UPDATNG OFUPDATNG OFDENGUE SHOCK MANAGEMENTDENGUE SHOCK MANAGEMENT
UPDATNG OFUPDATNG OFDENGUE SHOCK MANAGEMENTDENGUE SHOCK MANAGEMENT
Djatnika SetiabudiDjatnika Setiabudi
DEPARTMENT OF PEDIATRICSDEPARTMENT OF PEDIATRICS
HASAN SADIKIN GENERAL HOSPITALHASAN SADIKIN GENERAL HOSPITAL
BANDUNGBANDUNG
Djatnika SetiabudiDjatnika Setiabudi
DEPARTMENT OF PEDIATRICSDEPARTMENT OF PEDIATRICS
HASAN SADIKIN GENERAL HOSPITALHASAN SADIKIN GENERAL HOSPITAL
BANDUNGBANDUNG
Introduction Introduction (1)(1)
Dengue infection : Dengue infection : Public Health Problem in Public Health Problem in Tropics & Sub-tropicsTropics & Sub-tropics
Guiness World Records 2002 :Guiness World Records 2002 : most important viral hemorrhagic fever & most important viral hemorrhagic fever &
most geographically wide-spread of most geographically wide-spread of Arbovirus diseasesArbovirus diseases
DSS : DSS : causes a significant number of causes a significant number of childhood deathschildhood deaths
Introduction Introduction (2)(2)
Mortality rateMortality rate Indonesia Indonesia - 1968 : 41,3 % - 1984 : 3,0 %- 1968 : 41,3 % - 1984 : 3,0 % - 1998 : 1,9 % - 2003 : - 1998 : 1,9 % - 2003 : ++ 2,0 % 2,0 % Queen Sirikit National Institute of Child Queen Sirikit National Institute of Child
Health (Children Hospital) Bangkok : Health (Children Hospital) Bangkok : - 1970 : 10 % - 1970 : 10 % - 1984 : 2 %- 1984 : 2 % - 1990 : 0.2 %- 1990 : 0.2 % Target of WHO : < 1 %Target of WHO : < 1 %
WithoutHemorrhage
WithoutHemorrhage
With unusual
Hemorrhage
With unusual
HemorrhageShock (-)Shock (-) Shock (+)
DSS
Shock (+)
DSS
Undifferentiated Undifferentiated febrile illnessfebrile illness
Undifferentiated Undifferentiated febrile illnessfebrile illness
Dengue FeverDengue FeverDengue FeverDengue Fever Dengue Hemorrhagic FeverDengue Hemorrhagic FeverDengue Hemorrhagic FeverDengue Hemorrhagic Fever
AsymptomaticAsymptomaticAsymptomaticAsymptomatic SymptomaticSymptomaticSymptomaticSymptomatic
Dengue virus infectionDengue virus infectionDengue virus infectionDengue virus infection
Clinical spectrum of
Dengue Virus infection
PATHOGENESISPATHOGENESIS
1.1. IMMUNOPATHOLOGY THEORYIMMUNOPATHOLOGY THEORY
2.2. ANTIGEN- ANTIBODY THEORYANTIGEN- ANTIBODY THEORY
3.3. ANTIBODY DEPENDENT ANTIBODY DEPENDENT ENHANCEMENT ENHANCEMENT (ADE) (ADE) THEORYTHEORY
4.4. MEDIATOR THEORYMEDIATOR THEORY
DENGUE VIRUS INFECTION
FEVERANOREXIAVOMITING
BLEEDINGMANIFESTATION
HEPATOMEGALY INCREASEVASCULAR
PERMIABILITY
TROMBOCYTOPENIA
Plasma leakage :
HemoconcentrationHipoproteinemiaPleural effusionAscites
Hypovolemia
Shock
Anoxia
Death
AcidosisG.I. bleeding
DIC
Dehydration
Suchitra (1993)
Plasma leakage
Hypovolemia
Circulatorydisturbance
+ Bleeding
PATHOPHYSIOLOGY OF DSS
Four Grades of DHF Four Grades of DHF (1)(1)
Grade 1Grade 1 Fever and nonspecific constitutional Fever and nonspecific constitutional
symptomssymptoms Positive tourniquet test is only Positive tourniquet test is only
hemorrhagic manifestationhemorrhagic manifestation
Grade 2Grade 2 Grade 1 manifestations + Grade 1 manifestations +
spontaneous bleedingspontaneous bleeding
Grade 1Grade 1 Fever and nonspecific constitutional Fever and nonspecific constitutional
symptomssymptoms Positive tourniquet test is only Positive tourniquet test is only
hemorrhagic manifestationhemorrhagic manifestation
Grade 2Grade 2 Grade 1 manifestations + Grade 1 manifestations +
spontaneous bleedingspontaneous bleeding
Four Grades of DHF Four Grades of DHF (2)(2)
Grade 3Grade 3 Signs of circulatory failure Signs of circulatory failure
- rapid and weak pulse- rapid and weak pulse
- narrow pulse pressure : < 20 mmHg- narrow pulse pressure : < 20 mmHg
- cold/clammy skin- cold/clammy skin
- hypotension by age- hypotension by age
- oliguria, restlessness- oliguria, restlessness
Grade 4 : Profound shock Grade 4 : Profound shock (undetectable pulse and blood pressure)(undetectable pulse and blood pressure)
DSS = DHF grade 3 & 4DSS = DHF grade 3 & 4
Grade 3Grade 3 Signs of circulatory failure Signs of circulatory failure
- rapid and weak pulse- rapid and weak pulse
- narrow pulse pressure : < 20 mmHg- narrow pulse pressure : < 20 mmHg
- cold/clammy skin- cold/clammy skin
- hypotension by age- hypotension by age
- oliguria, restlessness- oliguria, restlessness
Grade 4 : Profound shock Grade 4 : Profound shock (undetectable pulse and blood pressure)(undetectable pulse and blood pressure)
DSS = DHF grade 3 & 4DSS = DHF grade 3 & 4
Principles of DSS Principles of DSS managementmanagement
Early detectionEarly detection
Prompt and adequate fluidPrompt and adequate fluid
replacementreplacement
Closed monitoringClosed monitoring
Warning Signs for Dengue ShockWarning Signs for Dengue Shock
Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets
Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets
Warning Signs for Dengue ShockWarning Signs for Dengue Shock
Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit
Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit
Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets
Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets
Warning Signs for Dengue ShockWarning Signs for Dengue Shock
Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit
Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit
Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)
Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)
Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets
Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets
Warning Signs for Dengue ShockWarning Signs for Dengue Shock
When Patients Develop DSS:• 3 to 6 days after onset of symptoms
When Patients Develop DSS:• 3 to 6 days after onset of symptoms
Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit
Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit
Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)
Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)
Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets
Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets
Warning Signs for Dengue ShockWarning Signs for Dengue Shock
When Patients Develop DSS:• 3 to 6 days after onset of symptoms
When Patients Develop DSS:• 3 to 6 days after onset of symptoms
Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit
Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit
Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)
Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)
Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets
Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets
Treatment of DSS
Therapetic objectives in the treatment of hypovolemic shock:
- normalize blood volume
- regulate blood pressure
- stabilize cardiac function
- improve tissue perfusion
- raise oxygen delivery
Treatment of DSS (1)
- Body-weight measurement
- ABC resuscitation
- Vascular access
- Blood sampling
- Fluid resuscitation
- Urine catheter
Sumber: Majalah Tempo
Treatment of DSS (2)
Body-weight measurement
- Important for baseline
- determine the volume of fluid needed
- important for monitoring (overload?)
Treatment of DSS (3)
ABC resuscitation
- Basic life support
- most important thing : OXYGEN
- Preventing and correcting hypoxemia
- Maintenance O2 saturation 95-100%
Treatment of DSS (4)
Vascular access and blood sampling
- Complete blood count
!! PCV, thrombocyte
- blood group , cross-match !
- Gas analysis and electrolyte
- Ureum, creatinine
- serologic studyserologic study
Treatment of DSS (5)
Fluid resuscitation
- Rapid and aggressive
- increasing preload and cardiac output
- restore effective circulation
- restore oxygen-carrying capacity
- correcting metabolic and electrolyte
disturbance
Treatment of DSS (6)
Urine Catheter
- monitor diuresis
keep urine output > 1 ml/kgBW/hour
- urinalysis : ! Specific gravity !
Repeat bolus
Crystalloid 3 ml/kgBW/hour
Stop IV fluid(no more than 48 hour)
Colloid 20 ml/kgBW/hour
-
Maintenance Stabil for 12 – 24 hour
Crystalloid 5 ml/kgBW/hour Stabil for 6 – 12 hour
SHOCK
Body weight measurement, ABC resuscitation (+Oxygen),vascular access and blood sampling, urine catheter
Fluid resuscitation 10-30 ml/kgBW/6-10 minute (bolus)
IMPROVEMENTCrystalloid 10 ml/kgBW/hour
Monitoring vital sign, diuresisPCV, Thrombocyte
NO IMPROVEMENT
NO IMPROVEMENT IMPROVEMENT *
Repeat bolus
Crystalloid 3 ml/kgBW/hour
Stop IV fluid(no more than 48 hour)
Colloid 20 ml/kgBW/hour
-
Maintenance Stabil for 12 – 24 hour
Crystalloid 5 ml/kgBW/hour Stabil for 6 – 12 hour
SHOCK
Body weight measurement, ABC resuscitation (+Oxygen),vascular access and blood sampling, urine catheter
Fluid resuscitation 10-30 ml/kgBW/6-10 minute (bolus)
IMPROVEMENTCrystalloid 10 ml/kgBW/hour
Monitoring vital sign, diuresisPCV, Thrombocyte
NO Improvement
NO IMPROVEMENT IMPROVEMENT *
NO IMPROVEMENT
- PCV low Bleeding Blood transfusion
- CVP : > 10 mmHg resuscitation drug
- Correcting acidosis & electrolyte
- Overload : diuretic
- ARDS: ventilation
Acute management of DSS:
A randomized, Double-blind Comparison of 4 Intravenous Fluid Regiments in the First Hour
- Setting: ICU of Dong Nai Pediatric Hospital, Vietnam
- Time : September 1996 – September 1997
- Subject: 230 pediatric patients (1-15 year) with DSS
222 DHF grade III – 8 DHF grade IV
- Regimen fluid :
Normal saline – RL – gelatin 3% - Dextran 70
- Dosing : DHF grade III : 20 ml/kgBW/hour
DHF grade IV : 20 ml/kgBW/15 minutes then
20 ml/kgBW/hour
Acute management of DSS:
A randomized, Double-blind Comparison of 4 Intravenous Fluid Regiments in the First Hour
Results :
- All the children survived
- No clear advantage to using any of the 4 fluids
- The most significant factor determining clinical response
was the pulse pressure at presentation
- Colloid fluid was more benefit in children presenting
with lower pulse pressure
Nhan NT, Phuong CXT, Kneen R, et al. Clin Inf Dis 2001
Treatment of DIC
- Massive bleeding , Hb / PCV low
Fresh whole blood : 10 – 20 ml/kgBW
- If NO Blood component transfusion
Thrombocyte : 1 Unit (Bag)/ 5 kgBW
Fresh Frozen Plasma : 10 - 15 ml/ kgBW
Cryoprecipitate ( if fibrinogen < 100 mg/dl)
1 bag / 3 kgBW : infant
1 bag / 6 kgBW in older children
Pearls in managementPearls in management
• Early recognition of sign of shock can modify
the severity of DHF patients
• The period of plasma leakage/shock is short :
24-48 hours
• DSS can be successfully resuscitated by using
crystalloid only : + 60%
plus colloidal : 20%
need blood/component transfusion: + 15%
Suchitra, 2002Suchitra, 2002
Pitfalls in managementPitfalls in management
• Use hypotonic solution and delay to use colloidal
during critical period of plasma leakage
• Failure to monitoring the rate/volume of replace
ment fluid: massive pleural effusion/ascites
pulmonary edema
• Failure to recognize concealed internal bleeding
prolonged shock, fluid over load, death
• Over use of platelet transfusion as prophylaxis
for bleeding in all shock cases
Suchitra, 2002Suchitra, 2002