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 % 11/20/2012 3

The severity of disease divided in 4

grade

I : Fever + non spesific + RL (+)

II : I + Other hemorrh manifest

III : II + mild shock

IV : 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)

Amount of fluid

(ml/kgBW/day)

< 7

7 – 11

12 – 18

> 18

220

165

132

88

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Table 2. Fluid need for

maintenance

Body Weight

(Kg)

Amount of fluid

(ml/kgBW/day)

<10

10 – 20

20

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 : RL – RL-D5% RA – RA-D5% NaCl 0.9 % - NaCl 0.9%-D5% Colloid : 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 Ambulatory

Paracetamol

Control until Fever

Tourniquet (+) Tourniquet (-)

Follow Up Clinical & Lab

While days 3th fever (+)

Attention for parents

Shock Sign

Trombocyte

> 100 000 / ul

Trombocyte

< 100 000 / ul

Hospitalization

Much drink

Paracetamol

Control until fever (-)

Ambulatory

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Figure 2. Management of DHF (Grade II)

Initial Fluid RL/NaCl 0.9% / RLD5/NaCL0.9 % + D5

(6-7ml/KgBW/H)

Decresed IV drip

Monitoring Vital Sign /

PCV and Trombocyte / 6 H

Restlessness (-)

Strong pulse

Stable BP

Diuresis 2 ml/kgBW/H

PCV 2 X exam

Improvement (+) Improvement (-)

Restlessness

Resp Distres

Pulse reate

BP < 20mmHg

Diuresis / -

10 ml/kgBW/H

Step by Step

15 ml/kgBW/h

Increased IV drip

Evaluation 12 – 24 h

Improvement

Unstable vital sign Resp Distres

PCV PCV

Coloid

20 – 30 ml/kgBW/h Fresh WB

10 ml/kgBW

Improvement

Improvement

Vital sign decrease

PCV

IVFD Stop (24 – 48 h)

If Vital Sign / PCV / Diuresis

stable

5 ml/kgBW/h

3 ml/kgBW/h

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

DHF Gr III 1. Oxygenation

2. 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 Shock (-) Shock (+)

DHF Gr IV

Improvement consiousness

Strong pulse

BP > 20 mmHg

No RDS / Cyanosis

Warm Extremities

Diuresis > 1 ml/kgBW/h

Decrese consiousness

Weak pulse / not palpable

BP < 20 mmHg

RDS / Cyanosis (+)

Cold Extremities

Diuresis < 1 ml/kgBW/h

Examine Glood Sugar Reduce IVFD (10ml/kgBW/h)

IVFD (15 -20 ml/kgBW/h)

Koloid / Plasma

(10-20 max 30 ml/kgBw/h

Correction accidosis

Evaluation 1 h

Shock (+)

Shock (-)

PCV high /

Koloid 20 ml/kgBW

PCV

Fresh WB 10 ml/kgBW

Can repeated

Strict Evaluation

Vital sign

Bleeding sign

Diuresis

Hb, PCV, Tr

Stable max 24 h

5 ml/kgBW/h

3 ml/kgBW/h IVFD stop ≤ 48 h 11/20/2012 14

COMPLICATIONS

Electrolyte Imbalance Hyponatremia

Hypocalcemia

Fluid overload Early IVFD

Hypotonic Solution

Not IVFD

Not Use Colloidal Sol / Plasma

Not Give blood transf

Not Calculate IVFD 11/20/2012 15

Signs and Symptoms of Fluid Overload

RSD, Dyspnea and Tachypnea

Massive acites

Rapid Pulse

↓ Pulse pressure

Crepitation/Ronchi

Porr tissue perfusion

COMPLICATIONS

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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

COMPLICATIONS

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Unusual manifestation of DHF

Less than 5% of patient

Encephalopathy/encephalitis

Hepatic failure

Renal failure

Dual infections

Underlying conditions

COMPLICATIONS

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Signs and Symptoms of Fluid Overload

Prolonged shock

Acute hemolysis + Hb uria

G6PD

Hemoglobinopathy

Management of acute hemolysis + Hb Uria

Transfussion PRC of FWB

IVFD according the stage

Alkaline urine

COMPLICATIONS

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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

COMPLICATIONS

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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

COMPLICATIONS

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Management of DHF hepatic encephalopathy

Maintain oxygenation

Prevent ↑ intracranial press : Restrict IV

Furosemide + / dexamethasone

↓ 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

COMPLICATIONS

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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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