Management Dengue

Infection
(WHO
Guideline,2009&2011)
Winarko Luminturahardjo
RS Panti Nirmala Malang
Santika Hotel, 22 Nopember
2014

Countries/areas at risk of dengue transmission,2008

PREVALENSI DF/DHF DI DUNIA

(WHO 2009)

FAKTOR YANG
BERPENGARUH
Viral : Virulensi, Viral Load
Host : Penyakit kompleks imun
Diperantarai oleh sel T
ADE,Komplemen
Penyakit autoimun
Apoptosis
Imunitas alamiah
Tsunami sitokin
Faktor genetik
Vector: Ae.aegypti, Ae.albopictus
Environment: Artificial container

ENDOTHELIAL
Dysfunction

Pathogenesis

Pathogenesis

Leakage

Symptomatic dengue virus infections were groups:

Undifferentiated fever
Dengue fever (DF)
Dengue haemorrhagic fever (DHF)
DHF, classified into four severity grades :
Grades III and IV being defined as Dengue
Shock Syndrome (DSS)

Evidence of plasma leakage manifested by at least one of

the following:
a rise in the haematocrit equal or greater than 20% above
average for age, sex
and population
a drop in the haematocrit following volume-replacement
treatment equal to
or greater than 20% of baseline
signs of plasma leakage such as pleural effusion, ascites, and
hypoproteinaemia.

Anon S. Plasma leakage in dengue haemorrhagic fever. Thromb. Haemost. 2009;

WHO,1997

Conditions that mimic the febrile phase of dengue infection

Flu-like syndromes
Chikungunya,

Influenza, measles,
infectious mononucleosis

, HIV
seroconversion illness
Rubella, measles,

Illnesses with a rash

scarlet fever,

meningococcal
infection, Chikungunya,
Diarrhoeal diseases
enteric infections
Illnesses with neurological manifestations
Febrile seizures

drug reactions
Rotavirus, other
Meningo/encephalitis,

Conditions that mimic the critical phase of dengue infection

Infectious
leptospirosis, typhoid, typhus,

Acute gastroenteritis, malaria,

viral hepatitis, acute HIV seroconversion

illness, bacterial
Malignancies
malignancies

sepsis, septic shock

Acute leukaemia and other

KRITERIA DENGUE (WHO

1997)

Demam tinggi mendadak, berlangsung 2-7

hr, pola demam spt punggung pelana kuda
Kecenderungan perdarahan, dibuktikan
dgn sedikitnya 1 hal sbb:
1.Uji bendungan positif
2.Bintik perdarahan spontan di kulit,
berupa: ptekiae, atau ekimosis/purpura
3.Perdarahan
spontan
spt:
mimisan,
perdarahan
gusi
sampai
hematemesis/melena

 Jumlah trombosit sp<100.000 sel/mm3

Tdp minimal satu dari tanda2 plasma
leakage akibat peningkatan kapiler:
1. Ht meningkat >20% dibanding Ht
rata2 usia, sex dan populasi yg sama
2. Ht turun >20% dp Ht awal setelah
pemberian cairan
3. Tdp tanda2 perembesan plasma
spt:
efusi
pleura,
asites,
hipoalbuminemia, dsb

DERAJAT BERAT DENGUE

(WHO 1997)

Derajat I
Demam mendadak tinggi dg gejala lain tak jelas
disertai bintik2 perdarahan pd uji bendungan
Derajat II
Derajat I disertai perdarahan spontan
Derajat III
Derajat II ditambah tanda2 kegagalan sirkulasi:
denyut kecil, cepat, lemah, TD rendah, kulit dingin
Derajat IV
Syok
berat:
nadi
lemah+cepat,tek
nadi
menyempit

Revised Dengue Classification (WHO 2009)

Dengue Warning Sign
Without
Warning Sign

With

Severe Dengue
1. Severe plasma leakage
2. Severe hemorrhage
3. Severe organ impairment

- Severe plasma leakage leading to:

Warning
signs*
Probable
Dengue
:
Live
in /travel to dengue
* Shock (DSS)
Abdominal
pain or tenderness
endemic area.
* Fluid accumulation with respiratory
Persistent vomiting
Fever and 2 of the following
Clinical fluid accumulation
criteria:
Nausea,
vomiting bleed
distress
Mucosal
Rash
- Severe bleeding as evaluated by
Lethargy, restlessness
Aches and pains
clinician
Liver enlargment
Tourniquet
test positive >2 cm
- Severe organ involvement:
Laboratory: increase in HCT
Leukopenia
Any warning sign concurrent with rapid * Liver: AST or ALT 1000
* CNS: Impaired consciousness
* Heart and other organs
in platelet count
*(requiring strict observation and medical
Laboratory-confirmed dengue (important when no sign of
intervention)
plasma
leakage)
decrease

KLASIFIKASI (WHO 2011)

1997

2009

2011

Dengue
Fever

Dengue without
warning sign

Dengue Fever

DHF grade I

Dengue with warning

sign

DHF grade I

DHF grade II
DHF grade III
DHF grade IV

Severe dengue :
without
hypovolemic shock
with hypovolemic
shock

DHF grade II
DHF grade III
DHF grade IV

EXPANDED
DENGUE
SYNDROME

Laboratory Investigation

Laboratory Investigation

Step I. Overall assessment

I.1 History, including information on symptoms, past medical and family
history
I.2 Physical examination, including full physical and mental assessment
I.3 Investigation, including routine laboratory and dengue-specific
laboratory

Step II. Diagnosis, assessment of disease phase and severity

Step III. Management
III.1 Disease notification
III.2 Management decisions. Depending on the clinical manifestations and
other circumstances, patients may:
be sent home (Group A);
be referred for in-hospital management (Group B);
require emergency treatment and urgent referral (Group C).

Referral centres
Referral Criteria :
early presentation with shock (on days 2 or 3 of
illness);
severe plasma leakage and/or shock;
undetectable pulse and blood pressure;
severe bleeding;
fluid overload;
organ impairment (such as hepatic damage,
cardiomyopathy,
encephalopathy, encephalitis and other unusual
complications).

Admission criteria :
Warning signs

Any of the warning signs

Signs and symptoms

tolerate oral fluids
related to hypotension
perpsiration, fainting,
(possible plasma leakage)
hypotension or cold

Dehydrated patient, unable to

Postural Hypotension, Profuse
prostration during defervescence,
extremities

Bleeding
of the platelet count

Spontaneous bleeding, independent

Organ impairment
cardiac

Renal, hepatic, neurological or

enlarged, tender liver, although

not yet in shock

chest pain or respiratory distress,
cyanosis
Findings through
Rising haematocrit, pleural
effusion,ascites or further investighation

HIGH RISK PATIENTS

(2011)
Infants and the elderly
Obesity
Pregnant woman
Peptic ulcer disease
Woman who have menstrual or abnormal
bleeding
Hemolytic disease
Thalassemia and other hemoglobinopathies
Congenital heart disease
Chronic disease (DM, hypertension, asthma,
ischemic heart disease, etc)
Chronic renal failure, liver cirrhosis

Treatment of Dengue
Fever

Continue monitoring after defervescence

If any doubt, provide intravenous fluids,
guided by serial hematocrits, blood
pressure, and urine output
The volume of fluid needed is similar to
the treatment of diarrhea with mild to
moderate isotonic dehydration (5%-8%
deficit)

Pan American Health Organization: Dengue and Dengue Hemorrhagic Fever : Guidelines for Prevention and
Control. PAHO: Washington, D.C., 1994: 67.

Rehydrating Patients Over 40

kg

Volume required for rehydration is twice the

recommended maintenance requirement
Formula for calculating maintenance volume:
1500 + 20 x (weight in kg - 20)
For example, maintenance volume for 55
kg patient is: 1500 + 20 x (55-20) = 2200
ml
For this patient, the rehydration volume
would be 2 x 2200, or 4400 ml

Pan American Health Organization: Dengue and Dengue Hemorrhagic Fever : Guidelines for
Prevention and Control. PAHO: Washington, D.C., 1994: 67.

Kristaloid

Colloid

TATALAKSANA KASUS DBD DERAJAT III & IV

(SSD) (EIMED 2012)

Problems in Dengue Infection Mild to Severe Clinical Manifestation

There is evidence of plasma leakage, such as:
high or progressively rising haematocrit;
pleural effusions or ascites;
circulatory compromise or shock
(tachycardia, cold and clammy extremities, capillary refill time
> 3, weak or undetectable pulse, narrow pulse pressure or, in
late shock, unrecordable blood pressure).

Only Fluids !!!!

There is significant bleeding.

There is an altered level of consciousness (lethargy or restlessness,coma,

convulsions).
There is severe gastrointestinal involvement (persistent vomiting,
increasing or intense abdominal pain, jaundice).
There is severe organ impairment (acute liver failure, acute renal failure,
cardiomyopathy,encephalopathy or encephalitis, or other unusual
manifestation)

What are the effects of supportive treatments for dengue

haemorrhagic fever or dengue shock syndrome in adult?

Clinical Evident BJM

Colloid

(DepKes RI)

1. Gelatin ( Gelofusin , Gelafudin , Haemaccel )

2. HES BM 130,000 Da (Tetrastarch, Voluven )
3. HES BM 200,000 Da (Haes Steril 6% / 10% , Firma Hes

Wida Hes)

4. HES BM 40,000 Da
5. Dextran 6% (Dextral )
6. Dextran 10%

(Expafusin)

, Hemo Hes,

There are 4 types of colloid products available for

clinical use:
albumin,
dextrans,
starchesStarches
and gelatins
Nature
Dextrans
Gelatins
Colloid
Markets

Albumin

Dextran 40

Dextran 70

Hetastarch
(6%)

Molecular
weight
(KD)
Plasma
volume
expansion
(ml/500ml
infused)
Cost (US $)
per litre
(in )
Incidence of

Haemacel
Pentastarch

70

40

70

450

260

35

500

500-1000

500-700

500-700

600-800

500

360

200

150

130

150

15-20*

0.011

1.1

1.1

0.09

Not available

0.06

allergic
reactions
Effect on
clotting
Comment

v. mild,
dilutional

Decreases in
von Willebrands
Increase in PT
v. mild,
factor
and APTT
dilutional
Decreases
Increases
Prolongs
blood
viscosity
blood
viscosity
bleeding
timeRJC N et al. Colloid Study in Kenya. 20
Samuel A, Samson G, Richard I, Greg F, Chi E, Charles

Characteristics of various different colloids used for plasma volume

support.
Colloid

Initial volume

Duration of volume Adverse effect

Allergic Other

significant
expansion (%)*

effect (hours)

on coagulation potential

side

effects

3% Gelatin
+

6080

34

+/

(MW = 35,000)

10% Dextran 40 170180

+
Renal failure in
(MW = 40,000)

46

++

68

++

hypovolaemic patients

6%
Dextran70
HES=Hydroxyethylstarch
+

100140

(MW = 70,000)

6% HES (Wida HES)100140

+/
(MW = 200,000/0.5)

68

Scott B H. Dengue. 200

Supportive care and adjuvant therapy in severe

dengue.
Renal Replacement Therapy, with a preference to continuous venovenous haemodialysis (CVVH), since peritoneal dialysis has a risk of
bleeding
Vasopressor and inotropic therapies as temporary measures to prevent
life-threatening hypotension in dengue shock and during induction for
intubation, while correction of intravascular volume is being vigorously
carried out
Treatment of organ impairment, such as severe hepatic involvement or
encephalopathy or encephalitis;
Treatment of cardiac abnormalities, such as conduction abnormalities,
may occur (the latter usually not requiring interventions).

Discard creteria
Clinical

No fever for 48 hours.

Improvement in clinical status (general wellbeing, appetite, haemodynamic status, urine
output, no respiratory distress).

Laboratory

Increasing trend of platelet count( >50000/mm3)

Stable haematocrit without intravenous fluids.