); line(s,6.65,2.3,6.65,2.42); line(s,6.65,2.42,6.65,2.62,True) box(s,5.05,2.62,3.2,0.95,"Adequate oral fluid intake?",LGREEN,GREEN,12,DARK,True,MSO_SHAPE.DIAMOND) line(s,5.05,3.095,3.6,3.095,True); lab(s,4.0,2.78,"YES") box(s,0.6,2.7,3.0,0.8,"Continue monitoring vitals; watch for early and warning signs of severe dengue",LBLUE,TEAL,10.5) line(s,8.25,3.095,9.0,3.095,True); lab(s,8.2,2.78,"NO") box(s,9.0,2.6,3.9,1.1,["Check HCT. Give IV isotonic crystalloid (NS or RL):","5-7 mL/kg/hr for 1-2 h, then 3-5 mL/kg/hr for 2-4 h"],LAMBER,AMBER,11) line(s,10.95,3.7,10.95,3.88,True) box(s,9.0,3.88,3.9,0.5,"Recheck HCT and reassess clinical status",LAMBER,AMBER,11) line(s,9.0,4.13,6.65,4.13); line(s,6.65,4.13,6.65,4.55,True) box(s,5.05,4.55,3.2,1.0,"Stable, HCT unchanged or minimal change?",LGREEN,GREEN,11.5,DARK,True,MSO_SHAPE.DIAMOND) line(s,5.05,5.05,3.6,5.05,True); lab(s,4.0,4.7,"YES") box(s,0.6,4.55,3.0,1.0,"Continue crystalloid 2-3 mL/kg/hr for 2-4 h; recheck HCT and reassess",LBLUE,TEAL,10.5) line(s,2.1,5.55,2.1,5.9,True) box(s,0.6,5.9,3.0,1.2,["Intake and urine output adequate, HCT falls to baseline: reduce IV step-wise, reassess before each change","5-10 mL/kg/hr x1-2 h → 3-5 x2-4 h → 2-3 x2-4 h"],LBLUE,TEAL,9.5) line(s,8.25,5.05,9.0,5.05,True); lab(s,8.2,4.7,"NO") box(s,9.0,4.55,3.9,1.0,["Worsening vitals or rising HCT:","increase to 5-10 mL/kg/hr for 1-2 h; recheck HCT and reassess"],LRED,RED,10.5) line(s,10.2,5.55,10.2,5.9,True) box(s,9.2,5.9,2.0,0.9,"Is the patient improving?",LGREEN,GREEN,10.5,DARK,True,MSO_SHAPE.DIAMOND) line(s,9.2,6.35,3.6,6.35,True); lab(s,8.4,6.0,"YES") line(s,11.2,6.35,11.5,6.35,True); lab(s,11.0,6.0,"NO") box(s,11.5,5.95,1.6,0.8,"Follow Group C emergency management",LRED,RED,9.5,DARK,True) note(s,"HCT: hematocrit; NS: normal saline; RL: Ringer lactate. Source: IAP STG 2022, adapted from CDC 2015.",7.15) # ---------- 7 Group C overview s=new_slide("Group C: dengue shock syndrome (PICU)",RED) card(s,0.4,1.1,4.1,5.7,"Recognizing shock",["Compensated: poor peripheral perfusion, narrow pulse pressure (below 20 mm Hg)","Hypotensive: low BP, or BP not recordable","Rising pulse, cold extremities, delayed capillary refill, falling urine output","Usually at or after defervescence (day 3-7)"],RED,12.5) card(s,4.62,1.1,4.1,5.7,"PICU admission if",["Severe plasma leakage with hypoperfusion and hypotension","Fluid accumulation with respiratory distress","Severe bleeding","Severe organ impairment: myocardial dysfunction, AKI, CNS dysfunction, ALT or AST above 1,000, HLH"],RED,12.5) card(s,8.84,1.1,4.1,5.7,"IAP principles",["Course over the next 24 h is unpredictable: continuous monitoring","Echocardiography after 20 mL/kg crystalloid or colloid, for a lung-safe approach","Without advanced monitoring, scale up fluids on clinical review","Avoid Ringer lactate and hyperosmolar fluids in acidosis","Avoid fluid overload and fluid creep"],RED,12.5) note(s,"Source: IAP Standard Treatment Guidelines 2022, Dengue in Children.",6.95) # ---------- 8 Group C flowchart s=new_slide("Flowchart 3: Group C dengue shock management",RED) box(s,3.4,1.0,6.5,0.6,"Dengue shock syndrome (compensated or hypotensive): poor perfusion, hypotension, BP not recordable",LRED,RED,11) line(s,9.9,1.3,10.4,1.3,True); box(s,10.4,1.05,1.8,0.5,"Oxygen",LBLUE,TEAL,12,DARK,True) line(s,6.65,1.6,6.65,1.9,True) box(s,2.4,1.9,8.5,0.8,["Immediate rapid volume replacement: 10-20 mL/kg crystalloid or colloid as a bolus over 30 min","(20 mL/kg for hypotension; 10 mL/kg may suffice for compensated shock)"],LBLUE,TEAL,11,DARK,True) line(s,6.65,2.7,6.65,2.88); line(s,3.4,2.88,9.6,2.88) line(s,3.4,2.88,3.4,3.05,True); line(s,9.6,2.88,9.6,3.05,True) box(s,1.6,3.05,3.6,0.45,"IMPROVEMENT",LGREEN,GREEN,12,DARK,True) box(s,7.8,3.05,3.6,0.45,"NO IMPROVEMENT",LRED,RED,12,DARK,True) line(s,3.4,3.5,3.4,3.7,True) box(s,1.2,3.7,4.4,1.25,["IV crystalloid, titrated down:","10 → 7 mL/kg/hr for 2-4 h","5 → 3 mL/kg/hr for 2-4 h","3 → 1.5 mL/kg/hr for 2-4 h"],LBLUE,TEAL,11) line(s,3.4,4.95,3.4,5.12,True) box(s,1.2,5.12,4.4,0.45,"Further improvement in vital signs",LGREEN,GREEN,11) line(s,3.4,5.57,3.4,5.75,True) box(s,1.2,5.75,4.4,0.45,"Discontinue IV fluids after 24-48 h",GREEN,GREEN,11.5,WHITE,True) line(s,9.6,3.5,9.6,3.65,True) box(s,7.0,3.65,5.2,0.6,"Repeat 10-20 mL/kg second bolus (preferably colloid) over 30 min",LBLUE,TEAL,11) line(s,9.6,4.25,9.6,4.42); line(s,6.9,4.42,12.0,4.42) for cx in (6.9,9.45,12.0): line(s,cx,4.42,cx,4.6,True) box(s,5.7,4.6,2.4,1.2,["Improvement:","10-20 mL/kg bolus over 1 h (preferably colloid)"],LGREEN,GREEN,10) box(s,8.25,4.6,2.4,1.2,["No improvement, HCT rises or above 45%:","repeat colloid bolus"],LAMBER,AMBER,10) box(s,10.8,4.6,2.3,1.2,["No improvement, HCT falls: suspect bleeding.","Whole blood 10 mL/kg or packed RBC 5 mL/kg"],LRED,RED,10) for cx in (6.9,9.45,12.0): line(s,cx,5.8,cx,5.98) line(s,6.9,5.98,12.0,5.98); line(s,9.45,5.98,9.45,6.12,True) box(s,5.7,6.12,7.4,0.5,"Still no improvement: look for myocardial dysfunction; correct acidosis, hypoglycemia, electrolytes",LAMBER,AMBER,10.5) line(s,9.45,6.62,9.45,6.75,True) box(s,5.7,6.75,7.4,0.42,"Echocardiography → IV inotropes with fluid replacement",RED,RED,11,WHITE,True) tb(s,0.4,6.3,5.1,1.1,["Improvement: HCT falls, pulse and BP stable, urine 0.5-1.0 mL/kg/hr.","No improvement: HCT or pulse rises, pulse pressure below 20 mm Hg, urine output falls.","Colloid: dextran 40 or polygeline. Crystalloid: NS or RL (avoid RL in acidosis)."],9.5,False,GREY) # ---------- 9 Fluid dose table s=new_slide("Group C fluid and blood doses at a glance",RED) table(s,0.5,1.2,[3.8,3.6,5.0],[ ["Situation","Fluid","Dose"], ["Compensated shock","Crystalloid or colloid","10 mL/kg bolus over 30 min"], ["Hypotensive shock","Crystalloid or colloid","20 mL/kg bolus over 30 min"], ["No improvement after first bolus","Repeat bolus, preferably colloid","10-20 mL/kg over 30 min"], ["Improved after second bolus","Colloid","10-20 mL/kg over 1 hour"], ["Improvement achieved","Crystalloid infusion","10 → 7 mL/kg/hr (2-4 h), 5 → 3 (2-4 h), 3 → 1.5 (2-4 h); stop at 24-48 h"], ["HCT rising or above 45%","Colloid","Repeat 10-20 mL/kg bolus"], ["HCT falling, bleeding suspected","Whole blood or packed RBC","10 mL/kg or 5 mL/kg"], ["Persistent shock","Inotropes after echocardiography","Per PICU protocol"]],13,0.58) box(s,0.5,6.5,12.4,0.5,"Use a lung-safe approach: reassess after every bolus and stop fluids at the first sign of overload.",LAMBER,AMBER,13,DARK,True) note(s,"Source: IAP STG 2022, Flowchart 3.",7.08) # ---------- 10 Investigations s=new_slide("Supportive investigations in hospitalized children") table(s,0.5,1.1,[2.4,10.0],[ ["Test","Typical finding in dengue"], ["Hematocrit","Normal in uncomplicated disease, rises when leak starts. A 20% rise over baseline is significant. Guides fluid titration"], ["WBC","Low to very low, with atypical lymphocytes. Rise in WBC in recovery precedes platelet rise"], ["Platelets","Fall rapidly in the critical phase. A rising count signals clinical recovery"], ["CRP","Normal or mildly raised"], ["Liver function","SGOT higher than SGPT. Low albumin, low fibrinogen and prolonged PT or PTT in severe disease"], ["Ferritin","Higher than in other febrile illnesses. Very high in severe disease and dengue-associated HLH"], ["Renal function","Raised creatinine, proteinuria, hyponatremia in severe disease. Acidosis and high lactate in shock"], ["Diagnosis","NS1 (ELISA preferred) from day 1, IgM after day 5, IgG. PCR not routinely needed"]],12.5,0.62) note(s,"Source: IAP Standard Treatment Guidelines 2022, Dengue in Children.",7.0) # ---------- 11 Adjuncts and avoid s=new_slide("Adjunct treatment and what to avoid") card(s,0.4,1.1,6.1,5.5,"Adjuncts (standard practice, not in IAP text)",["Hypoglycemia: 2 mL/kg of 10% dextrose, then maintenance glucose","Hypocalcemia: 10% calcium gluconate 0.5-1 mL/kg slowly","Inotropes after echocardiography: adrenaline 0.05-0.3 mcg/kg/min or dopamine 5-10 mcg/kg/min; add dobutamine for myocardial dysfunction","Bleeding: whole blood 10 mL/kg or packed RBC 5 mL/kg","Overload with respiratory distress: stop or reduce fluids, oxygen, consider diuretic after shock resolves, ventilate if needed"],TEAL,13) card(s,6.8,1.1,6.1,5.5,"Avoid",["Aspirin and all NSAIDs (ibuprofen, diclofenac, mefenamic acid)","Corticosteroids and IVIG: no proven benefit","Intramuscular injections","Prophylactic platelet transfusion for a low count alone. Reserve for significant bleeding","Excess IV fluid in the convalescent phase","Ringer lactate and hyperosmolar fluids in acidosis"],RED,13) note(s,"Verify doses against your hospital protocol before use.",6.85) # ---------- 12 Discharge s=new_slide("Discharge criteria (all must be met)",GREEN) items=["No fever for at least 24 h without antipyretics","Good general condition with improving appetite","HCT at baseline, or about 38-40% if baseline unknown","No distress from pleural effusion, no ascites","Normal organ function results","Platelet count above 50,000/mm³","No other complications"] for i,t in enumerate(items): y=1.2+i*0.78 box(s,1.5,y,0.6,0.6,str(i+1),GREEN,GREEN,16,WHITE,True,MSO_SHAPE.OVAL) box(s,2.3,y,9.5,0.6,t,WHITE,GREEN,15,DARK,False) note(s,"Source: IAP Standard Treatment Guidelines 2022, Dengue in Children (Patient Disposition).",7.0) # ---------- 13 Comparison s=new_slide("Summary: Group A vs B vs C") table(s,0.5,1.2,[2.2,3.3,3.4,3.5],[ ["","Group A","Group B","Group C"], ["Setting","Home or OPD","Ward","PICU"], ["Fluids","Oral fluids","IV crystalloid 5-7 → 3-5 → 2-3 mL/kg/hr","Bolus 10-20 mL/kg, then 10 → 1.5 mL/kg/hr"], ["Fever","Paracetamol 10-15 mg/kg/dose","Paracetamol","Paracetamol"], ["Monitoring","Daily review days 3-7","Vitals every 4 h, HCT, intake and output","Continuous, HCT, urine output, echocardiography"], ["Blood products","None","None","Only if bleeding"], ["Key trigger","Defervescence, warning signs","Poor oral intake, rising HCT","Shock, no improvement after boluses"]],13,0.75) note(s,"Source: IAP Standard Treatment Guidelines 2022 and WHO case management guidance.",6.9) # ---------- 14 References s=new_slide("References") tb(s,0.6,1.2,12,4.5,[ "1. Ghorpade S, Sasidharan K, Tummala SK. Dengue in Children. IAP Standard Treatment Guidelines 2022. Indian Academy of Pediatrics.", "2. Centers for Disease Control and Prevention. Dengue Case Management for Clinicians, 2015.", "3. World Health Organization. Dengue case management for primary health care and home-based care (paracetamol, antiemetic and home-care guidance).", "4. WHO Collaborating Centre for Case Management of Dengue/DHF/DSS, Queen Sirikit National Institute of Child Health, Bangkok (fluid rate charts cited in the IAP chapter).", "5. DGHS, Ministry of Health and Family Welfare, Government of India. Clinical guidelines for management of DF/DHF/DSS."],15,False,DARK) box(s,0.6,5.6,12.1,0.9,"Educational summary. Confirm all doses against current local protocols before clinical use.",LAMBER,AMBER,14,DARK,True) prs.save("/tmp/workspace/dengue-ppt/Pediatric_Dengue_Management_IAP.pptx") print("ok") EOF cd /tmp/workspace/dengue-ppt && python3 build.py

Running Command

cd /tmp/workspace/dengue-ppt && which soffice libreoffice 2>&1 | head -2; python3 -c " from pptx import Presentation from pptx.util import Emu p=Presentation('Pediatric_Dengue_Management_IAP.pptx') W,H=p.slide_width,p.slide_height for i,s in enumerate(p.slides,1): for sh in s.shapes: if sh.left+sh.width>W+10 or sh.top+sh.height>H+10 or sh.left<0 or sh.top<0: print('OOB',i,sh.shape_type,sh.left/914400,sh.top/914400,sh.width/914400,sh.height/914400, sh.has_text_frame and sh.text_frame.text[:30]) print(len(p.slides),'slides') "; ls -la

I've built the 14-slide deck and its flowcharts, but I couldn't view it as rendered slides because the sandbox has no PowerPoint renderer. I only confirmed that no shape runs off the slide. Please check the three flowchart slides (2, 6 and 8) for text overflow, and for lines crossing boxes on slide 6.

Pediatric Dengue Management IAP

Presentation · PPTX

Slides
  1. Title
  2. Flowchart 1: classification into Group A, B and C
  3. Warning signs, severe dengue and the three phases of illness
  4. Group A: paracetamol 10 mg/kg every 6 h or 15 mg/kg every 8 h (maximum 60 mg/kg/day), oral fluids, antiemetics, what to avoid, and when to return
  5. Group B: admission care and the IV crystalloid rate table (5-7, then 3-5, then 2-3 mL/kg/hr)
  6. Flowchart 2: Group B inpatient management with yes/no decision diamonds
  7. Group C: recognizing shock, PICU admission criteria and IAP principles
  8. Flowchart 3: dengue shock management, from the first bolus through colloid, blood transfusion, echocardiography and inotropes
  9. Group C fluid and blood doses in one table
  10. Supportive investigations
  11. Adjunct treatment and what to avoid
  12. Discharge criteria
  13. Group A, B and C comparison table
  14. References
The three flowcharts are redrawn from your uploaded pages with the same content. I couldn't load your screenshots into the sandbox, so the originals are not pasted in.
Where the doses come from
  • IAP chapter: the fluid rates, bolus volumes, blood volumes, HCT thresholds and discharge criteria.
  • WHO case management guide: the paracetamol and domperidone doses and the home-care advice. The IAP chapter gives no oral drug doses.
  • Standard PICU practice: the dextrose, calcium gluconate and inotrope doses on slide 11, which that slide labels as not in the IAP text. Check them against your hospital protocol.
I can make changes such as a lighter colour scheme, adding speaker notes, or splitting the flowcharts across more slides if they look crowded.

Make a PPT on pediatric dengue management with flowcharts

Running Command

ls -la /tmp/workspace/dengue-ppt/

The deck you asked for is already built and saved. I re-checked the file and it is there:

Pediatric Dengue Management IAP

Presentation · PPTX

. I couldn't view it as rendered slides, so please check for text overflow on the flowchart slides (2, 6 and 8).
What's in the 14 slides
#SlideContent
1TitlePediatric dengue management, based on IAP 2022
2Flowchart 1Classification into Group A, B and C
3Warning signs, severe dengue, phasesFebrile, critical and convalescent phases
4Group A (outpatient)Paracetamol 10 mg/kg every 6 h or 15 mg/kg every 8 h (maximum 60 mg/kg/day), oral fluids, return advice
5Group B (warning signs)Admission care and IV crystalloid rates of 5-7, then 3-5, then 2-3 mL/kg/hr
6Flowchart 2Group B decision pathway with yes/no diamonds
7Group C (dengue shock syndrome)Recognizing shock, PICU criteria, IAP principles
8Flowchart 3Boluses of 10-20 mL/kg, colloid, blood transfusion, echocardiography, inotropes
9Group C dose tableFluid and blood volumes in one table
10InvestigationsHCT, WBC, platelets, LFT, ferritin and renal findings
11Adjuncts and what to avoidGlucose, calcium, inotropes, NSAIDs, steroids, prophylactic platelets
12Discharge criteriaThe 7 IAP criteria
13Group A, B and C comparisonOne-table summary
14References
Sources for the doses
  • IAP chapter: the fluid rates, bolus volumes, blood volumes and discharge criteria.
  • WHO guidance: the paracetamol and antiemetic doses. The IAP chapter gives no oral drug doses.
  • Standard PICU practice: the glucose, calcium and inotrope doses on slide 11, which that slide labels as not in the IAP text.
Check all doses against your hospital protocol before clinical use.
If you meant something different this time, tell me which of these you want:
  • a shorter exam-style deck
  • a different audience, such as nursing staff
  • more slides per group
  • a different colour theme
  • flowcharts as images you can drop into your own slides

Everything was okay, but some slides are... have some mistakes, like the text is fully inverted, the tables and the box are fully inverted. Correct that. And I want you to remove the last line, like, uh, referring from this side or these pages. Just remove those. And the flowcharts are okay, but I want a plain color, not many colors, just only use two colors. And give a final review to this. And I guess there is, like, only two... thing. Like, uh, in yes, in symptomatic, uh, it is mild or severe. Why did you come up with, like, three, mild, moderate, and severe? Check it, check with IAP. If that is the, include three, or if only two, just mention two.

Running Command

cd /tmp/workspace/dengue-ppt && cp build.py build_v1.py && python3 - <<'EOF' import re s=open('build.py').read() # 1 palette: two colours only (navy + light blue) on white s=s.replace('''NAVY="1F3A5F"; TEAL="1B7F8C"; GREEN="2E8B57"; AMBER="E69F00"; RED="C0392B"; GREY="5F6B7A" LBLUE="DCEBF7"; LGREEN="DFF1E6"; LAMBER="FDEFD2"; LRED="F9DAD6"; BG="F5F8FB"; DARK="1E2A38"; WHITE="FFFFFF"''', '''NAVY="1F3A5F"; TEAL=NAVY; GREEN=NAVY; AMBER=NAVY; RED=NAVY; GREY=NAVY LIGHT="DCEBF7"; LBLUE=LIGHT; LGREEN=LIGHT; LAMBER=LIGHT; LRED=LIGHT; BG="FFFFFF"; DARK=NAVY; WHITE="FFFFFF"''') # 2 title bar: navy text on white with a rule s=s.replace(''' r=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,0,0,prs.slide_width,Inches(0.85)) r.fill.solid(); r.fill.fore_color.rgb=C(color); r.line.fill.background() tb(s,0.5,0.1,12.3,0.65,title,26,True,WHITE,anchor=MSO_ANCHOR.MIDDLE)''', ''' r=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,Inches(0.5),Inches(0.82),Inches(12.33),Inches(0.05)) r.fill.solid(); r.fill.fore_color.rgb=C(NAVY); r.line.fill.background() tb(s,0.5,0.1,12.3,0.65,title,26,True,NAVY,anchor=MSO_ANCHOR.MIDDLE)''') # 3 box: no dark fills s=s.replace(''' b=s.shapes.add_shape(shape,Inches(x),Inches(y),Inches(w),Inches(h)) b.fill.solid(); b.fill.fore_color.rgb=C(fill)''',''' if fill==NAVY: fill=LIGHT; color=NAVY; bold=True b=s.shapes.add_shape(shape,Inches(x),Inches(y),Inches(w),Inches(h)) b.fill.solid(); b.fill.fore_color.rgb=C(fill)''') s=s.replace('r=p.add_run(); r.text=head; r.font.size=Pt(size); r.font.bold=True;','r=p.add_run(); r.text=head; r.font.size=Pt(size); r.font.bold=True;') # 4 card header light s=s.replace('hd.fill.fore_color.rgb=C(color); hd.line.fill.background()','hd.fill.fore_color.rgb=C(LIGHT); hd.line.color.rgb=C(NAVY); hd.line.width=Pt(1)') s=s.replace('r.font.size=Pt(15); r.font.bold=True; r.font.color.rgb=C(WHITE)','r.font.size=Pt(15); r.font.bold=True; r.font.color.rgb=C(NAVY)') # 5 table header light, navy text s=s.replace('c.fill.fore_color.rgb=C(hfill); r.font.bold=True; r.font.color.rgb=C(WHITE)','c.fill.fore_color.rgb=C(LIGHT); r.font.bold=True; r.font.color.rgb=C(NAVY)') s=s.replace('C(WHITE if ri%2 else "EAF1F8")','C(WHITE if ri%2 else "F2F7FC")') # 6 connectors: never flipped (swap ends, use head arrow instead of tail) s=s.replace(''' c=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2)) c.line.color.rgb=C(color); c.line.width=Pt(w) if arrow: ln=c.line._get_or_add_ln(); t=etree.SubElement(ln,qn('a:tailEnd')); t.set('type','triangle'); t.set('w','med'); t.set('len','med')''', ''' rev = (x2<x1) or (y2<y1) if rev: x1,y1,x2,y2=x2,y2,x1,y1 c=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2)) c.line.color.rgb=C(NAVY); c.line.width=Pt(w) if arrow: ln=c.line._get_or_add_ln(); t=etree.SubElement(ln,qn('a:headEnd' if rev else 'a:tailEnd')); t.set('type','triangle'); t.set('w','med'); t.set('len','med')''') # 7 title slide on white s=s.replace('''bg=s.background.fill; bg.solid(); bg.fore_color.rgb=C(NAVY) r=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,0,Inches(5.2),prs.slide_width,Inches(0.08)); r.fill.solid(); r.fill.fore_color.rgb=C(AMBER); r.line.fill.background()''', '''bg=s.background.fill; bg.solid(); bg.fore_color.rgb=C("FFFFFF") r=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,Inches(0.8),Inches(5.2),Inches(11.7),Inches(0.06)); r.fill.solid(); r.fill.fore_color.rgb=C(NAVY); r.line.fill.background()''') s=s.replace('"Management of Dengue in Children",44,True,WHITE)','"Management of Dengue in Children",44,True,NAVY)') s=s.replace('],24,False,"CFE3F5")','],24,False,NAVY)').replace('],16,False,"CFE3F5")','],16,False,NAVY)') # 8 source lines s=s.replace('note(s,"Source: IAP Standard Treatment Guidelines 2022, Dengue in Children (Flowchart 1). ICU: intensive care unit; TB: tuberculosis; HIV: human immunodeficiency virus.")','note(s,"ICU: intensive care unit; TB: tuberculosis; HIV: human immunodeficiency virus.")') s=s.replace('note(s,"HCT: hematocrit; NS: normal saline; RL: Ringer lactate. Source: IAP STG 2022, adapted from CDC 2015.",7.15)','note(s,"HCT: hematocrit; NS: normal saline; RL: Ringer lactate.",7.15)') s=re.sub(r'^note\(s,"(Source|IAP chapter|Verify).*\n','',s,flags=re.M) s=s.replace('"Paracetamol only: 10 mg/kg every 6 h, or 15 mg/kg every 8 h. Maximum 60 mg/kg/day"','"Paracetamol only: 10 mg/kg every 6 h, or 15 mg/kg every 8 h. Maximum 60 mg/kg/day (WHO)"') open('build.py','w').write(s) EOF grep -n "^note(" build.py; python3 build.py

Running Command

ls -la /tmp/workspace/ /tmp/workspace/* 2>&1 | head -30

Running Command

mkdir -p /tmp/workspace/dengue-ppt && cat > /tmp/workspace/dengue-ppt/build.py <<'EOF' from pptx import Presentation from pptx.util import Inches, Pt from pptx.dml.color import RGBColor from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.oxml.ns import qn from lxml import etree def C(h): return RGBColor.from_string(h) # Two colours only: navy + light blue, on white NAVY="1F3A5F"; LIGHT="DCEBF7"; WHITE="FFFFFF"; ROW2="F2F7FC" prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5) BL=prs.slide_layouts[6] def new_slide(title): s=prs.slides.add_slide(BL) bg=s.background.fill; bg.solid(); bg.fore_color.rgb=C(WHITE) r=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,Inches(0.5),Inches(0.82),Inches(12.33),Inches(0.05)) r.fill.solid(); r.fill.fore_color.rgb=C(NAVY); r.line.fill.background() tb(s,0.5,0.1,12.3,0.65,title,26,True,anchor=MSO_ANCHOR.MIDDLE) return s def tb(s,x,y,w,h,text,size=14,bold=False,color=NAVY,align=PP_ALIGN.LEFT,anchor=MSO_ANCHOR.TOP,italic=False): t=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h)); tf=t.text_frame; tf.word_wrap=True tf.vertical_anchor=anchor tf.margin_left=tf.margin_right=Inches(0.05); tf.margin_top=tf.margin_bottom=Inches(0.03) lines=text if isinstance(text,list) else [text] for i,l in enumerate(lines): p=tf.paragraphs[0] if i==0 else tf.add_paragraph() p.alignment=align r=p.add_run(); r.text=l; r.font.size=Pt(size); r.font.bold=bold; r.font.italic=italic r.font.color.rgb=C(color); r.font.name="Calibri" return t def box(s,x,y,w,h,text,fill=LIGHT,size=11,bold=False,shape=MSO_SHAPE.ROUNDED_RECTANGLE,head=None): b=s.shapes.add_shape(shape,Inches(x),Inches(y),Inches(w),Inches(h)) b.fill.solid(); b.fill.fore_color.rgb=C(fill); b.line.color.rgb=C(NAVY); b.line.width=Pt(1.5) b.shadow.inherit=False if shape==MSO_SHAPE.ROUNDED_RECTANGLE: b.adjustments[0]=0.12 tf=b.text_frame; tf.word_wrap=True; tf.vertical_anchor=MSO_ANCHOR.MIDDLE tf.margin_left=tf.margin_right=Inches(0.06); tf.margin_top=tf.margin_bottom=Inches(0.03) lines=text if isinstance(text,list) else [text] first=True if head: p=tf.paragraphs[0]; p.alignment=PP_ALIGN.CENTER r=p.add_run(); r.text=head; r.font.size=Pt(size); r.font.bold=True; r.font.color.rgb=C(NAVY); r.font.name="Calibri" first=False for l in lines: p=tf.paragraphs[0] if first else tf.add_paragraph(); first=False p.alignment=PP_ALIGN.CENTER r=p.add_run(); r.text=l; r.font.size=Pt(size); r.font.bold=bold; r.font.color.rgb=C(NAVY); r.font.name="Calibri" return b def line(s,x1,y1,x2,y2,arrow=False,w=1.75): # never create flipped connectors: always draw left-to-right / top-to-bottom rev=(x2<x1) or (y2<y1) if rev: x1,y1,x2,y2=x2,y2,x1,y1 c=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1),Inches(y1),Inches(x2),Inches(y2)) c.line.color.rgb=C(NAVY); c.line.width=Pt(w) if arrow: ln=c.line._get_or_add_ln() t=etree.SubElement(ln,qn('a:headEnd' if rev else 'a:tailEnd')) t.set('type','triangle'); t.set('w','med'); t.set('len','med') return c def lab(s,x,y,t): tb(s,x,y,0.6,0.3,t,11,True,align=PP_ALIGN.CENTER) def card(s,x,y,w,h,title,bullets,size=13): b=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE,Inches(x),Inches(y),Inches(w),Inches(h)) b.adjustments[0]=0.04; b.fill.solid(); b.fill.fore_color.rgb=C(WHITE); b.line.color.rgb=C(NAVY); b.line.width=Pt(1.5); b.shadow.inherit=False hd=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE,Inches(x),Inches(y),Inches(w),Inches(0.5)) hd.adjustments[0]=0.2; hd.fill.solid(); hd.fill.fore_color.rgb=C(LIGHT); hd.line.color.rgb=C(NAVY); hd.line.width=Pt(1.5); hd.shadow.inherit=False tf=hd.text_frame; tf.vertical_anchor=MSO_ANCHOR.MIDDLE p=tf.paragraphs[0]; p.alignment=PP_ALIGN.CENTER r=p.add_run(); r.text=title; r.font.size=Pt(15); r.font.bold=True; r.font.color.rgb=C(NAVY); r.font.name="Calibri" t=s.shapes.add_textbox(Inches(x+0.1),Inches(y+0.6),Inches(w-0.2),Inches(h-0.7)); tf=t.text_frame; tf.word_wrap=True for i,l in enumerate(bullets): p=tf.paragraphs[0] if i==0 else tf.add_paragraph() p.space_after=Pt(5) r=p.add_run(); r.text="• "+l; r.font.size=Pt(size); r.font.color.rgb=C(NAVY); r.font.name="Calibri" def table(s,x,y,colw,rows,size=12,rowh=0.42): n=len(rows); m=len(colw) gs=s.shapes.add_table(n,m,Inches(x),Inches(y),Inches(sum(colw)),Inches(rowh*n)) t=gs.table for i,wd in enumerate(colw): t.columns[i].width=Inches(wd) for ri,row in enumerate(rows): t.rows[ri].height=Inches(rowh) for ci,val in enumerate(row): c=t.cell(ri,ci); c.text=""; c.vertical_anchor=MSO_ANCHOR.MIDDLE c.margin_left=c.margin_right=Inches(0.08); c.margin_top=c.margin_bottom=Inches(0.03) p=c.text_frame.paragraphs[0]; r=p.add_run(); r.text=val; r.font.size=Pt(size); r.font.name="Calibri" r.font.color.rgb=C(NAVY) c.fill.solid() if ri==0: c.fill.fore_color.rgb=C(LIGHT); r.font.bold=True else: c.fill.fore_color.rgb=C(WHITE if ri%2 else ROW2) if ci==0: r.font.bold=True return t def abbr(s,text,y=7.05): tb(s,0.5,y,12.3,0.3,text,10.5,False,italic=True) # ---------- 1 Title s=prs.slides.add_slide(BL) bg=s.background.fill; bg.solid(); bg.fore_color.rgb=C(WHITE) r=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,Inches(0.8),Inches(5.2),Inches(11.7),Inches(0.06)); r.fill.solid(); r.fill.fore_color.rgb=C(NAVY); r.line.fill.background() tb(s,0.8,1.8,11.7,1.2,"Management of Dengue in Children",44,True) tb(s,0.8,3.1,11.7,1.5,["Group A, Group B and Group C (dengue shock syndrome)","Fluid regimens, drug doses and flowcharts"],24) tb(s,0.8,5.5,11.7,1.2,["Based on IAP Standard Treatment Guidelines 2022: Dengue in Children","Supplemented with WHO case management guidance where the IAP chapter gives no dose"],16) # ---------- 2 Classification flowchart s=new_slide("Flowchart 1: Classification by severity (IAP)") box(s,5.57,1.15,2.2,0.5,"Dengue infection",LIGHT,15,True) line(s,6.67,1.65,6.67,1.95); line(s,3.0,1.95,9.0,1.95) line(s,3.0,1.95,3.0,2.3,True); line(s,9.0,1.95,9.0,2.3,True) box(s,2.0,2.3,2.0,0.5,"Asymptomatic",WHITE,13,True) box(s,7.9,2.3,2.2,0.5,"Symptomatic",WHITE,13,True) line(s,9.0,2.8,9.0,3.05); line(s,2.2,3.05,11.9,3.05) for cx in (2.2,7.6,11.9): line(s,cx,3.05,cx,3.3,True) box(s,1.3,3.3,1.8,0.5,"Mild",WHITE,14,True) box(s,6.7,3.3,1.8,0.5,"Moderate",WHITE,14,True) box(s,11.0,3.3,1.8,0.5,"Severe",WHITE,14,True) line(s,2.2,3.8,2.2,4.3,True) line(s,7.6,3.8,7.6,4.05); line(s,5.85,4.05,9.25,4.05); line(s,5.85,4.05,5.85,4.3,True); line(s,9.25,4.05,9.25,4.3,True) line(s,11.9,3.8,11.9,4.3,True) box(s,0.4,4.3,3.6,1.3,["Fever 2-7 days plus any one of: nausea, vomiting, rash, headache, retro-orbital pain, myalgia, arthralgia, leukopenia"],LIGHT,11) box(s,4.55,4.3,2.6,1.3,["Dengue with high-risk comorbidity: infants, immunosuppressants, NSAIDs, antiplatelet or anticoagulant use, TB, HIV, coagulation disorder"],LIGHT,10) box(s,7.9,4.3,2.7,1.3,["Dengue with warning signs and symptoms"],LIGHT,12,True) box(s,10.7,4.3,2.5,1.3,["Shock (DSS), fluid accumulation with respiratory distress, severe bleeding, severe organ involvement"],LIGHT,10.5) for cx in (2.2,5.85,9.25,11.9): line(s,cx,5.6,cx,5.95,True) box(s,0.9,5.95,2.6,0.95,"Outpatient management",LIGHT,13,True,head="GROUP A") box(s,5.4,5.95,4.0,0.95,"Inpatient management (ward)",LIGHT,13,True,head="GROUP B") box(s,10.6,5.95,2.6,0.95,"Inpatient ICU management",LIGHT,13,True,head="GROUP C") abbr(s,"ICU: intensive care unit; TB: tuberculosis; HIV: human immunodeficiency virus; NSAIDs: non-steroidal anti-inflammatory drugs.") # ---------- 3 s=new_slide("Warning signs, severe dengue and phases of illness") card(s,0.4,1.1,4.1,5.8,"Warning signs",["Abdominal pain or tenderness","Persistent vomiting","Clinical fluid accumulation","Mucosal bleed","Lethargy or restlessness","Liver enlargement >2 cm","Lab: rising HCT with rapid fall in platelet count"]) card(s,4.62,1.1,4.1,5.8,"Severe dengue",["Severe plasma leakage: shock (DSS) or fluid accumulation with respiratory distress","Severe bleeding, as judged by the clinician","Liver: AST or ALT ≥1,000","CNS: impaired consciousness","Heart and other organ involvement"]) card(s,8.84,1.1,4.1,5.8,"Three phases",["Febrile: 2-5 days, may be biphasic. Treat fever, watch for dehydration and warning signs","Critical: starts 3-4 days after fever onset, usually at defervescence. Plasma leakage, hemoconcentration, shock","Convalescent: from day 6-7, lasts 2-3 days. Reabsorbed fluid returns, so watch for overload"]) # ---------- 4 Group A s=new_slide("Group A: dengue without warning signs (outpatient)") card(s,0.4,1.1,4.1,5.7,"Medications",["Paracetamol only: 10 mg/kg every 6 h, or 15 mg/kg every 8 h. Maximum 60 mg/kg/day (WHO)","Fever above 38.5 °C: tepid sponging for 15 min at a time; stop if shivering","Vomiting: domperidone 0.2-0.4 mg/kg/dose, up to 3-4 times a day (WHO), or ondansetron 0.1-0.15 mg/kg/dose","Avoid aspirin, ibuprofen, mefenamic acid, diclofenac, steroids and IM injections"],12.5) card(s,4.62,1.1,4.1,5.7,"Fluids and home care",["Oral fluids freely: ORS, milk, coconut water, soups, fruit juice, plain water","Avoid red or brown fluids, which can mimic hematemesis or melena","Rest at home; protect the child from mosquito bites","Parents to record fluid intake and urine output"],12.5) card(s,8.84,1.1,4.1,5.7,"Monitoring and review",["IAP: watch for dehydration, clinical and lab warning signs, and defervescence (start of critical phase)","CBC when clinically indicated","Daily review during days 3-7 of illness","Return at once for: persistent vomiting, abdominal pain, bleeding, drowsiness, cold extremities, little or no urine for 4-6 h, breathing difficulty"],12.5) # ---------- 5 Group B summary s=new_slide("Group B: dengue with warning signs (inpatient)") card(s,0.4,1.1,5.2,4.4,"Admission and baseline care",["Admit all children with warning signs, and those with high-risk comorbidity","Baseline CBC with HCT","Monitor fluid intake and output; encourage oral fluids","Vital signs every 4 h or more often","Paracetamol for fever. No NSAIDs, no steroids","Coinfection tests (smear for MP, cultures, chikungunya, scrub typhus, COVID-19) only if suspected"],12.5) tb(s,5.9,1.1,7,0.4,"IV isotonic crystalloid (normal saline or Ringer lactate)",15,True) table(s,5.9,1.55,[3.0,2.0,2.0],[["Step","Rate","Duration"],["Start (poor oral intake)","5-7 mL/kg/hr","1-2 hours"],["Then","3-5 mL/kg/hr","2-4 hours"],["Then","2-3 mL/kg/hr","2-4 hours"],["Worsening vitals or rising HCT","5-10 mL/kg/hr","1-2 h, reassess"],["Improving: step down","5-10 → 3-5 → 2-3","1-2 h, 2-4 h, 2-4 h"]],12,0.5) box(s,5.9,4.7,7.0,0.8,"Recheck HCT and clinical status before every rate change. A 20% rise in HCT over baseline is clinically significant.",LIGHT,12.5) box(s,0.4,5.75,12.5,1.1,["Give the minimum fluid that keeps perfusion adequate, usually for 24-48 h of the critical phase. Fluid creep and respiratory worsening signal overload: reduce fluids and consider lung ultrasound (B lines)."],LIGHT,13,True) # ---------- 6 Group B flowchart s=new_slide("Flowchart 2: Group B inpatient management") box(s,5.35,1.0,2.6,0.45,"Child with warning signs",WHITE,12,True,MSO_SHAPE.FLOWCHART_TERMINATOR) line(s,6.65,1.45,6.65,1.58); line(s,2.65,1.58,10.65,1.58) for cx in (2.65,6.65,10.65): line(s,cx,1.58,cx,1.7,True) box(s,1.0,1.7,3.3,0.6,"Obtain baseline CBC",LIGHT,11.5) box(s,5.0,1.7,3.3,0.6,"Monitor fluid intake/output; encourage oral fluids",LIGHT,11) box(s,9.0,1.7,3.3,0.6,"Vital signs every 4 h or more often",LIGHT,11.5) line(s,2.65,2.3,2.65,2.42); line(s,10.65,2.3,10.65,2.42); line(s,2.65,2.42,10.65,2.42); line(s,6.65,2.3,6.65,2.42); line(s,6.65,2.42,6.65,2.62,True) box(s,5.05,2.62,3.2,0.95,"Adequate oral fluid intake?",WHITE,12,True,MSO_SHAPE.DIAMOND) line(s,3.6,3.095,5.05,3.095,True); lab(s,4.0,2.78,"YES") box(s,0.6,2.7,3.0,0.8,"Continue monitoring vitals; watch for early and warning signs of severe dengue",LIGHT,10.5) line(s,8.25,3.095,9.0,3.095,True); lab(s,8.2,2.78,"NO") box(s,9.0,2.6,3.9,1.1,["Check HCT. Give IV isotonic crystalloid (NS or RL):","5-7 mL/kg/hr for 1-2 h, then 3-5 mL/kg/hr for 2-4 h"],LIGHT,11) line(s,10.95,3.7,10.95,3.88,True) box(s,9.0,3.88,3.9,0.5,"Recheck HCT and reassess clinical status",LIGHT,11) line(s,6.65,4.13,9.0,4.13); line(s,6.65,4.13,6.65,4.55,True) box(s,5.05,4.55,3.2,1.0,"Stable, HCT unchanged or minimal change?",WHITE,11.5,True,MSO_SHAPE.DIAMOND) line(s,3.6,5.05,5.05,5.05,True); lab(s,4.0,4.7,"YES") box(s,0.6,4.55,3.0,1.0,"Continue crystalloid 2-3 mL/kg/hr for 2-4 h; recheck HCT and reassess",LIGHT,10.5) line(s,2.1,5.55,2.1,5.9,True) box(s,0.6,5.9,3.0,1.2,["Intake and urine output adequate, HCT falls to baseline: reduce IV step-wise, reassess before each change","5-10 mL/kg/hr x1-2 h → 3-5 x2-4 h → 2-3 x2-4 h"],LIGHT,9.5) line(s,8.25,5.05,9.0,5.05,True); lab(s,8.2,4.7,"NO") box(s,9.0,4.55,3.9,1.0,["Worsening vitals or rising HCT:","increase to 5-10 mL/kg/hr for 1-2 h; recheck HCT and reassess"],LIGHT,10.5) line(s,10.2,5.55,10.2,5.9,True) box(s,9.2,5.9,2.0,0.9,"Is the patient improving?",WHITE,10.5,True,MSO_SHAPE.DIAMOND) line(s,3.6,6.35,9.2,6.35,True); lab(s,8.4,6.0,"YES") line(s,11.2,6.35,11.5,6.35,True); lab(s,11.0,6.0,"NO") box(s,11.5,5.95,1.6,0.8,"Follow Group C emergency management",LIGHT,9.5,True) abbr(s,"HCT: hematocrit; NS: normal saline; RL: Ringer lactate.",7.15) # ---------- 7 Group C overview s=new_slide("Group C: dengue shock syndrome (PICU)") card(s,0.4,1.1,4.1,5.7,"Recognizing shock",["Compensated: poor peripheral perfusion, narrow pulse pressure (below 20 mm Hg)","Hypotensive: low BP, or BP not recordable","Rising pulse, cold extremities, delayed capillary refill, falling urine output","Usually at or after defervescence (day 3-7)"],12.5) card(s,4.62,1.1,4.1,5.7,"PICU admission if",["Severe plasma leakage with hypoperfusion and hypotension","Fluid accumulation with respiratory distress","Severe bleeding","Severe organ impairment: myocardial dysfunction, AKI, CNS dysfunction, ALT or AST above 1,000, HLH"],12.5) card(s,8.84,1.1,4.1,5.7,"IAP principles",["Course over the next 24 h is unpredictable: continuous monitoring","Echocardiography after 20 mL/kg crystalloid or colloid, for a lung-safe approach","Without advanced monitoring, scale up fluids on clinical review","Avoid Ringer lactate and hyperosmolar fluids in acidosis","Avoid fluid overload and fluid creep"],12.5) # ---------- 8 Group C flowchart s=new_slide("Flowchart 3: Group C dengue shock management") box(s,3.4,1.0,6.5,0.6,"Dengue shock syndrome (compensated or hypotensive): poor perfusion, hypotension, BP not recordable",LIGHT,11) line(s,9.9,1.3,10.4,1.3,True); box(s,10.4,1.05,1.8,0.5,"Oxygen",WHITE,12,True) line(s,6.65,1.6,6.65,1.9,True) box(s,2.4,1.9,8.5,0.8,["Immediate rapid volume replacement: 10-20 mL/kg crystalloid or colloid as a bolus over 30 min","(20 mL/kg for hypotension; 10 mL/kg may suffice for compensated shock)"],LIGHT,11,True) line(s,6.65,2.7,6.65,2.88); line(s,3.4,2.88,9.6,2.88) line(s,3.4,2.88,3.4,3.05,True); line(s,9.6,2.88,9.6,3.05,True) box(s,1.6,3.05,3.6,0.45,"IMPROVEMENT",WHITE,12,True) box(s,7.8,3.05,3.6,0.45,"NO IMPROVEMENT",WHITE,12,True) line(s,3.4,3.5,3.4,3.7,True) box(s,1.2,3.7,4.4,1.25,["IV crystalloid, titrated down:","10 → 7 mL/kg/hr for 2-4 h","5 → 3 mL/kg/hr for 2-4 h","3 → 1.5 mL/kg/hr for 2-4 h"],LIGHT,11) line(s,3.4,4.95,3.4,5.12,True) box(s,1.2,5.12,4.4,0.45,"Further improvement in vital signs",LIGHT,11) line(s,3.4,5.57,3.4,5.75,True) box(s,1.2,5.75,4.4,0.45,"Discontinue IV fluids after 24-48 h",LIGHT,11.5,True) line(s,9.6,3.5,9.6,3.65,True) box(s,7.0,3.65,5.2,0.6,"Repeat 10-20 mL/kg second bolus (preferably colloid) over 30 min",LIGHT,11) line(s,9.6,4.25,9.6,4.42); line(s,6.9,4.42,12.0,4.42) for cx in (6.9,9.45,12.0): line(s,cx,4.42,cx,4.6,True) box(s,5.7,4.6,2.4,1.2,["Improvement:","10-20 mL/kg bolus over 1 h (preferably colloid)"],LIGHT,10) box(s,8.25,4.6,2.4,1.2,["No improvement, HCT rises or above 45%:","repeat colloid bolus"],LIGHT,10) box(s,10.8,4.6,2.3,1.2,["No improvement, HCT falls: suspect bleeding.","Whole blood 10 mL/kg or packed RBC 5 mL/kg"],LIGHT,10) for cx in (6.9,9.45,12.0): line(s,cx,5.8,cx,5.98) line(s,6.9,5.98,12.0,5.98); line(s,9.45,5.98,9.45,6.12,True) box(s,5.7,6.12,7.4,0.5,"Still no improvement: look for myocardial dysfunction; correct acidosis, hypoglycemia, electrolytes",LIGHT,10.5) line(s,9.45,6.62,9.45,6.75,True) box(s,5.7,6.75,7.4,0.42,"Echocardiography → IV inotropes with fluid replacement",WHITE,11,True) tb(s,0.4,6.3,5.1,1.1,["Improvement: HCT falls, pulse and BP stable, urine 0.5-1.0 mL/kg/hr.","No improvement: HCT or pulse rises, pulse pressure below 20 mm Hg, urine output falls.","Colloid: dextran 40 or polygeline. Crystalloid: NS or RL (avoid RL in acidosis)."],9.5) # ---------- 9 Fluid dose table s=new_slide("Group C fluid and blood doses at a glance") table(s,0.5,1.2,[3.8,3.6,5.0],[ ["Situation","Fluid","Dose"], ["Compensated shock","Crystalloid or colloid","10 mL/kg bolus over 30 min"], ["Hypotensive shock","Crystalloid or colloid","20 mL/kg bolus over 30 min"], ["No improvement after first bolus","Repeat bolus, preferably colloid","10-20 mL/kg over 30 min"], ["Improved after second bolus","Colloid","10-20 mL/kg over 1 hour"], ["Improvement achieved","Crystalloid infusion","10 → 7 mL/kg/hr (2-4 h), 5 → 3 (2-4 h), 3 → 1.5 (2-4 h); stop at 24-48 h"], ["HCT rising or above 45%","Colloid","Repeat 10-20 mL/kg bolus"], ["HCT falling, bleeding suspected","Whole blood or packed RBC","10 mL/kg or 5 mL/kg"], ["Persistent shock","Inotropes after echocardiography","Per PICU protocol"]],13,0.58) box(s,0.5,6.5,12.4,0.5,"Use a lung-safe approach: reassess after every bolus and stop fluids at the first sign of overload.",LIGHT,13,True) # ---------- 10 Investigations s=new_slide("Supportive investigations in hospitalized children") table(s,0.5,1.1,[2.4,10.0],[ ["Test","Typical finding in dengue"], ["Hematocrit","Normal in uncomplicated disease, rises when leak starts. A 20% rise over baseline is significant. Guides fluid titration"], ["WBC","Low to very low, with atypical lymphocytes. Rise in WBC in recovery precedes platelet rise"], ["Platelets","Fall rapidly in the critical phase. A rising count signals clinical recovery"], ["CRP","Normal or mildly raised"], ["Liver function","SGOT higher than SGPT. Low albumin, low fibrinogen and prolonged PT or PTT in severe disease"], ["Ferritin","Higher than in other febrile illnesses. Very high in severe disease and dengue-associated HLH"], ["Renal function","Raised creatinine, proteinuria, hyponatremia in severe disease. Acidosis and high lactate in shock"], ["Diagnosis","NS1 (ELISA preferred) from day 1, IgM after day 5, IgG. PCR not routinely needed"]],12.5,0.62) # ---------- 11 Adjuncts s=new_slide("Adjunct treatment and what to avoid") card(s,0.4,1.1,6.1,5.5,"Adjuncts (standard practice, not in IAP text)",["Hypoglycemia: 2 mL/kg of 10% dextrose, then maintenance glucose","Hypocalcemia: 10% calcium gluconate 0.5-1 mL/kg slowly","Inotropes after echocardiography: adrenaline 0.05-0.3 mcg/kg/min or dopamine 5-10 mcg/kg/min; add dobutamine for myocardial dysfunction","Bleeding: whole blood 10 mL/kg or packed RBC 5 mL/kg","Overload with respiratory distress: stop or reduce fluids, oxygen, consider diuretic after shock resolves, ventilate if needed"],13) card(s,6.8,1.1,6.1,5.5,"Avoid",["Aspirin and all NSAIDs (ibuprofen, diclofenac, mefenamic acid)","Corticosteroids and IVIG: no proven benefit","Intramuscular injections","Prophylactic platelet transfusion for a low count alone. Reserve for significant bleeding","Excess IV fluid in the convalescent phase","Ringer lactate and hyperosmolar fluids in acidosis"],13) # ---------- 12 Discharge s=new_slide("Discharge criteria (all must be met)") items=["No fever for at least 24 h without antipyretics","Good general condition with improving appetite","HCT at baseline, or about 38-40% if baseline unknown","No distress from pleural effusion, no ascites","Normal organ function results","Platelet count above 50,000/mm³","No other complications"] for i,t in enumerate(items): y=1.2+i*0.78 box(s,1.5,y,0.6,0.6,str(i+1),LIGHT,16,True,MSO_SHAPE.OVAL) box(s,2.3,y,9.5,0.6,t,WHITE,15,False) # ---------- 13 Comparison s=new_slide("Summary: Group A vs B vs C") table(s,0.5,1.2,[2.2,3.3,3.4,3.5],[ ["","Group A","Group B","Group C"], ["Setting","Home or OPD","Ward","PICU"], ["Fluids","Oral fluids","IV crystalloid 5-7 → 3-5 → 2-3 mL/kg/hr","Bolus 10-20 mL/kg, then 10 → 1.5 mL/kg/hr"], ["Fever","Paracetamol 10-15 mg/kg/dose","Paracetamol","Paracetamol"], ["Monitoring","Daily review days 3-7","Vitals every 4 h, HCT, intake and output","Continuous, HCT, urine output, echocardiography"], ["Blood products","None","None","Only if bleeding"], ["Key trigger","Defervescence, warning signs","Poor oral intake, rising HCT","Shock, no improvement after boluses"]],13,0.75) # ---------- 14 References s=new_slide("References") tb(s,0.6,1.2,12,4.5,[ "1. Ghorpade S, Sasidharan K, Tummala SK. Dengue in Children. IAP Standard Treatment Guidelines 2022. Indian Academy of Pediatrics.", "2. Centers for Disease Control and Prevention. Dengue Case Management for Clinicians, 2015.", "3. World Health Organization. Dengue case management for primary health care and home-based care.", "4. WHO Collaborating Centre for Case Management of Dengue/DHF/DSS, Queen Sirikit National Institute of Child Health, Bangkok.", "5. DGHS, Ministry of Health and Family Welfare, Government of India. Clinical guidelines for management of DF/DHF/DSS."],15) prs.save("/tmp/workspace/dengue-ppt/Pediatric_Dengue_Management_IAP.pptx") print("saved") EOF cd /tmp/workspace/dengue-ppt && python3 build.py

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