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Dengue Hemorrhagic

Fever
Dr. Dwi Lingga Utama, SpA(K)

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DEFINITION
Dengue fever, a benign syndrome
caused by several arthropod-borne
viruses, is characterized by biphasic
fever, myalgia or arthralgia, rash,
leukopenia, and lymphadenopathy.
Dengue hemorrhagic fever (DHF)
Dengue shock syndrome (DSS)
Etiology
There are at least 4 antigenic types
of dengue virus.
Viruses are transmitted by
mosquitoes of the Stegomyia family.
Aedes aegypti, a daytime biting
mosquito, is the principal vector.
Pathogenesis
The pathogenesis is incompletely
understood, but epidemiologic
studies suggest that it is usually
associated with second infections
with dengue types 14 (the
secondary heterologous infections).
Homologous Antibodies Form
Non-infectious Complexes

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1

1
1 Dengue 1 virus
Neutralizing antibody to Dengue 1 virus

Non-neutralizing antibody
1 Complex formed by neutralizing antibody and virus
Heterologous Complexes Enter
More Monocytes, Where Virus
Replicates

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2
2
2
2
2 2
2
2

2 Dengue 2 virus

Non-neutralizing antibody

2 Complex formed by non-neutralizing


antibody and Dengue 2 virus
Secondary heterologous dengue infection

Virus replication Anamnestic antibody respons

Complex virus-antibody

Complemen activation
Complemen

Anafilatoxin (C3a, C5a)


Urine Histamin
Capillary permeability increase
Ht increase
30% shock Plasma leakage Natrium
decrease
Hipovolemia Intra serous
fluid
Anoxia Acidosis
Shock
Death
ICEBERG PHENOMENON
Dengue virus infections
10,000
Asymptomatic Symptomatic
9,000 1,000

Undifferentiated Fever Dengue Fever Dengue Hemorrhagic Fever


(Viral syndrome) (DF) (DHF)
400 100
500

Plasma leakage
50DF, 50 DHF

Non-shock Shock
DHF DSS
(Dengue shock syndrome)
48 1-2
DHF
Grading of Illness
Grade I
Unspecified febrile, Tourniquet test
positive
Grade II
Grade I + spontaneous bleeding
Grade III
Circulatory failure (restless, fast &
small pulse, pulse pressure < 20mmHg,
hypotension, cyanosis, cold & moist
extremities)
Grade IV
Shock, undetected pulse and blood 11
Criteria from WHO (1999)
Clinical :
Fever 2 7 days
Bleeding : RL test (+)/spontaneous bleeding
Hepatomegaly
Shock 2 clinical + lab
Laboratories :
Low platelet count (<100.000 /ul)
Hemoconcentrate (>20%)

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Dengue Classification 2009
DENGUE Warning SEVERE
Signs DENGUE
With
Without 1.Severe plasma
Warnin leakage
g 2.Severe haemorrhage
3.Severe organ
Signs impairment

Warning Signs* 1. Severe plasma leakage


Abdominal pain or leading to
tenderness Shock (DSS)
Persistent vomiting Fluid accumulation with
Clinical fluid accumulation respiratory distress
Mucosal bleed 2. Severe bleeding
Lethargy; restlessness as evaluated by clinician
Liver enlargement >2cm 3. Severe organ involvement
Laboratory: Increase in Liver: AST or ALT>=1000
HCT concurrent with rapid CNS: Impaired consciousness
decrease Heart and other organs
* Requiring strict observation and medical intervention
Warning signs
Terjadi perubahan klinis saat suhu turun
Nyeri perut kanan atas yg menetap
Muntah berkelanjutan
Iritabel/ gelisah, bayi nangis terus
menerus
Berkeringat, kulit lembab dan dingin,
mottling
Lemas dan mengantuk
Tidak bak 4-6 jam
Early Management
(Home Care)
1. Drink as much as possible (avoid tea, coffee,
and chocolate-to differentiate the bleeding)
2. Record micturition, frequency and quantities.
3. Gives food if possible
4. Antipiretic for the fever ( > 38 C dose
10mg/kg/times (4-5 x/day)
5. Control to the doctor/primary health care/
hospital everyday
6. Laboratory checkup (Hematocrit and platelet
count) (day 3) 15
TEST UJI BENDUNG

Systolic + Diastolic
2
= 5 menit
INTERPRETASI HASIL
PEMERIKSAAN IgM dan IgG

IgM IgG Interpretasi


(+) (-) Infeksi primer
(+) (+) Infeksi sekunder
(-) (+) Tersangka infeksi
sekunder
(-) (-) Tidak ada infeksi
Natural course of DHF
Day 1 2 3 4 5 6 7 8 9

Fever Shock

Pleural effusion,
Ascites

Plasma leakage Stop leakage Reabsorption

IV fluid: NSS, DAR, DLR


W Colloid: 10%Dextran,
B 10%Haes-steril
C M+5% Deficit
(= 4,600 ml in adult)
WBC 8,000 5,000
Platelet count 200,000+ 100,000
Hct rising 20%
Albumin 3.5 gm
%
Cholesterol Professor Siripen Kalayanarooj
100 mg%
General Policy in DHF
Management
In-patient care depends on the grade
Grade I/II: Primary Health Care / One
Day Nursing
Grade III/IV: Hospital, ICU if indicated
(severe shock, repeated shock, GI tract
bleeding, enchepalopathy)
Laboratory (24 hours)
Trained Nurses
Blood Bank
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Monitoring The Illness
Vital sign monitoring (take caution for
signs of early shock)
Counscioussness: decreased/restless
Blood pressure: can be normal
Pulse, respiratory rate: increased
Hepatomegaly
Pain in right hypocondriac
Urine output (caution if urine output is
low, maintain : >1ml/kgBW/hour)
Ht: start to increase.

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Temperature curve for dengue infection

Temp

Time of defervescence

Days of illness
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Temperature Curve for
Dengue Hemoragic Fever
Clinilcal getting worse, faint,
restless, cold hands and feet,
increase RR, low urine output,
loss of appetite

Shock

Days of illness 22
Protokol 1
Tersangka infeksi Virus
Dengue Demam tinggi mendadak, terus <7
hari tanpa sebab yang jelas

Ada Kegawatan Tidak ada kegawatan


Tanda Syok,
Muntah terus
Periksa uji Torniquet (Rample Leede)
menerus, kejang,
kesadaran
menurun, muntah Uji Torniquet (+) Uji Torniquet (-)
darah, Berak darah
Jumlah Trombosit Jumlah Trombosit
< 100.000/uL > 100.000/uL Rawat Jalan

Parasetamol
Rawat Inap Rawat Jalan Kontrol @ hari sampai
Lihat Protokol 2 demam hilang
Minum banyak
Parasetamol k/p Kontrol @
hari sampai demam turun Nilai tanda klinis & Jml
Bila demam menetap Trombosit, Ht bila msh
px: Hb, Ht, Tromb demam hari sakit ke 3

Bila timbul tanda syok; gelisah, lemah kaki


tangan dingin, nyeri perut, berak hitam, kencing
berkurang, Hb/Ht naik dan trombosit turun Segera Bawa ke
Rumah Sakit
DEMAM DENGUE Gejala Klinis: demam 2-7 hari,
uji Torniquet (+) atau Perdarahan
spontan Pasien tidak dapat Minum
Laboratorium: Hematokrit tidak ada Pasien muntah terus menerus
Pasien masih hemokonsentrasi, dengan atau tanpa
dapat Minum Trombositopenia
RAWAT INAP
Pasang Infus
Jumlah dan jenis sesuai
RAWAT JALAN kebutuhan
Beri minum banyak 1-2 l/hr atau 1 sdk
mkn @ 5 menit
Jenis minuman; air putih, teh manis,
sirup, jus buah, susu, oralit.
Bila suhu > 38,5oC beri Parasetamol, Pantau Gejala Klinis & Lab
Bila kejang beri obat anti konvulsi Perhatikan tanda syok, Palpasi hati @ hari,
Ukur diuresis setiap hari, Awasi perdarahan,
Px Ht,Hb, trombo @ 12 -24 jam

Perbaikan Klinis dan Laboratoris Ht naik

Infus Ganti Ringer Laktat


(Tetesan disesuaikan, lihat protokol 3)
PULANG
(Kriteria memulangkan Pasien)

Protokol 2. Tatalaksana Demam


Dengue
DBD derajat I atau II
Cairan awal
RL/RA/NS:
BB < 15 kg : 6-7 ml/KgBB/jam
BB 15-40 kg : 5 ml/kgbb/jam
BB > 40 kg : 3-4 ml/kgbb/jam

Pantau tanda vital tiap 3 jam,


Ht & Trombosit @ 6 jam

Perbaikan Perburukan
Tidak gelisah, Nadi kuat, Tanpa Tanda syok
TD stabil, Diuresis cukup Gelisah, Distres
Ht tetap tinggi/naik
(1 cc/kg/jam,Ht turun pernafasan, Frek Nadi
(2x pemerksaan) naik, Ht tetap tinggi/naik,
Tek. Nadi<20 mmHg,
Tetesan Dikurangi Diuresis kurang/tidak ada
Rumatan atau sesuai
kebutuhan
Tetesan
dipertahankan Masuk ke protokol Syok

Pantau lebih ketat


Perbaikan Tanda vital setiap jam, Ht
Sesuaikan tetesan
tiap 3 jam

IVFD stop stl 24-48 jam


apabila tanda vital/Ht Protokol 3. Tatalaksana DBD derajat I dan II
stabil & diuresis cukup
DBD DERAJAT III ATAU IV
Airway
Breathing : Oksigenasi (2-4 l/m)
Circulation : Cairan kristaloid dan atau koloid, 20 ml/kgBB
Perhatikan tanda-tanda hipovolumia/overload dan respon pemberian cairan

Evaluasi Tidak Teratasi

Teratasi Lanjutkan cairan (Kristaloid 20 ml/kgbb/jam dan


atau koloid 10-20 ml/kgbb/jam (sesuai dosis
maksimal koloid)
Kristaloid 10 ml/kgbb/jam
O2 2-4 L/menit O2 2-4 L/menit
Hb, HT, trombosit, leukosit Hb, HT, trombosit, leukosit
Status keseimbangan asam basa Status keseimbangan asam basa
Pantau tanda vital Pantau tanda vital
Pantau diuresis ( 1 ml/kgbb/jam) Pantau diuresis ( 1 ml/kgbb/jam)
Stabil 6-12 jam Stabil 6-12 jam
Ht < 40% atau penurunan Ht 10-20% Ht < 40% atau penurunan Ht 10-20%

Evaluasi

Kembali protokol 3 Teratasi Tidak Teratasi

Ht tetap tinggi/naik
Tidak ada tanda kelebihan cairan
Jika syok Ht turun
berulang lagi
koloid 10-20 ml/kgbb/jam
Tranfusi PRC sesuai dosis maksimal
10 ml/kg.
Kembali ke awal
protokol 4 ini
Teratasi Tidak Teratasi

Protokol 4. Tatalaksana DBD derajat


Pertimbangkan pemakaian inotropik dan
III dan IV
koloid sesuai dosis maksimal
Returning Home Criteria for the Patient

No fever for 24 hours without


antipiretic
Good appetite
Clinically better
Stable Hematocrit
Three days after shock recovery
Platelet count increased (>50.000/ul)
No respiratory distress found
(because of pleural efusion or acidosis)
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Hematom
pada bekas tusukan
Perdarahan pada DIC
darah merembes dari tusukan jarum

Kasa basah, darah segar merembes


Perdarahan hebat akibat DIC
pada DSS
Conclusion
Dengue viral infection is varies, DHF
must be differed with DF
Additional work up and monitoring is
the key for managing DHF
Diagnose criteria from WHO can only
be used for DHF
Outcome is depends on the duration
of shock recovery
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