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Warning Signs and Fluid Management
for Dengue Infection
Leonard Nainggolan
Div. Tropical and Infectious Disease Dept. Internal Medicine
Faculty of Medicine Universitas Indonesia
Pathogenesis and Patophysiology
of Dengue Infection:
Virulence and viral load
Immune complex disease
T-cell-mediated
ADE
Complement
Autoimmune disease
Apoptosis
Innate immunity
Cytokine Tsunami
Genetic
CAPILLARY
ENDOTHELIUM
Lei HY et al. Immunopathogenesis of Dengue infection. J Biomed 2001
Lei HY et al. Immunopathogenesis of Dengue infection. J Biomed 2001
Leakage of intravascular fluids into the extravascular space*,**
due to widening of the endothelial gaps#,## hypovolemia,
hemoconcentration, weakness, edema, and visceral congestion. *. Vaughn DW.et al. J Infect Dis.1997;176:322-30.
**. Duane J. Gubler. Clin Microbiol Rev. 1998 July; 11(3): 480–496.
#. McDonald DM, Thurston G, Baluk P. Microcirculation 1999;6(1): 7-22.
##. Dejana E. J Clin Invest 1997;100(11):S7-S10.
Hematocrit ↑
Right Pleural effusion is prominent in Right Lateral decubitus position compare to the Anterior-Posterior Chest X-ray.
Pleural-Effusion Index (PEI)
# PEI at time of admission had the most critical role to predict
shock in DHF
# PEI > 6% at time of admission had significant correlations with
the occurance of shock
Pleural Effusion
A. PANORAMIC IMAGING (SIESCAPE) show a sagital sonography section with
massive pleural effusion (69), subhepatic (9) anechoic ascites (68)
inundating intestinal loop (46).
B. B. SAGITAL IMAGES show fluid collection of ascites.
A B
A. The evaluation of the gall bladder should be done preprandially. The
normal thickness of GB wall should not exceed 3 mm.
B & C. SAGITAL & TRANSVERSE IMAGES of hypoalbuminemia show marked
thickening of the gallbladder wall with a small lumen.
A B C
Patient with pericardial effusion (PE).
Dengue Diagnostic
WHO 2011
Dengue Case Management
Dengue guidelines for diagnosis, treatment, prevention, and control.
World Health Organization, UNICEF, UNDP. New Edition 2009.
Fluid Replacement Therapy
Bed rest
Anti-pyretics (avoid aspirin and NSAIDs)
Monitor Blood Pressure, haematocrite, platelets level, and level of consciousness
Dengue Case Management
Guidelines WHO 2011
Fluid Replacement Therapy:
Intravenous Fluid Drip?
A) Gases and nutrients
diffuse from capillary to
interstitial fluid
B) Forces responsible for the
direction and amount of fluid
crossing capillary walls
(Hydrostatic and Osmotic
pressure).
Arteriole Venule
Hydrostatic Pressure Oncotic Pressure
pre-Capillary Hydr. Pr > Onc. Pr
post-capillary Onc. Pr > Hydr. Pr
Lactated Ringer’s
Ringer Acetate
Normal Saline
Ringerfundin
Fluid Replacement Therapy
Colloids
Albumin
PPL
Dextran
solutions
HES
solutions
Gelatin
solutions
Crystalloids
Size, Electricity charge
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-)
(-) (-)
(-)
(-)
(-)
(-)
(-)
(-)
“Repelling Effect”:
Negative charges of endothelial
cells will repel with negative
charges of MFG molecules
Result:
Strong Volume effect, Longer
Duration effect
& minimalism chloride
Resuscitation
Management
Nutrition Crystalloid
Replace acute loss (hemorrhage, GI loss, Third
compartment)
1. Normal requirements (IWL + urine+ faeces) 2. Nutritional Support
Fluid Replacement
Coloid
Electrolyte
Repair
Dengue Case Management
Suspect DHF
Spontaneous and Massive Bleeding( - ) Shock (-)
- Hb, Ht (n) - Platelets< 100.000 - Crystalloid infusion * - Hb, Ht, Plt every 24 hours
- Hb, Ht increase 10-20% - Platelets< 100.000 - Crystalloid Infusion * - Hb, Ht, Plt every 12 hours **
- Hb, Ht increase > 20% - Platelets< 100.000
Protocol – Fluid Replacement DHF with increased Ht > 20%
* Daily crystalloid volume required:
According to formula : 1500 + 20 x (body weight in kg - 20)
Example of calculation for body weight of 55 kg : 1500 + 20 x (55-20) = 2200 ml
(Pan American Health Organization:
Dengue and Dengue Hemorrhagic Fever: Guidelines for Prevention and Control.
PAHO: Washington, D.C., 1994: 67).
** Monitoring is adjusted with phase/day of disease development and symptoms
Fluid Replacement on Probable Dengue Infection in Wards
Management of DHF with Increase of Haematocrite >20%
Management of Dengue Shock Syndrome
Airway Breathing : O2 1-2 L/min with nasal cannuls, higher use a simple mask Circulation : crystalloid / colloid 10-20 mL/kg BW loading (If possible less than 10 min) . Evaluate BP, PP, pulse & diuresis after 15 – 30 minutes
Response*
Not Response Not Response, shock still happen
Response
Crystalloid 7 mL/kg BW in 1 h
Crystalloid 5 mL/kg BW in 1 h
Consider for nutrition after 12 h (Dx 5 % If no contraindication)
Within 24-48 h after shock controlled, vital signs/Ht stable,
urine output increasing
Crystalloid 20-30 mL/kg BW loading for 20-30 min
Not Response
Ht increase Ht decrease
Colloid 10-20 mL/kg BW loading for 10-15 min Blood transfusion 10 mL/kg BW can be repeated if
necessary
Not Response Response*
Colloid until max 30 mL/kg BW
Not Response Response*
CVP Stop infusion
Response
Crystalloid 3 mL/kg BW in 1 h
Response
CVP
Colloid, if max dose does not reached yet or
crystalloid/gelatin (if colloid have reached max
dose) 10 mL/kgBW in 10 min, can be repeated
until 30 mL/kgBW ; CVP target 15-18 cmH2O
Hypovolemic Normovolemic
Monitoring crystalloid
for 10-15 min
Not Response
Acid-base & electrolyte
disturbance, hypoglycemia, anemia, secondary infection
correction
Inotropic, Vasopressor,
drug
Vasopressor gradual
increment
Colloid & crystalloid
combination
Response*
Response:
1. Systolic BP 100 mmHg
2. PP > 20 mmHg
3. Heart Rate < 100 x/mnt, adequate vol
4. Warm extremities
5. Diuresis 0,5-1 cc/kgBW/hour
Protocol 5…(Continued)
Thank You