• 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 TATALAKSANATERKINI
DEMAM BERDARAHDENGUE
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
2. Oral intake
3. Urine output
Capillary permeability
Organ Impairment
Laboratory
changes Platelet
4. WBC WBC
5. Platelet
Haematocrit
6. HCT
IgM/IgG
Viraemia
Pada KLB:
Demam tinggi
Tourniquet positif
atau petekie
Leukopenia (<5000)
PPV 83%
DBD Eksantema
Infeksi SSP fase Akut
demam
Penyakit
• Infeksi enterik diare
• Rotavirus
“Warning Signs”
• Tidak ada perbaikan klinis • Perdarahan : epistaksis,
• Asupan minum sulit hematemesis, melena,
menoragia,
• Muntah terus
hemoglobinuria or
• Nyeri perut hematuria
• Letarg, perubahan • Giddines
perilaku
• Diuresis menurun
• Pucat, tangan dan kaki
dingin, lembab
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)
• Takikardia • Asidosis
• Diastolik Syok • Hipotensi metaboli
Syok meningkat berkepanjangan Profoun k berat
terkom tanpa dekom
pensasi • Hipoksia d • Multi organ
pensasi peningkata shock failure
n sistolik
Gangguan koagulasi
Trombositipenia Perdarahan masif (akibat DIC)
• Leukemia akut
Keganasan • Keganasan lain
Infection lainnya
• Gastroenteritis, • Abdomenakut,
• Malaria, • Apendisitis akut
• Leptospirosis, DBD • Kolesistitis,
• Demamtifoid, • Kawasaki,
• Hepatitisvirus, fase • Asidosis laktat
• Syok septik kritis
Penting : membedakan DD vsDBD
• 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)
Neuro
logi Gastro
Lain hepato
logi
Muskulo Respira
skeletal si
• Gangguanelektrolit
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
Perdaraha
Obesitas n 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%
Trombosit x1000/l
50 Hematokrit ✪ 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
Pemeriksaan laboratorium
• 79% kasus infeksi • Transaminase: SGOT
dengue memiliki meningkat pd 90%
Leukosit < 5000/l kasus, SGPT PD
62.8% kasus
WHO 2011
Uji deteksi antigen dan serologidengue
1 2 3 4 5
9 day of fever
Uji deteksi antigen dan antibodidengue
• 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
Warning signs
Better clinical manifestation
Clinical Worst in clinical
Goodappetite
judgment manifestations, sign of
Goodfluid intake
dehidration/hypovolemi
Fluid losses
c shock
Suspected Dengue Infection
• Fever <7 days • Headache, retroorbital pain,
• Skin rash myalgia, arthralgia
• Bleeding manifestations • Leucopenia (4000/mL)
(tourniquet test/spontaneous) • 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
Send home
Warning DHF DHF with Expanded Dengue
managed at 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
52 7ml/
g/hr
48 7ml/
g/hr
46 5ml/
g/hr
Febrile phase
Limit IV fluids (oral fluidadvice)
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
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
indicated by:
Improving haemodynamic signs
Increasing urine output
Adequate oral fluid intake Haematocrit decreasesbelow
baseline value in a stablepatient
Lum L. Dengue symposium,Bangkok 2014, WHO 2011
When to stop intravenous fluids?
Plasma leakage is self-limiting
Definitely stop:
1. Features of intravascular compartmentoverload
a. Oedema palpebra
b. Breathing difficulties, pulmonary oedema
c. Hypertension with good volumepulse
2. 48 hours afterdefervescence
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 JMed, 2005, 353:877–889.
Kriteria Memulangkan Pasien
• Tidak demam selama 24 jam tanpaantipiretik
• 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 padaekstremitas
Take home message
• Diagnosis dini dan tata laksana DBD yang
adekuat mencegah kematian
• Pemantauan klinis dan laboratoriumberkala
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