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
 Current updates on
diagnosis and management of
dengue infection in children

Mulya Rahma Karyanti, MD, MSc

Division of Infection and Tropical Pediatrics,

Departemen of Pediatrics, Cipto Mangunkusumo hospital, Universitas Indonesia
 Outline
• Diagnosis dengue classification
• Body water composition
• Change body water composition in dengue
• Fluid therapy in dengue
• Evidence based medicine studies
 WHO 2011 dengue classification

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.
 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
 WHO 2009 dengue classification

DENGUE Warning Signs SEVERE DENGUE

With 1.Severe plasma leakage

Without Warning 2.Severe haemorrhage
Signs 3.Severe organ
impairment

Presumptive Diagnosis Warning Signs* 1. Severe plasma leakage leading

•Fever •Abdominal pain or tenderness to
•Anorexia and nausea •Persistent vomiting •Shock (DSS)
•Rash •Clinical fluid accumulation •Fluid accumulation with
•Aches and pains •Mucosal bleed respiratory distress
•± Warning signs •Lethargy; restlessness 2. Severe bleeding
•Leucopenia
•Liver enlargement >2cm as evaluated by clinician
•Tourniquet test +
•Laboratory: Increase in HCT 3. Severe organ involvement
Neighbourhood dengue/history concurrent with rapid decrease §Liver: AST or ALT>=1000
of travel to dengue endemic area in platelet count §CNS: Impaired consciousness
§Heart and other organs

* Requiring strict observation and medical intervention

 Dengue with/without
Warning Signs
• Pasien tinggal di daerah endemik dengue atau baru
kembali dari daerah endemik dengue
• Demam dan 2 dari kriteria:
• Mual, disertai muntah
• Ruam
• Nyeri pada tulang, sendi, retro-orbital
• Uji torniket positif
• Leukopenia
• Gejala lain yang termasuk dalam warning signs
• Hasil laboratorium terbukti dengue (penting jika tidak ada
kebocoran plasma)
 Warning Signs
1. Nyeri perut
2. Muntah terus menerus
3. Penumpukan cairan
4. Perdarahan mukosa
5. Letargi/gelisah
6. Pembesaran hati ≥ 2 cn
7. Parameter laboratorium: Peningkatan HCT yang terjadi
bersamaan dengan penurunan angka trombosit dengan
cepat
Membutuhkan monitor yang cermat
Severe Dengue
Severe plasma leakage
• Akan menyebabkan syok hipovolemik (DSS)
• Dan atau penimbunan cairan disertai distress pernapasan

Severe bleeding
• Perdarahan disertai hemodinamik yang tidak stabil sehingga memerlukan
pemberian cairan pengganti dan atau transfusi darah
• Hematemesis, melena, perdarahan lain

Severe organ involvement

• Hati: SGOT atau SGPT 1000
• Keterlibatan sistem saraf pusat
• Jantung dan organ lain
 Dengue classification based
International Classification of Disease
ICD-10 use dengue classification WHO1997
• A90: Demam fever
• A91: Dengue Hemorrhagic Fever

A91 & R57 : DBD & syok hipovolemik

A91 & K92.2 : DBD & perdarahan saluran cerna

A91 & G93.41 : DBD & ensefalopati

 Dengue classification based
International Classification of Disease
ICD-11 use dengue classification WHO2009
ICD-11 has been released on June 18, 2018.
It was presented at the World Health Assembly in May 2019
and will come into effect on January 1, 2022
ICD-11 will have an impact on coding in all specialties.

https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1435254666
 Guideline Dengue WHO
WHO SEARO
WHO 1997 WHO TDR 2009 2011

Dengue without warning

Dengue fever Dengue fever
signs
DHF grade I DHF grade I
Dengue with warning
DHF grade II signs DHF grade II

DHF grade III DHF grade III

Severe dengue
DHF grade IV
(severe plasma leakage,
hemorrhage, organ Expanded dengue syndrome
DHF grade IV involvement) (unusual manifestation,
organ involvement, co-
morbidity)
Adult Management Adult Management
 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
 Laboratory diagnosis of Dengue

• Primer infection
IgM detected earlier than IgG or in the beginning of infection no IgG was detected
• Secondary infection
IgG detected at the beginning of infection; IgM titer sec infection <IgM primary infection
Body water composition
Distribution water in the body

Percentage based body weight and age

 PERCENTAGE TOTAL BODY WATER
BASED BODY WEIGHT

Extracellular Intracellular
20-25% 30-40%
285
Osmolality

Plasma Interstitial Intracellular Transcellular

mOsm

5% 15% 30-40% 2%

0
Connecti
ve tissue,
bone 8%

Nelson, 2000
 Physiology of normal fluid balance
Total body water (TBW)
60% body weight

Extracellular fluid (ECF) Intracellular fluid (ICF)

33% TBW 67% TBW
Na+ = 145 mmol/L Na+ = 12 mmol/L
K+ = 4 mmol/L K+ = 150 mmol/L

Cell membrane, permeable to water but not most

ions or protein
Intertitial fluid Intravascular fluid/ plasma
75% ECF 25% ECF (5%-8% TBW), Protein +++
Protein +/-
Capillary wall, permeable to water & ions, but
not most protein
Change body water composition in dengue

Water, electrolytes
n n
n n
n
n n n Albumin
n
n
n n n
n n

Extracellular fluid ¯
Hemoconcentration
Blood viscosity ­
Decreased of Blood flow ¯
oncotic pressure Hypovolemia/shock
Peripheral perfusion ¯
DIC
 “Warning Signs”
• No clinical improvement at
a-febrile phase
• Refused oral intake
• Recurrent vomiting
• Severe abdominal pain
• Lethargy, change of behavior
• Pale, cold hand and foot
• Bleeding tendency:
epistaxis, black stool,
hematemesis, menorrhagia
haemoglobinuria or
hematuria
• Giddines
• Decreased diuresis within 4-
6 hours

Early shock detection

 Fluid therapy in dengue
Crystalloid Colloid
Hipertonik Hiperonkotik
Isotonik
Isoonkotik
Hipotonik

Ringer Laktat Dextran

Ringer Asetat Gelatin
NaCl 0.9% HES
 General principles of fluid therapy
• Isotonic crystalloid solutions, except < 6 months
0,45% sodium chloride may be used
• Colloid solutions may be used if not responding
to crystalloid
• Dengue without shock given a volume of about
maintenance + 5-10% dehydration
• Plasma leakage duration 24-48 hours
• In obese, use ideal body weight to calculate fluid
volume

WHO SEARO 2011

Rate of IV fluid in children and adults
Note Children rate Adult rate
(ml/kg/hour) (ml/hour)
Half the 1.5 40-50
maintenance M/2
Mauntenance (M) 3 80-100

M + 5% deficit 5 100-120

M + 7% deficit 7 120-150

M + 10% deficit 10 300-500

WHO SEARO 2011

 Evidence base medicine studies
• Comparison of ringer lactate (RL), normal saline, 3%
gelatin and dextran 70 in 50 children aged 5-15 years
with dengue shock showed no difference in
occurrence/duration of shock
Dung NM, et al. Clinical Infectious Diseases 1999;29:787-94

• A randomized blinded comparison of 4 fluids

(Dextran 70, gelafundin, RL and 0,9% saline) for
initial resuscitation of 230 children with DSS showed
that there was no clear advantage to using any 4
fluids, but longest recovery times occurred in RL
group
Nhan NT, et al. Clinical Infectious Diseases 2001;32:204-13
 Evidence base medicine studies
• A double-blind, randomized comparison of 3
fluids for initial resuscitation in 383 children with
DSS showed that RL is indicated for moderately
severe DSS, dextran 70 & 6% HES perform no
difference in severe shock
Will BA, et al.New England Journal of Medicine 2005;353:877-89

• For children with DSS, there is no evidence colloids

are superior to crystalloids for initial resuscitation
Smart K, Safitri I. J Trop Ped. 2009;55:145-7
 Evidence base medicine studies
• First-choice fluid resuscitation in neonates and
children with hypovolemia should be isotonic saline
Boluyt N, et al. Intensive Care Med. 2006;32:995-1003

• Treatment and outcome of DHF is optimized by early

recognition and cautious titrated fluid replacement
Ranjit S, Kissoon N. Pediatr Crit Care Med. 2011;12:90-100
 Evidence base medicine studies
• Systematic review: no sufficient evidence to inform
the preferential use of either colloids/ crystalloids for
treating pediatric shock

Akech S, et al. BMJ. 2010;341:4416

 Evidence base medicine studies
• Aggressive management of dengue shock syndrome
decrease mortality rate.
Ranjit S, et al. Pediatr Crit Care Med. 2005;6(4):490-2.

• Both colloid of HES 10% and 10% dextran-40 in

severe DHF were safe and no allergic reaction
observed, no interference in renal functions and
hemostasis.
Kalayanooj S. J Med Assoc Thai. 2008;91:s97-103.
 Tatalaksana Dengue
Step 1: Anamnesis

Step 2: Pemeriksaan Fisik

Step 3: Investigasi

Step 4: Assessment (diagnosis & fase + severity)

Step 5: Keputusan tatalaksana

GRUP A GRUP B GRUP C

Rawat jalan Rujuk untuk MRS Rujuk segera untuk
Tx emergensi
 Tatalaksana Dengue

Anamnesis Pem. fisik Investigasi Assessment

• Riwayat • Status mental • CBC • Dengue atau

demam • Status • Khusus: Hb, bukan
• Tanda dan hemodinamik leko, Ht, • Fase
gejala • Status hidrasi Trombo • Status hidrasi
• Warning signs • Uji diagnostik • Warning signs
dengue spesifik
• Tanda dan • Status
gejala plasma • Lain2: LFT, hemodinamik
leakage atau Ur/Cr,
perdarahan elektrolit, GDS
 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, hematemesis,
• Refused oral intake menorrhagia, black color urine (haemoglobinuria) or
• Recurrent vomiting hematuria
• Severe abdominal pain • Giddines
• Lethargy, change of behavior • Pale, cold extrimities
• Decreased diuresis within 4-6 hours

No Yes

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

Hospitalization
• Social indication

Send home Warning DHF DHF with Expanded Dengue

managed at Closed signs shock Syndrome
out patient follow-up
• Organ involvement
clinic • 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
 Tatalaksana Dengue
GRUP A (seluruhnya)
• Asupan oral adekuat
• Berkemih tiap 4-6 jam sekali
• Tidak terdapat warning
signs
• Hematokrit dan status
hemodinamik stabil
• Tidak terdapat kondisi
penyerta
1. Berikan panduan antisipatif
sebelum pasien
dipulangkan
2. Pantau setiap hari
3. Lakukan CBC serial
4. Identifikasi dini warning
signs
GRUP B (salah satu)
• Terdapat warning signs
• Terdapat kondisi penyerta:
DM, gagal ginjal, bayi atau
orang tua
• Terdapat kendala sosial:
hidup sendiri atau tempat
tinggal jauh
1. Rawat inap
2. Pantau status hemodinamik
sesering mungkin
3. Gunakan Ht untuk
memandu intervensi
4. Gunakan cairan isotonis
secara bijak
5. Koreksi asidosis metabolik,
elektrolit atas indikasi
GRUP C (salah satu)
• Plasma leakage hebat
disertai syok dan/atau
akumulasi cairan disertai
gangguan pernapasan
• Pendarahan hebat
• Kerusakan organ parah:
• AST atau ALT ≥1000
dan/atau gangguan
kesadaran
Memerlukan perawatan
darurat dan rujukan segera
WHO 2009
 Penilaian Hemodinamik – Parameter Klinis
Parameter' Sirkulasi'Stabil' Shock'Terkompensasi'
Tingkat( Sadar(penuh( Sadar(penuh( 3a.(Perfusi(otak(normal(
kesadaran(
CRT( Cepat((<2(de6k)( Memanjang((>2(de6k)(
Ekstremitas( Hangat(dan(merah( Perifer(dingin(
muda( (Perfusi(perifer(
(warna,(suhu)( menurun(
Volume(nadi( Volume(baik( Lemah(dan(kecil(
perifer(
Frek(nadi( FN(normal(sesuai(usia( Takikardi(sesuai(usia(
Tekanan(nadi( TN(normal(sesuai(usia( Tek(sistolik(normal(
Cardiac(output(
Tek(diastolik(meningkat(
menurun(
Tekanan(darah( TD(normal(sesuai(usia( TN(menyempit(
Hipotensi(postural(
Frek(napas( FP(normal(sesuai(usia( Takipneu( Asidosis(jaringan(
Diuresis( Normal( Tren(menurun( Perfusi(ginjal(menurun(
 Pearls dalam pemeriksaan klinis pasien dengue

Pegang tangan pasien untuk mengevaluasi perfusi perifer

Selamatkan jiwa dalam 30 detik dengan mengenali shock
 Penilaian Hemodinamik – Parameter Klinis

Parameter
Tingkat
3a. Perfusi organ (otak)
kesadaran
CRT
Ekstremitas Pegang tangan
1. Perfusi perifer
(warna, suhu)
pasien
Volume nadi 5 in 1 magic touch
perifer CCTV-R
Frek nadi
Tekanan nadi 2. Cardiac output
Tekanan darah
Frek napas 4. Kompensasi pernapasan untuk hipoksia jaringan
Diuresis 3b. Perfusi organ (ginjal)
 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
 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
 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,
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
 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.
 Distribution of crystalloid and colloid
Crystalloid Colloid

IC
Colloid fill in the
intravascular space
differently from
crystalloid
IS

Blood vessel (IV) Blood vessel (IV)

Sodium (Na+) Cloride (Cl) Koloid

 Colloid solution
Characteristic of various different colloids
used for plasma support
Characteristic of Initial volume Duration vol Adverse effect Allergic Other
colloid solution expansion effect (hours) on coagulation potential significant
side effect
3% Gelatin 60-80 3-4 +/- ++
MW 35.000
10% Dextran40 170-180 4-6 ++ + Renal
MW 40.000 failure
6%Dextran70 100-140 6-8 ++ +
MW 70.000
6% HES 100-140 6-8 + +/-
MW 200,000/0.5
6% HES 80-100 12-24 ++ +
MW 400,000
Wills B. Management of Dengue. In: Dengue, Halstead SB, 2008
MFG / Succinylated Gelatin 4% = Gelofusine®
 Pearls: How to recognize severe bleeding
Determine if the patient has UNSTABLE haemodynamic status
NOTE: If NO clinical improvement with reduced HCT, think significant occult bleeding

Any ONE of the following:

1. Abdominal distention and pain increase

2. Massive bleeding, regardless of the HCT level
3. A decreased HCT after fluid resuscitation, especially with colloids
4. Decompensated shock with low/normal HCT before fluid resuscitation
5. Refractory shock
6. Persistent metabolic acidosis

Remember that clinical signs come as a “package”. Mostly likely,

more than one of the above will be observed.
Group and CROSS MATCH for all dengue SHOCK (esp Decompensated) patients at admission
Lum L. Dengue symposium,Bangkok 2014
 Emergency treatment
of haemorrhagic complications

Give: 5–10 ml/kg of fresh packed red blood cells or

10–20 ml/kg of fresh whole blood at appropriate rate
Reduce colloid/crystalloid infusions

What is a good clinical response?

• Improving haemodynamic state – vital signs, peripheral
perfusion and urine output
• Improving acid-base balance

When should you consider repeating blood transfusion?

1. Further blood loss

2. Unstable haemodynamic state

Lum L. Dengue symposium,Bangkok 2014, WHO 2011

 Thrombocyte transfusion indication
• Severe bleeding (gastrointestinal bleeding,
metrorrhagia)
• Together with Fresh frozen plasma (+PRC if
necessary)
• Low platelet count with stable vital signs not
indicated
• Not indicated for prophylactic

Sellahewa KH. Dengue Bulletin 2008;32:211-8.

Thomas L,et al. Transfusion:49:1400-11
 High risk group
Underlying
diseases/
comorbid Prolonged
Pregnancy
shock

Obese Significant
patients bleeding

High
Infants, elderly risk Encephalopathy
group

UKK IPT 2014, WHO 2011

 Fluid management in dengue infection
NO plasma leakage Plasma leakage

Dengue fever/ DHF non-shock/ DHF shock/

Dengue without WS Dengue with WS Severe dengue

Oral or maintenance Maintenance + Loading crystalloid of

(Dextrose 5%:NS=3:1) deficit 5-10% 20 ml/kgBW,followed
(crystalloid) by colloid if
necessary, then
reduce by titration

Adequate fluid therapy gives good response without inotropics

 Hematocrit
Summary of Monitoring AndinDengue
IV fluid therapy dengue

Inadequate Adequate Excessive

Hypovolaemia Improved circulation Fluid overload:

and tissue perfusion • Pulmonary oedema
Compensated shock • Respiratory distress
•Worsening pleural effusion
• Capillary refill <2 seconds
Decompensated • Normal heart rate and ascites
shock • Normal blood pressure • Clinical deterioration
• Normal pulse pressure
• Urine 0.5ml/kg/hr
• Bleeding
• ¯ HCT to normal
• DIC • Improving acid-base
• Multi-organ failure
 Criteria to send home
• No fever 24 hours without antipyretic
• Clinical improvement
• Good appetite
• Thrombocyte > 50.000/uL
• Hematocrit stable
• No respiratory distress
• No bradicardia
• Rash convalescense or itchy
 Take home message
• Early diagnosis and prompt treatment prevent
deaths
• Awareness of warning signs in dengue cases
before developing to shock is important
• No evidence colloid is superior than crystalloid
for initial resuscitation in children
• Dynamic situation means frequent assessment
and adjustment according to patient response
or lack of response
THANK YOU