Dr.

Mulya Rahma Karyanti, SpA(K), MSc

Ketua Divisi Infeksi dan Pediatri Tropik,
Departemen Ilmu Kesehatan Anak, RSCM-FKUI

• Pendidikan
• Dokter Umum - Fakultas Kedokteran UI, 1994
• Spesialis Anak - Fakultas Kedokteran UI, 2004
• Master of Science in clinical epidemiology - Utrecht Medical Centre, 2011
• Konsultan Infeksi dan Pediatri Tropis - Fakultas Kedokteran UI, 2011
• Organisasi
• Anggota IDAI Jaya, 2004 – Sekarang
• Bendahara PP IDAI 2009-2011
• Pengurus UKK Infeksi dan Pediatri Tropik, 2017 - 2020
• Ketua Satgas Farmasi Pediatri PP IDAI, 2017 – Sekarang
• KOMLI Demam Berdarah Dengue
• KOMLI Malaria
• Komite verifikasi nasional eliminasi campak dan pengendalian rubela
(CRS)
• Komite ahli pengendalian difteri
DIAGNOSIS DAN TATALAKSANA TERKINI
DEMAM BERDARAH DENGUE

Dr. Mulya Rahma Karyanti, SpA(K), MSc

Divisi Infeksi dan Pediatri Tropik,

Departemen Ilmu Kesehatan Anak,
FKUI-RSCM Jakarta
 Topik
• Kriteria diagnosis klinis infeksi dengue
• Kriteria diagnosis laboratorium infeksi
dengue
• Tanda bahaya dengue
• Tata laksana infeksi dengue
• Peran triage
 Klasifikasi diagnosis dengue menurut
WHO 2011

Source: Comprehensive guideline for prevention and control of dengue and dengue haemorrhagic fever.
Revised and expanded edition. Regional office for South-East Asia, New Delhi, India 2011.
Kriteria diagnosis klinis
infeksi dengue
 Days of illness: 0 1 2 3 4 5 6 7 8 9 10
Phases of dengue: Febrile Critical Recovery
6 Key features:
40
1. Temperature
38

Potential
Dehydration Reabsorption
clinical issues Fluid overload
Shock
2. Oral intake
3. Urine output Bleeding

Capillary permeability

Organ Impairment
Laboratory
changes Platelet

4. WBC WBC
5. Platelet
Haematocrit
6. HCT

IgM/IgG
Viraemia

Virology and Serology

Adapted from WCL Yip, 1980 by Hung NT, Lum LCS, Tan LH
 DEMAM DENGUE
• Demam 2–7 hari mendadak, tinggi, terus-menerus, bifasik.
• Ada manifestasi perdarahan spontan seperti petekie,
purpura, ekimosis, epistaksis, perdarahan gusi, hematemesis
dan atau melena; maupun uji tourniquet positif.
• Nyeri kepala, mialgia, artralgia, nyeri retroorbital.
• Adanya kasus DBD baik di lingkungan sekolah, rumah atau di
sekitar rumah.
• Leukopenia <4.000/mm3
• Trombositopenia <100.000/mm3

Demam ditambah > 2 tanda dan gejala lain

UKK IPT 2014, WHO 2011

 DEMAM BERDARAH DENGUE
• Demam 2–7 hari mendadak, tinggi, terus-menerus
• Ada manifestasi perdarahan spontan seperti petekie, purpura, ekimosis,
epistaksis, perdarahan gusi, hematemesis dan atau melena; maupun uji
Tourniquette yang positif
• Sakit kepala, mialgia, artralgia, nyeri retroorbital
• Hepatomegali
• Adanya kebocoran plasma yang ditandai dengan salah satu:
- Peningkatan nilai hematokrit, >20% dari pemeriksaan awal atau dari data
populasi menurut umur
- Ditemukan adanya efusi pleura, asites
- Hipoalbuminemia, hipoproteinemia
• Trombositopenia <100.000/mm3

Demam disertai > 2 manifestasi klinis,

ditambah bukti perembesan plasma dan trombositopenia
UKK IPT 2014, WHO 2011
DEMAM BERDARAH DENGUE

Pada KLB:
Demam tinggi
Tourniquet positif
atau petekie
Leukopenia (<5000)
PPV 83%

Uji Tourniquette positif

Pemeriksaan radiologi thoraks

Posisi tegak Posisi Right lateral decubitus

• Hemithoraks kanan: lebih opaque dari paru kiri

• Hilus kanan lebih padat dari kiri
• Diafragma kanan lebih tinggi dari kiri (> 2 tulang
iga)
• Efusi pleura kanan
Diagnosis Banding DBD fase demam
• Influenza,
• Campak, Flu-like
• Chikungunya syndromes
• Rubella, campak,
• Demam skarlatina,
• Infeksi meningokokus,

DBD Eksantema
Infeksi SSP fase Akut
demam

• Kejang demam • Chikungunya,

• Ensefalitis • Reaksi obat (drug fever)

Penyakit
• Infeksi enterik diare
• Rotavirus
 “Warning Signs”
• Tidak ada perbaikan klinis • Perdarahan : epistaksis,
• Asupan minum sulit hematemesis, melena,
• Muntah terus menoragia,
hemoglobinuria or
• Nyeri perut hematuria
• Letarg, perubahan • Giddines
perilaku
• Diuresis menurun
• Pucat, tangan dan kaki
dingin, lembab

Waspada awal fase kritis

 SINDROM SYOK DENGUE
• Memenuhi kriteria Demam Berdarah Dengue
• Ditemukan adanya tanda dan gejala syok
hipovolemik baik yang terkompensasi maupun
yang dekompensasi
– Tekanan nadi menyempit <20 mmHg berdasar umur
– Nadi cepat dan lemah
– Waktu pengisian kapiler menurun >2 detik
– Ekstremitas dingin, lembab.
 DERAJAT DBD
• Derajat I: hanya tourniquet positif
• Derajat II: I + perdarahan spontan
• Derajat III: syok dengan perbedaan sistolik &
diastolik < 20mmHg
• Derajat IV: Profound syok : tekanan darah tidak
terukur dan nadi tidak teraba
– Cat: semua pasien DBD harus terbukti adanya
kebocoran plasma dan trombosit <100.000
 Sindrom Syok Dengue (DSS)
Compensated Decompensated
Profound shock
shock shock
• Tachycardia • Tachycardia • Unpalpable
• Tachypnea • Hypotensive pulse,
• Pulse rate <20 • Narrow of pulse • Undetectable
mmHg rate blood pressure
• Capillary refill • Hyperpnea or
time > 2 sec Kussmaul
• Cold skin • Cyanosis
• Decreased urine • Cold and clamp
output skin
• Restless
 Sindrom Syok Dengue (DSS)

Beberapa jam Beberapa menit Kolaps kardiovaskular

• Takikardia • Asidosis
• Hipotensi metabolik
Syok • Diastolik
meningkat
Syok
berkepanjangan Profound berat
dekom
terkom tanpa pensasi • Hipoksia shock • Multi organ
pensasi peningkatan failure
sistolik

Gangguan koagulasi
Trombositipenia Perdarahan masif (akibat DIC)

Tanpa pengobatan tepat dan segera, kematian terjadi dengan cepat

(“tsunami storm”)
 Komplikasi dengue
berdasarkan perjalanan penyakit
Fase
Fase demam Fase kritis konvalesen

• Dehidrasi • Syok • Hipervolemik

• Kejang hipovolemik • Edema paru
demam • Perdarahan
masif
• Keterlibatan
organ

Warning signs! Reperfusi plasma

 Diagnosis Banding DBD fase kritis

• Leukemia akut
Keganasan • Keganasan lain

Infection lainnya

• Gastroenteritis, • Abdomen akut,

• Malaria, • Apendisitis akut
• Leptospirosis, DBD • Kolesistitis,
• Demam tifoid, • Kawasaki,
• Hepatitis virus,
fase • Asidosis laktat
• Syok septik kritis
 Penting : membedakan DD vs DBD
• DD tidak terjadi kebocoran plasma, tidak syok
• DD prognosis baik
• Perdarahan pada DD ringan
• Penting: monitor suhu saat perpindahan fase demam ke fase syok
(hari sakit ke 3-5)

Time of fever Dengue Dengue

defervescence Setelah suhu turun,
(fever ceased) • kondisi klinis baik,
• nafsu makan & minum baik

Demam Berdarah Dengue

Setelah suhu turun,
• kondisi klinis memburuk,
• asupan minum sulit
• lemas/ tidur terus
• bak berkurang
 Expanded dengue syndrome
(unusual or atypical manifestations)

• Manifestasi tidak lazim

– jarang
– neurologi (ensefalopati): kejang, spastis, penurunan
kesadaran, transient paresis
– melibatkan organ hati, ginjal, dan organ lain

• Komplikasi dari syok berat (severe profound

shock),
– ko-morbiditas
– penyakit penyerta
 Keterlibatan Organ lain
Expanded Dengue Syndrome
(unusual or atypical manifestations)

Neuro
logi Gastro
Lain hepato
logi

Mata Unusual Ginjal

manifesta
tions
Limfo
reticula/
sumsum Jantung
tulang

Muskulo Respira
skeletal si
 • Gangguan elektrolit
Komplikasi • Kelebihan cairan (fluid overload)
infeksi dengue

Expanded
Dengue
Syndrome

Manifestasi klinis
yang tidak lazim • Ensefalopati dengue
(unusual • Perdarahan hebat (massive bleeding),
manifestations) • Infeksi ganda (dual infections),
• Kelainan ginjal,
• Miokarditis
 Lansia,
Komorbid Syok
Kehamilan
berkepanjangan

Perdarahan
Obesitas nyata

Bayi
Risiko Ensefalopati
Tinggi
Kriteria diagnosis laboratorium
infeksi dengue
Pemeriksaan laboratorium
infeksi dengue

• Hematologi
• Virus isolation
• Deteksi antigen virus
• Deteksi respon imun/ uji serologi
 Hematokrit, trombosit dan limfosit atipik
(limfosit plasma biru) pada penyakit DBD

✜
Hematokrit vol%

Hematokrit

Trombosit x1000/µl
50 ✪ ✜
¤ 250
✜
✪ ✪ ✜
✪ ✜
✪
40 ✜ ✪ ¤ ¤ 200
✪ ✜ ✪
¤ ✜
30 ✪ 150
¤
¤ ✪
Trombosit
20 ¤ 100
¤ ¤
✜
10 ¤ 50
✜
Limfosit atipik
0 0

1 2 3 4 5 6 7 8 9 Hari
10 Fase demam Fase kritis Fase konvalesen of illness
 Pemeriksaan laboratorium
• 79% kasus infeksi • Transaminase: SGOT
dengue memiliki meningkat pd 90%
Leukosit < 5000/µl kasus, SGPT PD
62.8% kasus

Uji Tourniquette positif + L < 5000/µl

èNilai Duga Positif 83%

Lekopenia + limfositosis relatif + limfosit atipik

menunjukkan dalam 24 jam demam turun maka
masuk fase kritis
 Laporan kasus infeksi dengue
untuk surveillance
• Suspected dengue: Klinis dengue dengan
pemeriksaan hemokonsentrasi/ tanda
kebocoran plasma dan trombositopenia
• Probable dengue: diatas + uji serologi
antibodi IgG & IgM dengue
• Confirmed dengue: diatas + uji virologi/
serologi antigen dengue NS1/ELISA meningkat
4 kali

WHO 2011
 Uji deteksi antigen dan serologi dengue

1 2 3 4 5
9 day of fever
 Uji deteksi antigen dan antibodi dengue

• Infection primer
IgM terdeteksi lebih awal dari pada IgG / IgG pada awal tidak terdeteksi
• Infeksi sekunder
IgG terdeteksi pada awal infeksi; kadar IgM pada infeksi sekunder lebih rendah da
IgM infeksi primer
 Triage System
Patient with fever 2-7
days, to differentiate
whose patient has TRIAGE
warning signs

1. Need direct hospitalization Outpatient

2. Need closed monitor Hospitalized care
3. Treat as outpatient

Emergency + One Day Care Discharge:

Actions: treat, monitor warning signs (24 hours) for observation
& observed closed monitor during fever
Treat properly

• By use the triage system (one day care=ODC),

reduced 76% hospitalization of suspected dengue cases
• ODC is very useful in outbreak situation
Sri Rezeki Hadinegoro, Tumbelaka AR. Sari Ped 1998;1:1-4
 Priorities at the Front-Line:
the first 3 days
• Focus should be on adequacy of oral fluid
intake:
“3 Golden Questions”:
1. How much fluid intake? What types of fluids?
2. How much urine passed?
3. What activities could patient do?

• Identifying risk factors for severe disease: infants, co-

morbid conditions such as chronic hemolytic diseases,
obesity, life-style diseases, pregnancy, old age

• Home care: Fever control, Education of warning signs

Priorities at the Front-Line: the first 3 days
Follow-up on fever is important!
Time of fever defervescence

Warning signs
Better clinical manifestation
Clinical Worst in clinical
Good appetite
judgment manifestations, sign of
Good fluid intake
dehidration/hypovolemi
Fluid losses
c shock
 Suspected Dengue Infection
• Fever <7 days
• Skin rash
• Bleeding manifestations
(tourniquet test/spontaneous)
• Headache, retroorbital pain,
myalgia, arthralgia
• Leucopenia (£4000/mL)
• Dengue case in the
neighborhood

Warning signs
• No clinical improvement at afebrile phase • Bleeding tendency: epistaxis, black stool,
• Refused oral intake hematemesis,
• Recurrent vomiting menorrhagia, black color urine
• Severe abdominal pain (haemoglobinuria) or hematuria
• Lethargy, change of behavior • Giddines
• Pale, cold extrimities
• Decreased diuresis within 4-6 hours
No Yes

No • Co-morbidity Yes Hospitalization Clinical & lab follow-up

• Social indication

Send home Expanded Dengue

managed at Warning DHF DHF with
Syndrome
out patient clinic Closed signs shock
follow-up
• Organ involvement
• Complication
• Co-morbidity
• Co-infection
 Home care advice for patients
• Take adequate bed rest
• Adequate intake of fluids: milk, fruit juice, isotonic
electrolyte solution, ORS.
• Keep body temperature below 390C, give paracetamol
10-15 mg/kg/dose every 6 hours, avoid aspirin, NSAID &
ibuprofen

• Take to hospital soon

¤ Worst clinical manifestation at a-febrile phase
¤ Severe abdominal pain
¤ Recurrent vomiting,
¤ Cold hand and foot and clamp
¤ Lethargy
¤ Bleeding
¤ Dyspnea
¤ Convulsion
Laboratory examinations in
dengue infection
 Formulir pemantauan DBD
Tg Dema Ja Kesadar FN FP TD Suh LP Nyeri Hepat Diuresi Pendar Sesa Hb Ht L Tr IVFD
l m hari m an u (cm perut omeg s ahan k
ke- ) ali
52 7ml/
g/hr

48 7ml/
g/hr

46 5ml/
g/hr

Tanda vital dan diuresis dipantau setiap jam!

 A-B-C-S Examination
Abbreviation Lab exam Note
A – Acidosis Blood gas Indicate prolonged shock, multi organ failures
analysis Examined: liver function, BUN, ureum,
creatinin.
B – Bleeding Hematocrit If Ht dropped compared to previous value or
not rising, cross match for blood transfusion
soon
C – Calcium Electrolyte Ca++ Hypocalcemia always occur in all DHF cases
but asymptomatic. In severe or complicated
case is indicated.
S – Blood sugar Blood sugar Most severe cases have poor appetite and
(dextrostix) vomiting
Those with liver dysfunction hypoglycemia.
Some cases may have hyperglycemia.
Note: profound shock or have complications, and cases with no clinical improvement
 Who should get an IV Fluid?

1. Those with shock

2. Those with warning signs during the critical

phase

3. No shock and no warning signs BUT

“not able to drink enough to urinate enough”
during critical phase
When to start and stop intravenous fluid therapy

Febrile phase
Limit IV fluids (oral fluid advice)
Early IV therapy may lead to fluid overload especially with
non-isotonic IV fluid
Critical phase
IV fluids are usually required for 24 – 48 hours
NOTE: For patients who present with shock, IV therapy
should be <48 hours
Recovery phase
IV fluids should be stopped so that extravasated fluids can be
reabsorbed
 Compensated Dengue Shock Syndrome
• Give oxygen 2-4L/minute
• Check hematocrit
•Crystalloid RL/RA 10-20ml/kg.BW within 60 minutes

Yes Shock recovered No

IVFD 10ml/kg.BW, 1-2 hours Check Ht, blood gas, blood glucose,
calcium, bleeding (ABCS)
Correction soon for acidosis,
hypoglycemia, hypocalcaemia
Stabile,
Decreased IVFD gradually
7, 5, 3 , and 1,5 Ht increased Ht decreased
ml/kg.BW/hour
2nd bolus for crystalloid
Or colloid 10-20ml/kg.BW Bleeding
within 10-20 minutes Unclear
Stop IVFD
maximal 48 hours
after shock recover Colloid 10-20ml/kg.BB
within 10-20menit, if shock Blood transfusion
persist suggested blood
transfusion UKK IPT 2014, WHO 2011
 Decompensated Dengue Shock Syndrome
• Give oxygen 2-4L/minute
• Examine hematocrite, blood gas, blood glucose, calcium, bleeding
(ABCS)
• Crystalloid or colloid 10-20ml/kg.BW within 10-20 minutes
Yes Shock recovered No

IVFD 10ml/kg.BW, 1-2 hours Evaluated Ht, blood gas, blood glucose,
calcium, bleeding (ABCS)
Correction soon for acidosis,
Stabile, hypoglycemia, hypocalcaemia
Decreased IVFD gradually
7, 5, 3 , and 1,5 Ht increased Ht decreased
ml/kg.BW/hour
2nd bolus for crystalloid
Or colloid 10-20ml/kg.BW Bleeding
within 10-20 minutes Unclear
Stop IVFD
maximal 48 hours
after shock recover Colloid 10-20ml/kg.BB
within 10-20menit, if shock Blood transfusion
persist suggested blood
transfusion UKK IPT 2014, WHO 2011
HOW MUCH & HOW FAST to run intravenous fluid?

Child
Compensated shock: 10 to 20 ml/kg over 1 hour
Decompensated shock: 20 ml/kg over 15 to 30 minutes
AFTER correction of shock:
REDUCE IV infusion rate in step-wise manner whenever:
• Haemodynamic state is stable
• Rate of plasma leakage decreases towards end of
critical phase/ hematocrite decreases 2 times serial

indicated by:
Improving haemodynamic signs
Increasing urine output
Adequate oral fluid intake Haematocrit decreases below
baseline value in a stable patient
Lum L. Dengue symposium,Bangkok 2014, WHO 2011
 When to stop intravenous fluids?
Plasma leakage is self-limiting

Knowing when is critical to dengue management

Step-wise reduce IV infusion rate until it is stopped, same as
in earlier slide.
Definitely stop:
1. Features of intravascular compartment overload
a. Oedema palpebra
b. Breathing difficulties, pulmonary oedema
c. Hypertension with good volume pulse
2. 48 hours after defervescence

Lum L. Dengue symposium,Bangkok 2014, WHO 2011

 Colloid therapy in dengue shock

When are colloids given?

1. Decompensated shock1,2,3
2. Repeated shock – 2nd or 3rd shock and onwards
3. After >20 to 30 ml/kg of crystalloids
4. HCT does not decrease after crystalloid
administration in shock state

DOSE: Limited to 30 ml/kg/day

1 Dung NM, Day NP, Tam DT. Clin Infect Dis, 1999, 29:787–794; 2 Ngo NT, Cao XT, Kneen R. Clin Infect Dis,
2001, 32:204–213. 3 Wills BA et al. N Engl J Med, 2005, 353:877–889.
 Kriteria Memulangkan Pasien
• Tidak demam selama 24 jam tanpa antipiretik
• Nafsu makan membaik
• Klinis membaik
• Diuresis > 1 ml/kgBB/jam
• Jumlah trombosit meningkat (>50.000/ul)
• Hematokrit stabil
• Tidak ada distres pernafasan
• Rash convalesence atau gatal pada ekstremitas
 Take home message
• Diagnosis dini dan tata laksana DBD yang
adekuat mencegah kematian
• Pemantauan klinis dan laboratorium berkala
dengan tanda2 bahaya penting
• Pemeriksaan penunjang infeksi dengue adalah
antigen NS1 dengue (<5 hari) atau uji serologi
antibodi IgG dan IgM dengue (> 5 hari)
TERIMA KASIH