demam berdarah dengue - CPD FK Trisakti University

FLUID TREATMENT CHOICE
IN DENGUE INFECTION
Djatnika Setiabudi
Child Health Department
Medical Faculty Padjadjaran University
Outline

Introduction
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Dengue Classification (WHO 2011)
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Patophysiology
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Fluid Treatment
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Resume
Dengue Infection
Burden of disease
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Endemic in > 100 tropical and subtropical countries
50–100 million dengue fever infections per year globally
500,000 cases of severe dengue  DHF and DSS
Average case fatality 2–5%
Indonesia (Profil Kesehatan tahun 2010):
- DHF the second most hospitalized patients
- 156,086 cases; insidence rate 65.7/100,000 /year
- Case Fatality Rate (CFR): 0.87%
New Guidelines
WHO /SEARO,
2011
Important notes:
1. Clinical spectrum added:
expanded dengue
syndrome
2. If fever and significant
plasma leakage: DHF clinical
diagnosis is most likely even
if there is
no bleeding manifestation
or thrombocytopenia
Manifestations of dengue virus infection
(WHO, 2011)
WHO classification of dengue infections
and grading of severity of DHF (2011)
DENGUE VIRUS INFECTION
FEVER
BLEEDING
ANOREXIA
MANIFESTATION
VOMITING
HEPATOMEGALY
INCREASE
TROMBOCYTOPENIA
VASCULAR
PERMEABILITY
Plasma leakage :
Hemoconcentration
Hipoproteinemia
Dehydration
Pleural effusion
Hypovolemia
DIC
G.I.
bleeding
Suchitra (1993)
Ascites
Shock
Anoxia
Death
Acidosis
The course of Dengue illness
Perjalanan penyakit Demam Dengue
Suhu reda, klinis membaik,
nafsu makan membaik
Time of fever defervescence
(Saat suhu reda)
emp
Hari sakit
Perjalanan penyakit DBD
Klinis memburuk, lemah, gelisah,
tangan kaki dingin, nafas cepat,
diuresis berkurang,
tidak ada nafsu makan
emp
Time of fever defervescence
Fase demam
Fase syok
Fase konvalesens
Hari sakit
Principle of dengue management
1.
Fluid replacement
Vascular permeability increase Plasma leakage
 hemoconcentration  hypo-volemic shock
2.
Early detection and managememnet of
circulatory disturbance:
Clinically and serial Blood laboratory exam
3.
Detection and management of bleeding
manifestation:
Clinically and laboratory exam
4. Supportive and symptomatic treatment
Fluid treatment: Principle of “4-J”
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Jalan/jalur pemberian : per oral – intravena ?
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Jenis cairan :
oralit- jus buah - kristaloid – koloid ?
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Jumlah cairan :
rumatan – dehidrasi atau hemokonsentrasi?
Syok atau tidak syok
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Jadwal pemberian :
bolus - per jam – per hari ?
Indication for intravenous fluid
-
(Persistent) vomiting
-
Nausea and anorexia (small drinking)
-
Abdominal pain and tenderness
-
Impaired concioussness
-
Increasing Haematocrit value
-
Circulatory disturbance
Choice of fluids
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Suspected dengue and Dengue Fever:
- isotonic crystalloid : normal saline, Ringer’s
lactate, Ringer’s acetate, Ringer’s dextrose
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Dengue hemorrhagic Fever (DHF I and II):
- isotonic crystalloid : glucose contained solution?
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DSS:
crystalloid versus colloid ?
TANDA VITAL TIDAK STABIL
Penurunan jumlah urine output
Tanda-tanda syok
DBD derajat III*
Oksigen melalui face mask atau kanula hidung
Penggantian volume secara cepat: inisiasi terapi IV
10 ml/kg/jam larutan isotonik kristaloid selama 1-2 jam
Perbaikan
Tidak ada perbaikan
Pengurangan dari 10 ml/kg/jam
menjadi 7, 5, 3, 1.5 ml/kg/jam
sesuai keadaan klinis dan hasil
pemeriksaan hematokrit
Periksa ABCS
(Acidosis, Bleeding, Calcium,
Sugar), dan koreksi
Peningkatan hematokrit
Perbaikan lebih lanjut
Koloid IV
(Dextran 40 atau HES)
Penurunan hematokrit
Transfusi darah :
FWB10 ml/kg
atau PRC 5 ml/kg
Menghentikan terapi IV
selama 24-48 jam
Perbaikan
Pengurangan dari 10 ml/kg/jam
menjadi 7, 5, 3, 1.5 ml/kg/jam
tergantung keadaan klinis dan
hematokrit . Hentikan terapi IV
selama 24-48 jam
* Dalam kasus dengan syok yang lebih berat (DBD derajat IV) laju IV adalah 10 ml/kg selama 1015 menit atau 20 mL/kg dalam 30 menit, selanjutnya dikurangi menjadi 10 ml/kg/jam
Tatalaksana DSS (DBD III dan IV)
Randomised Controlled Trials
of Fluid Management in DSS
Dung NM, Day NP, Tam DT, Loan HT, Chau HT, Minh LN, et al.
Fluid replacement in dengue shock syndrome: a randomized, double-blind
comparison of four intravenous-fluid regimens.
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A pilot study involving 50 children with DSS
Children were randomised to receive:
crystalloid : normal saline (n=12), Ringer’s lactate (n=13)
colloid
: dextran 70 (n=12) or 3% gelatin (n=13)
Result:
- colloid group had significantly greater increases in mean
haematocrit (P=0·01), blood pressure (P=0·005), pulse
pressure (P=0·02)
Overall : showed minor differences in the immediate
clinical responses to different fluids
Clin Infect Dis. 1999;29:787–94
Ngo NT, Cao XT, Kneen R, Wills B, Nguyen VM, Nguyen TQ, et al.
Acute management of dengue shock syndrome: a randomized double-blind
comparison of 4 intravenous fluid regimens in the first hour.
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A larger study: 230 DSS children , compared the same four fluids
Result:
- comparisons between all other solutions were not significant (However,
pulse pressure at presentation was identified as a potential confounder)
- in severe patients (pulse pressure < 10 mmHg) differences were found
Conclusion:
- mild-to-moderate DSS patients have respond well to crystalloid treatment
- more severe: may require more aggressive management with colloids
- However, this study was statistically underpowered
- Recommendation:
further large-scale studies, stratified for admission pulse pressure,
Clin Infect Dis. 2001;32:204–13.
Wills BA, Nguyen MD, Ha TL, Dong TH, Tran TN, Le TT, et al.
Comparison of three fluid solutions for resuscitation in dengue shock
syndrome.
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largest randomised study ,stratified for presenting pulse pressure.
Group 1: Moderately shock (pulse pressure >10 to 20 mmHg, n=383)
were randomised to receive Ringer’s lactate (n=128), 6% dextran 70
(n=126) or 6% HES 200/0·5 (n=129).
Group 2: severe shock (pulse pressure 10 mmHg) were randomised to
receive one of the colloids – dextran 70 (n=67) or HES (n=62)
Result:
- Group 1: RL was found to be as effective as colloid therapy
- Group 2: - both colloid preparations performed equally result.
- dextran more adverse events than HES (allergic-reactions)
- no differences in severe adverse events
(significant bleeding or clinical fluid overload)
N Engl J Med. 2005;353:877–89.
Characteristics of three Vietnam Studies
Author, Year
Population
Intervention: Study fluids
Dung et al.,
1999
50 Vietnamese child with
clinical DSS;
5-15 years old
Lactated Ringer’s solution, isotonic
saline, dextran, gelatin
Fluid rate :20mL/kg for 1 hr, then
10mL/kg for the 2nd hour
Nhan et al.,
2001
230 Vietnamese children
clinically diagnosed DHF
DHF grade III = 222
DHF grade IV = 8
1-15 years old
Lactated Ringer’s solution, isotonic
saline, dextran, gelatin
Fluid rate :
DHF grade III: 20mL/kg for 1 hr
DHF grade IV: 20ml/kg for 15min,
then 20mL/kg over the following hour
Willis et al.,
2005
512 Vietnamese children
with clinical DSS
Moderate shock = 383
Severe shock = 129
2-15 years old
Lactated Ringer’s solution, starch,
dextran
Fluid rate:
15mL/kg for 1 hr, then 10mL/kg for
the 2nd hr
Kalayanarooj S.
Choice of colloidal solutions in dengue hemorrhagic fever patients.
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A study of 104 DHF patients with severe plasma leakage who
had failed to respond to crystalloids and required fluid
resuscitation
compared bolus doses of two colloids, 10% dextran 40 (n=57)
and 10% HAES-steril (n=47)
Objective: compare their effectiveness, impact on renal function
and haemostasis and any complications.
Result:
- HAES-steril was found to be as effective as dextran 40.
- Both colloidal solutions were safe in these patients (no allergic
reactions, interference with renal function or haemostasis)
J Med Assoc Thai. 2008;91(suppl. 3):S97–103.
SYSTEMATIC REVIEW
The Use of Colloids and Crystalloids in Pediatric
Dengue Shock Syndrome:
a Systematic Review and Meta-analysis*
Jalac SLR, de Vera M and Alejandria MM.
Philippine Journal of Microbiology and Infectious Diseases
2010;39(1):14-27
Objectives:
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1.
2.
3.
4.
5.
6.
to compare the therapeutic effects of colloids
versus crystalloids of children with DSS in
reducing:
the recurrence of shock
the requirement for rescue fluids
the need for diuretics
the total volume of intravenous fluids given
the haematocrit level and pulse rates
mortality rates
Results:
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1.
2.
3.
4.
5.
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Colloids and crystalloids did not differ significantly in
decreasing:
t:he risk for recurrence of shock (RR 0.92, 95% CI 0.62 - 1.38)
the need for rescue fluids (RR 0.90, 95% CI 0.70 - 1.16)
mortality rates
total volume of intravenous fluids given
the need for diuretics (RR=1.17, 95% CI 0.84 to 1.64)
significant improvements from baseline in the haematocrit
levels and pulse rates of patients who were given colloids
Allergic type reactions were seen in patients given colloids
Conclusion:
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no significant advantage was found colloid over
crystalloids in reducing the recurrence of shock,
the need for rescue colloids, the total amount of
fluids, the need for diuretics, and in reducing
mortality
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Colloids decreased the haematocrit and pulse rates
of children with DSS after the first two hours of
fluid resuscitation
Resume
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These studies show that the majority of DSS children can
be treated successfully with isotonic crystalloid solutions
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If a colloid is considered necessary:
- rely on personal experience
- familiarity with particular products
- local availability and cost
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A medium-molecular-weight preparation : optimal choice
- good initial plasma volume support
- good intravascular persistence and
- acceptable tolerability profile
Characteristics of colloids
used for plasma volume support
Initial volume Duration of
Adverse effect
expansion volume effect
on coagulation
(%)*
(hrs)
3% Gelatine
(MW = 35,000)
60–80
3–4
+/−
Allergic
potential
Other
significant
side-effects
++
10% Dextran 40
(MW = 40,000)
170–180
4–6
++
+
6% Dextran 70
(MW = 70,000)
100–140
6–8
++
+
6% Hydroxy-ethyl
starch = HES
(MW = 200,000/0·5)
100–140
6–8
+
+/−
6% HES
(MW = 400,000)
80–100
12–24
++
+
Renal failure in
hypovolaemic
patients
Management of dengue; Wills B. Halstead SB (Ed.) : 2008 Imperial College Press.
Note: *Infused volume; MW, molecular weight
Countries and areas at risk of dengue transmission, 2008
Dengue Classification........
Dengue virus infection
Asymptomatic
Undifferentiated
febrile illness
Symptomatic
Dengue Fever
syndrome
Dengue hemorrhagic fever
(plasma leakage)
(viral syndrome)
Without
haemorrhage
With unusual
haemorrhage
No shock
Dengue shock
syndrome
Clinical Spectrum of Dengue Viral Infection, WHO 1997
WHO, 1997
Ditjen Yanmed
Ditjen P2PL
WHO/TDR
Guidelines 2009
These guidelines
are not intended toreplace
national guidelines but to
assist in the development of
national or regional
guidelines
Suggested dengue classification and level of severity
WHO, 2009
Tata laksana DBD derajat I & II
Cairan awal : Rumatan + 5%
(7ml/kgBB/jam)
Monitor tanda vital
Hb,Ht,trombo tiap 6-12jam
Perbaikan
Tidak ada perbaikan
Tidak gelisah
Nadi kuat
Tek drh stabil
Ht turun
Diuresis 2ml/kgBB/jam
Tetesan dikurangi
5ml/kgBB/jam
Gelisah
Distres nafas
Frek nadi naik
Ht tinggi
Tek nadi <20mmHg
Diuresis kurang
Tetesan dinaikkan
10 ml/kgBB/jam
Evaluasi 12-24jam
3ml/kgBB/jam
1,5 mL/kg/jam
Tatalaksana DSS
Stop dalam 24-48jam
Tanda vital tidak stabil
DBD derajat I dan II
Jumlah Cairan :
Rumatan
: Halliday & Segar
BB (Kg)
Jumlah cairan / 24 jam
< 10
10 – 20
>20
100cc/kg BB
1000 + 50cc/kg BB untuk tiap kelebihan > 10 kg
1500 + 20cc/kg BB untuk tiap kelebihan > 20 kg
Kehilangan cairan : DHF dianggap dehidrasi sedang = 5-8%,
setiap 1% = 10cc/kg BB
DBD derajat I dan II
Contoh : berat badan 18 kg
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Rumatan = (10 x 100) + (8x50)
= 1400 cc
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Kehilangan cairan = 18 x 5 x 10 cc =

Jumlah :
900 cc
2300 cc/24 jam
Order untuk kebutuhan tiap jam ( + 100cc /jam) 
selanjutnya cairan disesuaikan bergantung pada
hasil monitoring Hematokrit dan klinis