DIAGNOSIS AND MANAGEMENT OF DHF AND DSS

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INTRODUCTION

DHF relatively new diseases in Indonesia 1968 in Surabaya and Jakarta 1973 in Manado Management divided in DHF and DSS Mortality rate in : 1968 41.3 % 1992 2.9 % 1995 2.5 %
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DIAGNOSIS WHO 1975 / 1986

Base on 4 clinical and 2 laboratoric criteria Clinical :

High fever 2 7 days Hemorrhagic manifestation Hepatomegaly Shock

Laboratoric

Thrombocytopenia Hemoconcentration

Dx : Minimally 2 clinical + Lab criteria The accuracy : 75 90 %

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The severity of disease divided in 4 grade

I II III IV

: : : :

Fever + non spesific + RL (+) I + Other hemorrh manifest II + mild shock III + severe shock

Grade I + II : DHF III + IV : DSS

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DHF : - permeability - Fever crisis DHF I, II :

Crisis days III > IVFD 12 24 hours PCV , Tr < 50 000 Health center / >

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Fever phase

Oral fluid : 50 ml/kgBW for 4 6 hours IVFD manitenance : 80 100 ml/kg/days Antipyretic : paracetamol 10 mg/kgBW/time Convulsion : Phenobarbital 5 mg/kgBW/days Critical Ill : Days 3 - 5

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SUBSTITUTION FLUID IN DHF

Maintenance + 5 8 % Vomiting every time Cannot drink fever PCV periodically Acidosis : NaBic PCV > 20 % IVFD : GED mild - mod
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Table 1. Fluid need for moderate dehidration.

Body Weight (Kg) <7 7 11 12 18 > 18
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Amount of fluid (ml/kgBW/day) 220 165 132 88

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Table 2. Fluid need for maintenance

Body Weight (Kg) <10 10 20 20 Amount of fluid (ml/kgBW/day) 100 / kgBW 1000 + 50/kgBW(>10 kg) 1500 + 20/kgBW(>20 kg)

Example : 40 Kg = 1500 + (20X20) = 1900 ml

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Temperature leakage Reconvalescen reabsorbtion of fluid Sign + symptom of shock hospitalization Fluid Recommended (WHO)

Cristaloid Colloid

: RL RL-D5% RA RA-D5% NaCl 0.9 % - NaCl 0.9%-D5% : Plasma Dextran L 40 HAES Gelofusin Gelofundin
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DSS Shock emergency fluid recovery 48 hours Replacement of plasma volume Cristaloid : 20 ml/kgBW/30 min Still Shock : Koloid 10 20 ml/kgBW/h Maximal 30 ml/kgBW Improvement : Cristaloid 10 20 ml/kgBW/h Still syok, PCV bleeding blood PCV > 40 blood 10 ml/kgBW/h Massive bleeding blood 20 ml/kgBW/h Improvement Cristaloid

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Figure 1. Management of suspect DHF

Suspect DHF Sudden high fever Continously < 7 d URTI (-) Emergency (+) Emergency (-)

Shock Vomit Convulsion Consiousness Hematemesis Melena

Tourniquet (+)

Tourniquet (-)

Trombocyte < 100 000 / ul

Trombocyte > 100 000 / ul

Ambulatory Paracetamol Control until Fever

Hospitalization

Ambulatory

Follow Up Clinical & Lab While days 3th fever (+)

Attention for parents Shock Sign
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Much drink Paracetamol Control until fever (-)

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Figure 2. Management of DHF (Grade II)

Initial Fluid
Improvement (+) Restlessness (-) Strong pulse Stable BP Diuresis 2 ml/kgBW/H PCV 2 X exam Monitoring Vital Sign / PCV and Trombocyte / 6 H RL/NaCl 0.9% / RLD5/NaCL0.9 % + D5 (6-7ml/KgBW/H) Improvement (-) Restlessness Resp Distres Pulse reate BP < 20mmHg Diuresis / Increased IV drip 10 ml/kgBW/H Step by Step 15 ml/kgBW/h

Vital sign decrease PCV

Decresed IV drip 5 ml/kgBW/h

Improvement
Evaluation 12 24 h

Improvement

3 ml/kgBW/h
IVFD Stop (24 48 h) If Vital Sign / PCV / Diuresis stable
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Resp Distres PCV Coloid 20 30 ml/kgBW/h

Unstable vital sign

PCV

Fresh WB 10 ml/kgBW Improvement

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Figure 3. Management of DSS (DHF III and IV)

DHF Gr III
1. 2. Oxygenation Plasma volume replacement RL/NaCL 20 ml/kgBW imediately (bolus 30 min) Evaluation 30 min Follow up vital sign every 10 min Record fluid balans

DHF Gr IV

Shock (-)

Shock (+) Decrese consiousness Weak pulse / not palpable BP < 20 mmHg RDS / Cyanosis (+) Cold Extremities Diuresis < 1 ml/kgBW/h Examine Glood Sugar

Improvement consiousness Strong pulse BP > 20 mmHg No RDS / Cyanosis Warm Extremities Diuresis > 1 ml/kgBW/h
Reduce IVFD (10ml/kgBW/h) Strict Evaluation Vital sign Bleeding sign Diuresis Hb, PCV, Tr Stable max 24 h 5 ml/kgBW/h PCV Fresh WB 10 ml/kgBW Can repeated IVFD stop 48 h Shock (-)

Shock (+)

IVFD (15 -20 ml/kgBW/h) Koloid / Plasma (10-20 max 30 ml/kgBw/h Correction accidosis Evaluation 1 h

PCV high / Koloid 20 ml/kgBW

3 ml/kgBW/h

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COMPLICATIONS

Electrolyte Imbalance

Hyponatremia Hypocalcemia Early IVFD Hypotonic Solution Not IVFD Not Use Colloidal Sol / Plasma Not Give blood transf Not Calculate IVFD
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Fluid overload

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COMPLICATIONS

Signs and Symptoms of Fluid Overload RSD, Dyspnea and Tachypnea Massive acites Rapid Pulse Pulse pressure Crepitation/Ronchi Porr tissue perfusion
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COMPLICATIONS

Management of fluid overload Change IV to Dextrans 40 Urinary Catheter Furosemide 1 mg/kgBW, IV Still Shock Dextrans 40, 10 mg/kgBW in 10-15 min Record Urine output Furosemide may repeat if still RDS CVP if not Response furosemide Ventilatory support Pleural/peritoneal tapping
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COMPLICATIONS

Unusual manifestation of DHF Less than 5% of patient Encephalopathy/encephalitis Hepatic failure Renal failure Dual infections Underlying conditions
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COMPLICATIONS

Signs and Symptoms of Fluid Overload Prolonged shock Acute hemolysis + Hb uria

G6PD Hemoglobinopathy Transfussion PRC of FWB IVFD according the stage Alkaline urine
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Management of acute hemolysis + Hb Uria

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COMPLICATIONS
Dual Infections Associate : GI, Salmonella RI, Pneumonia Urinary infections Skin + soft tissue inf Nosocomial Thrombophlebitis Pneumonia UTI (Catheter) Others Transfussion reaction Hepatitis Massive GI Hem Drugs reactions
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COMPLICATIONS

Common causes of encephalopathy Hepatic encephalopathy

Severeshock Inborn error of metab Hepatotoxic drugs Underlying liver diseases

Electrolyte imbalance Metabolic distrubance (hypoglycemia) Intracranial bleeding Cerebral thrombosis/ischemia

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COMPLICATIONS Management of DHF hepatic encephalopathy Maintain oxygenation Prevent intracranial press :

Restrict IV Furosemide + / dexamethasone

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Amonia production Vit K1 3-10 mg IV Correct metab acidosis PRC if indicated Antibiotic H2 Blocker if massive GI Bleeding Avoid unnecessary drugs Exchange tranf if needed Dyalisis if needed Branch chain aminoacid

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INDICATION FOR DISCHARGE

Not fever in 24 h Good appetite Good general condition Diuresis Normal PCV (38 40) 2 days after shock No dyspnea Platelet > 50 000/mm3 No complication
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CAUSES OF DEATH

Prolonged shock Fluid overload Massive bleeding Unusual manifestation

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