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Penatalaksanan Penatalaksanan intensif intensif pasien pasien dengan dengan

Penyakit Penyakit Tropik Tropik Berat Berat


di di ICU ICU
Dr . Dr .Dadik Dadik Wahyu Wahyu Wijaya Wijaya SpAn SpAn
Departemen Departemen Anestesiologi Anestesiologi & & Reanimasi Reanimasi / / Instalasi Instalasi
Pelayanan Pelayanan Intensif Intensif (ICU) (ICU)
FK FK--USU / RSUP USU / RSUP H.Adam H.Adam Malik Malik -- Medan Medan
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Indikasi Indikasi Umum Umum Pasien Pasien dirawat dirawat di di ICU ICU
Berdasarkan Berdasarkan Prioritas Prioritas
Berdasarkan Berdasarkan Diagnosis Diagnosis
Berdasarkan Berdasarkan Nilai Nilai--nilai nilai Parameter Parameter
Hasil Hasil Laboratorium Laboratorium
2 2
Penyakit Penyakit Tropik Tropik Berat Berat (yang (yang sering sering
di di ICU : ICU :
Tetanus Tetanus Berat Berat (Severe Tetanus) (Severe Tetanus) Tetanus Tetanus Berat Berat (Severe Tetanus) (Severe Tetanus)
DHF Grade III DHF Grade III--IV (DSS) IV (DSS)
Malaria Malaria Berat Berat (Severe Malaria) (Severe Malaria)
3 3
TETANUS BERAT TETANUS BERAT TETANUS BERAT TETANUS BERAT
4 4
Derajat Derajat Keparahan Keparahan
(Severity Grading (Severity Grading))
Philips Philips
Dakar Dakar Dakar Dakar
Udwadia Udwadia Gambaran Gambaran Klinis Klinis
Ablett Ablett
Blect Blect
5 5
Philips Score Philips Score
Waktu Masuk Skor Selama Perawatan Skor
Masa Inkubasi
> 14 hari
> 10 hari
5 10 hari
2 5 hari
< 48 jam
1
2
3
4
5
Spasme
Hanya trismus
Kaku seluruh badan
Kejang terbatas
Kejang seluruh badan
Optistotonus
1
2
3
4
5
Imunisasi
Lengkap
< 10 tahun
> 10 tahun
Ibu diimunisasi
Tidak diimunisasi
0
2
4
8
10
Frekuensi Spasme
6 x dalam 12 jam
Dengan rangsangan
Terkadang spontan
Spontan < 3x per 15 menit
Spontan > 3x per 15 menit
1
2
3
4
5
Luka Infeksi Suhu Luka Infeksi
Tidak diketahui
Distal/perifer
Proksimal
Kepala
Badan
1
2
3
4
5
Suhu
36.7 - 37 C
37.1 37.7 C
37.8 38.2 C
38.3 38.8 C
> 38.8 C
1
2
4
8
10
Komplikasi
Tidak ada
Ringan
Tidak membahayakan
Mengancam Nyawa (tidak langsung)
Mengancam nyawa
1
2
4
8
10
Pernafasan
Sedikit berubah
Apnea saat kejang
Kadang apnea setelah kejang
Selalu apnea setelah kejang
Perlu trakeostomi
0
2
4
8
10
Total Skor Derajat Keparahan
< 9 Ringan
9 - 18 Sedang
>18 Berat 6 6
Grade I (mild)
Mild trismus, general spasticity, no respiratory compromise, no
spasms, no dysphagia
Grade 2 (moderate)
Ablett Classification of Severity
Grade 2 (moderate)
Moderate trismus, rigidity, short spasms, mild dysphagia, moderate
respiratory involvement, ventilatory frequency > 30
Grade 3 (severe)
Severe trismus, generalized rigidity, prolonged spasms, severe
dysphagia, apnoeic spells, pulse > 120, ventilatory frequency > 40
Grade 4 (very severe)
Grade 3 with severe autonomic instability
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Derajat Derajat Keparahan Keparahan hendaknya hendaknya tidak tidak
dipakai dipakai sebagai sebagai pedoman pedoman Kaku Kaku untuk untuk
indikasi indikasi rawat rawat ICU ICU
Indikasi Indikasi Rawat Rawat ICU ICU bilamana bilamana cara cara--cara cara
konvensional konvensional yang yang dilakukan dilakukan di di ruang ruang konvensional konvensional yang yang dilakukan dilakukan di di ruang ruang
perawatan perawatan tidak tidak berhasil berhasil mengatasi mengatasi kejang kejang
//spasme spasme atau atau pasien pasien mengalami mengalami
gangguan gangguan pernafasan pernafasan akibat akibat kejang kejang atau atau
aspirasi aspirasi, , atau atau telah telah terjadi terjadi gagal gagal nafas nafas
atau atau gangguan gangguan sistem sistem lain yang lain yang
memerlukan memerlukan terapi terapi supportif supportif..
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Clinical diagnosis of tetanus
Secure Airway
Tracheostomy
Benzodiazepines
2
Midazolam
Diazepam
Antitoxin
2
HIG im/it
Equine antitoxin im
Antibiotics
2
Metronidazole
Manage autonomic dysfunction
Flow diagram showing the management of tetanus.
1limited evidence; 2some evidence; 3good evidence.
Magnesium
2
Inotropes
1
Benzodiazepines
2
Bupivacaine
2
Morphine
2
Clonidine
2
Consider
DVT Prophylaxis
1
Control Muscle Spasms
Benzodiazepines
2
Dantrolene
1
NDNMBAs
1
Baclofen
2
Magnesium
2
Full primary course of immunisation
1
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Therapeutic Management Therapeutic Management
Immunization Immunization
Wound debridement Wound debridement
Antibiotics Antibiotics Antibiotics Antibiotics
Control muscle spasm Control muscle spasm
Control Autonomic Disturbance Control Autonomic Disturbance
Other supportive therapy Other supportive therapy
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MANAGEMENT MANAGEMENT
1. 1. Neutralize toxin outside of CNS Neutralize toxin outside of CNS
-- Human Tetanus Immune Globulin Human Tetanus Immune Globulin
HTIG HTIG)) 150 units/kg IM or 5,000 150 units/kg IM or 5,000-- HTIG HTIG)) 150 units/kg IM or 5,000 150 units/kg IM or 5,000--
10,000 units IV 10,000 units IV
-- ATS ATS 500 UI/kgBB intramuscular. 500 UI/kgBB intramuscular.
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22. . Prevent further toxin release Prevent further toxin release
-- Early surgical debridement of Early surgical debridement of
wounds wounds
-- Antibiotics : Antibiotics : Metronidazole Metronidazole 500mg 500mg
MANAGEMENT MANAGEMENT
-- Antibiotics : Antibiotics : Metronidazole Metronidazole 500mg 500mg
8 hourly and Penicillin G 1 MU 6 8 hourly and Penicillin G 1 MU 6--88
hourly. hourly.
Heavily contaminated wound may Heavily contaminated wound may
need additional antibiotics. need additional antibiotics.
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MANAGEMENT MANAGEMENT
3. 3. Minimize the effects of toxin already Minimize the effects of toxin already
exists in CNS exists in CNS
-- Control rigidity and spasm Control rigidity and spasm -- Control rigidity and spasm Control rigidity and spasm
-- Respiratory support as necessary Respiratory support as necessary
-- Control of autonomic dysfunction. Control of autonomic dysfunction.
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Drug used to control spasm and Drug used to control spasm and
autonomic disturbance autonomic disturbance
Benzodiazepine Benzodiazepine
Morphine Morphine
Muscle relaxant: Muscle relaxant: vecuronium vecuronium, , rocuronium rocuronium, , Muscle relaxant: Muscle relaxant: vecuronium vecuronium, , rocuronium rocuronium, ,
pancuronium pancuronium
Magnesium sulfate Magnesium sulfate
Dantrolen Dantrolen
Baclofen Baclofen
Bupivacain Bupivacain, atropine, , atropine,
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Benzodiazepine Benzodiazepine
Common used as anticonvulsant in Common used as anticonvulsant in
tetanus. tetanus.
Has sedative effect Has sedative effect
Dose of Diazepam vary 100 Dose of Diazepam vary 100--400 mg/24 h 400 mg/24 h Dose of Diazepam vary 100 Dose of Diazepam vary 100--400 mg/24 h 400 mg/24 h
max until 2400mg/24 h max until 2400mg/24 h
Preservative used can cause acidosis in Preservative used can cause acidosis in
large dose large dose
No/little effect on autonomic disturbance No/little effect on autonomic disturbance
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Magnesium Sulfate Magnesium Sulfate
-- Pre synaptic neuromuscular blocker Pre synaptic neuromuscular blocker
-- Blocks catecholamine release from nerve and Blocks catecholamine release from nerve and
adrenal medulla adrenal medulla
-- Reduce receptor responsiveness to release Reduce receptor responsiveness to release
catecholamines catecholamines
-- It antagonizes calcium in myocardium and at It antagonizes calcium in myocardium and at
the neuromuscular junction the neuromuscular junction
-- Inhibits parathyroid hormone release Inhibits parathyroid hormone release
anticonvulsant-vasodilator
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Dose Dose
Adult : a loading dose of 5 gram over 20 Adult : a loading dose of 5 gram over 20
minutes IV followed by 1g hourly minutes IV followed by 1g hourly
increasing to 2.5 gram hourly when increasing to 2.5 gram hourly when
necessary. Titrate to symptoms necessary. Titrate to symptoms necessary. Titrate to symptoms necessary. Titrate to symptoms
Pediatrics : 100mg /kg/24 hours, can be Pediatrics : 100mg /kg/24 hours, can be
increased when necessary. Titrate to increased when necessary. Titrate to
symptoms symptoms
Sometimes MgSO4 is inadequate to be used alone,
combination with benzodiazepine is also mandatory
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Monitoring of possible side effects Monitoring of possible side effects
-- Patellar reflex Patellar reflex
Diminished at the level of Magnesium >4 Diminished at the level of Magnesium >4 mmol mmol/L /L
-- Respiratory depression because of muscle Respiratory depression because of muscle
paralysis (>Mg 6 paralysis (>Mg 6 mmol mmol/L) /L)
-- Bradyarrhythmia Bradyarrhythmia, hypotension , hypotension -- Bradyarrhythmia Bradyarrhythmia, hypotension , hypotension
-- Urine output Urine output
Low output causes drug accumulation Low output causes drug accumulation
-- Blood Calcium level, blood Magnesium level Blood Calcium level, blood Magnesium level
should be checked regularly should be checked regularly
-- Overdose may cause sedation and anesthesia. Overdose may cause sedation and anesthesia.
Day 4
Day 6
Magnesium can be a prospective
alternative for treatment of tetanus,
especially when there are mass
casualties since it reduces the need for casualties since it reduces the need for
mechanical ventilation, however,
meticulous ICU monitoring is needed
with ready for use ventilator.
Gempa Yogyakarta
Others Drugs & Regiment Others Drugs & Regiment
Obat Obat pelemas pelemas otot otot (muscle relaxant) (muscle relaxant)
intermittent intermittent bila bila diperlukan diperlukan. .
Baclofen Baclofen (beta (beta [4 [4--chlorophenyl] gamma chlorophenyl] gamma
amino butyric acid) amino butyric acid) sebagai sebagai PP--GABA GABA amino butyric acid) amino butyric acid) sebagai sebagai PP--GABA GABA
receptor agonist, receptor agonist, menghambat menghambat pelepasan pelepasan
asetilkolin asetilkolin presinaps presinaps diotak diotak, , diberikan diberikan
intrathekal intrathekal
Propofol Propofol (1,6 (1,6--diisopropyl phenol) diisopropyl phenol) dapat dapat
dipakai dipakai sebagai sebagai sedasi sedasi, , dengan dengan dosis dosis
tritrasi tritrasi. .
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Others Drugs & Regiment Others Drugs & Regiment
Penghambat Penghambat beta : beta :
Propanolol,Labetolol Propanolol,Labetolol, , Esmolol Esmolol
Agonist alfa Agonist alfa--2 : 2 : Clonidine Clonidine
Dexmedetomidine Dexmedetomidine Dexmedetomidine Dexmedetomidine
Opioid Opioid kombinasi kombinasi dengan dengan sedative : sedative :
Morphine + Morphine + midazolam midazolam atau atau diazepam diazepam
Sodium Sodium valproate valproate
ACE Inhibitor ACE Inhibitor
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Terapi Terapi supportif supportif lainnya lainnya
Terapi fisik (fisioterapi) karena pasien Terapi fisik (fisioterapi) karena pasien
imobilisasi cukup lama. imobilisasi cukup lama.
Ventilasi Ventilasi mekanik mekanik
MANAGEMENT MANAGEMENT
Ventilasi Ventilasi mekanik mekanik
Metabolik : Nutrisi enteral , ditambah Metabolik : Nutrisi enteral , ditambah
parenteral bila perlu. parenteral bila perlu.
Penggunaan inotropik dan atau Penggunaan inotropik dan atau
vasopresor vasopresor
Antikoagulan Antikoagulan
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3 major complications cause death 3 major complications cause death
Ventilatory Ventilatory restriction leading to respiratory restriction leading to respiratory Ventilatory Ventilatory restriction leading to respiratory restriction leading to respiratory
complication and sepsis complication and sepsis
Autonomic disturbance Autonomic disturbance
Stress ulcer/gastric bleeding Stress ulcer/gastric bleeding
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DHF GR III DHF GR III--IV (DSS) IV (DSS) DHF GR III DHF GR III--IV (DSS) IV (DSS)
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DF DHF (Grades)
I II III IV
Febrile
Phase
(3-7 days)
Afebrile Phase
(Critical Stage) (Critical Stage)
Convalescent
Phase
If Appropriate Treatment not provided, there is a high rist death
RECOVERY
Grading the Severity of Dengue Infection
DF/DHF Grade* Symptoms Laboratory
DF
DHF
DHF
I
II
Fever with two or more of the
following signs : headache, retro
orbital pain, myalgia, arthalgia
Above signs plus positive Tourniquet
test
Above signs plus spontaneous
Leukopenia, Occasionally,
Thrombocytopenia, may be
present, no evidence of
plasma loss
Thrombocytopenia, < 100,000,
Hct rise 20 %
Thrombocytopenia, < 100,000, DHF
DHF
DHF
II
III
IV
Above signs plus spontaneous
bleeding
Above signs plus circulatory failure
(weak pulse, hypotension,
restlessness)
Profound shock with undetectable
blood presure and pulse
Thrombocytopenia, < 100,000,
Hct rise 20 %
Thrombocytopenia, < 100,000,
Hct rise 20 %
Thrombocytopenia, < 100,000,
Hct rise 20 %
* DHF Grade III and IV are also called as Dengue Shock Syndrome (DSS)
Clinical Manifestation DSS Clinical Manifestation DSS
Increase of Vascular permeability : Increase of Vascular permeability :
Haemoconcentration Haemoconcentration, , Hypoalbuminemi Hypoalbuminemi, ,
Hypoproteinemia Hypoproteinemia, Shock, Pleural , Shock, Pleural
effusion effusion effusion effusion
Thrombopathy Thrombopathy
Coagulopathy Coagulopathy
Hemorrhage
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PENATALAKSANAAN
Afebrile phase
Duration two days
after febrile stage
Manifestations
In addition to the manifestations of
DHF Grade II :
Circulatory failurse manifested by
rapid and weak pulse, narrowing
of pulse pressure (20 mmHg or
less) or Hypotension with the
presence of cold clammy skin
and restlessness
Capillary relief time more than
two seconds
Management
Check haematocrits/platelet
Initiate IV Therapy (5%D/NSS) 10 ml/kg/h
Check Haematocrit , vital signs, urine output every
hour.
If patient improves IV fluids should be reduced every
hour from 10 to 6 and from 6 to 3 ml/kg/h which can be
maintained up to 24 to 48 hours.
If patients has already received one hour treatment of
20 ml/kg/hr of IV fluids and vital signs are not stable
check haematocrit again and
two seconds
Profound shock with undetectable
pulse and blood pressure.
check haematocrit again and
If haematocrit is increasing change IV fluid to colloidal
solution preferably Dextran or plasma at 10 ml/kg/h
every hr.
If haematocrit is increasing from initial value give fresh
whole blood transfusion, 10 ml/kg/h and continue fluid
therapy at 10 ml/kg/h and reducing it stepwise bring
down the volume to 3 ml/kg/h and maintain it up to 24
48 hours.
Initial IV therapy (5% D/NSS) 20 ml/kg as a bolus one
or two times
Oxygen therapy should be given to all patients.
In case of continued shock colloidal fluids (Dextran or
Plasma) should be given at 10 20 ml/kg/hr.
Afebrile phase
Con Phase
Manifestation
Profound shock with undetectable
Pulse and blood pressure
Manifestation
Management
- If shock still persists and the haemotocrit level
continues declining give fresh whole blood 10
ml/kg as a bolus
- Vital signs should be monitored every 30
60 minutes
- In case of severe bleeding gives fresh whole blood
20 ml/kg as a bolus
- Give platelet rich plasma transfusion exceptionally
when platelet counts are below 5.000 10.000 / mm
3
- After blood transfusioncontinues fluid therapy at 10
ml/kg/h and reduce it stepwise to bring it down to 3
ml/kg/h and maintain in for 24 48 hrs
Management Con Phase
Duration 2 3 days
After recovery from
critical/shock stage
Manifestation
- 6 12 hours after critical/shock
stage some symptoms of
respiratory distress (pleural
effusion or arcites)
- 2-3 days after critical stage ,
strong pulse, normal blood
pressure.
- Improved general
condition/return of appetite.
- Good urine output
- Stable haematocrit
- Pletelet count > 50.000 per mm
3
- Patient could bedischarged from
hospital 2 3 days after critical
stage
- Bradycardia/arrhytmia
- Asthenia and depression (few
weeks) in adult
Management
- Rest for 1 2 days
- Normal diet
- No need for medication
Fluid Therapy in DSS Fluid Therapy in DSS
The policy of initial fluid therapy in DSS The policy of initial fluid therapy in DSS
according to the according to the Department of Health Department of Health
and WHO until 2003 : and WHO until 2003 :
Crystalloid (Lactate Ringer), followed Crystalloid (Lactate Ringer), followed
with colloid ( with colloid (Dextran Dextran) if not responded ) if not responded
32 32
Department of Health Department of Health
Indonesian Intensive Care Association Indonesian Intensive Care Association
Indonesian Anesthesiology Ass Indonesian Anesthesiology Ass
Indonesian Indonesian Paed Paed. Ass (2004) . Ass (2004)
Review on the management of DHF Review on the management of DHF Review on the management of DHF Review on the management of DHF
Change the protocol Change the protocol
Include colloid MMW Include colloid MMW--6% HES as alternative as 6% HES as alternative as
initial fluid resuscitation in DSS initial fluid resuscitation in DSS
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Lactated Ringer's
Volume Replacement Therapy Volume Replacement Therapy
Colloids
Crystalloids Crystalloids
HES
solutions
Dextran
solutions
Gelatin
solutions
Albumin
PPL
Lactated Ringer's
Normal Saline
34 34
Crystalloid (RL, RA, Crystalloid (RL, RA, NaCL NaCL))
Distributed to the interstitial space Distributed to the interstitial space
Very short period in the intravascular space Very short period in the intravascular space Very short period in the intravascular space Very short period in the intravascular space
Need more fluid to maintain intravascular Need more fluid to maintain intravascular
volume volume risk for interstitial edema / risk for interstitial edema /
pulmonary edema pulmonary edema
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HES: ( MW 100.000 HES: ( MW 100.000--300.000 300.000 kD kD ): Sealing ): Sealing
effect +, effect +, good intravascular volume effect, good intravascular volume effect,
longer duration in the intravascular space, longer duration in the intravascular space,
Colloid Colloid
DO2, DO2, VO2 VO2
Dextran Dextran : : LMW colloid (40.000 LMW colloid (40.000- -70.000 70.000 kD kD) )
with good preservation volume effect, with good preservation volume effect, no no
sealing effect sealing effect, increase anaphylactic , increase anaphylactic
reaction reaction
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Hydroxyethyl Hydroxyethyl Starch (HES) Starch (HES)
- - Effective Effective and safe plasma substitute and safe plasma substitute
- - HES HES broad range of MW, from very small until broad range of MW, from very small until
several hundred thousand Dalton several hundred thousand Dalton
- - Classification of HES (by in vitro) according to Classification of HES (by in vitro) according to - - Classification of HES (by in vitro) according to Classification of HES (by in vitro) according to
MW: MW:
-- HIGH MOLECULAR WEIGHT (HMW) HIGH MOLECULAR WEIGHT (HMW) 450 K 450 K Da Da
-- MEDIUM MOLECULAR WEIGHT (MMW) MEDIUM MOLECULAR WEIGHT (MMW) 200 K 200 K Da Da
-- LOW MOLECULAR WEIGHT (LMW) LOW MOLECULAR WEIGHT (LMW) 70 K 70 K Da Da
Sealing effect Sealing effect : HES with 100 : HES with 100 300.000 D MW 300.000 D MW
Effect Effect of HES on Blood Coagulation of HES on Blood Coagulation
HMW HMW--HES HES more effect on blood coagulation more effect on blood coagulation
((vWF vWF, factor VIII) , factor VIII)
LMW (HES 70/0.5/4)/ LMW (HES 70/0.5/4)/MMW(HES 200/0.5/6 MMW(HES 200/0.5/6) ) did did LMW (HES 70/0.5/4)/ LMW (HES 70/0.5/4)/MMW(HES 200/0.5/6 MMW(HES 200/0.5/6) ) did did
not affect on blood coagulation not affect on blood coagulation
Possible Possible dilutional dilutional coagulation effect : PT, coagulation effect : PT, aPTT aPTT
(significant prolongation after HMW (significant prolongation after HMW--HES 480) HES 480)
Fluid Resuscitation in DSS Fluid Resuscitation in DSS
Primary importance in the management Primary importance in the management
of of hypoperfusion hypoperfusion state state
Goal of therapy Goal of therapy Goal of therapy Goal of therapy
Tissue DO Tissue DO
22
Blood Pressure Blood Pressure
VO VO
22
Reversing Lactic Acidosis Reversing Lactic Acidosis
Colloid Colloid
MMW MMW
39 39
Study on DSS using colloid (HES ) Study on DSS using colloid (HES )
as initial fluid resuscitation as initial fluid resuscitation
Tatty E. Tatty E. Setiati Setiati
Different
RESULT
Tatty E. Tatty E. Setiati Setiati
(2000) (2000)
Herminia Herminia L. L. Cifra Cifra
(2001 (2001) H ) H
RESULT
Different
method of
study
40 40
RL group Colloid group
(HAES Steril 6%)
Duration of
shock
( Hour)
7.9+/- 2.6 2.3 +/- 2
Ventilators days 8 +/- 1.1 4.0 +/- 0.71
Pleural effusion 30
M2/Mod7/S21
_
ALI /PaO2/FiO2=200-250
4 1
ARDS
PaO2/FiO2 < 200
6 2
Conclusion Conclusion
Evidenced showed that endothelial dysfunction Evidenced showed that endothelial dysfunction
lead to vascular leakage and lead to vascular leakage and hemostatic hemostatic
disturbances occurred in DSS disturbances occurred in DSS
MMW which has a sealing effect could MMW which has a sealing effect could MMW which has a sealing effect could MMW which has a sealing effect could
minimizing vascular leakage, good preservation minimizing vascular leakage, good preservation
volume effect, and lowering mortality volume effect, and lowering mortality
MMW HES can be used as alternative for initial MMW HES can be used as alternative for initial
fluid resuscitation in DSS fluid resuscitation in DSSS S
42 42
What not to do in DSS
Do not give Aspirin or Ibuprofen for treatment of fever.
Avoid giving intravenous therapy before there is evidence
of haemorrhage and bleeding.
Avoid giving blood transfusion unless indicated, reduction
in haematocrit or severe bleeding. in haematocrit or severe bleeding.
Avoid giving steroids. They do not show any benefit.
Do not use antibiotics
Do not change the speed of fluid rapidly, i.e. avoid rapidly
increasing or rapidly slowing the speed of fluids.
Insertion of nasogastric tube to determine concealed
bleeding or to stop bleeding (by cold lavage) is not
recommended since it is hazardous.
43 43
Signs of Recovery
Stable pulse, blood pressure and breathing rate
Normal temperature
No evidence of external or internal bleeding
Return of appetite Return of appetite
No vomiting
Good urinary output
Stable haematocrit
Convalescent confluent petechiae rash
44 44
SEVERE MALARIA SEVERE MALARIA SEVERE MALARIA SEVERE MALARIA
45 45
What is severe malaria?
Severe malaria is the serious or life-threatening
form of falciparum malaria which needs active
appropriate patient management.
According to WHO criteria in 1990, severe malaria
patients have asexual forms of Plasmodium
falciparum on a blood film and may have any one
or more of the following manifestations and
complications :
46 46
1. Cerebral malaria (unrousable coma not
attributable to any other cause)
2. Severe normocytic anemia (haematocrit <15%
or hemoglobin <5 g/dl)
3. Acute renal failure (urine output <400 ml/24 3. Acute renal failure (urine output <400 ml/24
hours in adults or 12 ml/kg/24 hours in children,
failing to improve after redydration and
serum creatinine >265 mmol/l (3 mg/dl))
4. Pulmonary edema or adult respiratory distress
syndrome (ARDS)
47 47
5. Hypoglyceamia (whole blood glucose <2.2
mmol or l40 mg/dl)
6. Circulatory collapse, shock: hypotension
(systolic blood pressure <50mmHg in children
aged 1-5 years or <70 mmHg in adults), with
cold clammy skin or core-skin temperature
difference >10 C)
7. Spontaneous bleeding/disseminated
intravascular coagulation (DIC)
8. Repeated generalized convulsions
9. Acidaemia (arterial pH <7.25) or acidosis
(plasma bicarbonate <15 mmol/l)
10. Macroscopic haemoglobinuria
11. Post-mortem confirmation of diagnosis
48 48
WHO MULTICENTER STUDY ON SEVERE MALARIA IN UNDER WHO MULTICENTER STUDY ON SEVERE MALARIA IN UNDER
FIVES IN 10 AFRICAN COUNTRIES (1230 CASES, 1999 FIVES IN 10 AFRICAN COUNTRIES (1230 CASES, 1999 2000) 2000)
PREVALENCE OF SIGNS AND SYMPTOMS PREVALENCE OF SIGNS AND SYMPTOMS
SIGNS AND SYMPOMS NUMBER %
SEVERE ANEMIA 666 54.1 SEVERE ANEMIA 666 54.1
PROSTRATION 371 30.2
CONVULSIONS 279 22.7
CEREBRAL MALARIA 218 17.7
HYPOGLYCEMIA 162 13.2
HYPOGLOBINURIA 41 3.3
JAUNDICE 21 1.7
RESPIRATORY DISTRESS 12 1.0
DISSEMINATED INTRAVASCULAR 1 0.08
COAGULATION
49 49
Different clinical manifestation between
adults and children with severe malaria
Adult Children
Cough Uncommon early symptom Common early symptom
Convulsions Indicate cerebral involvement May indicate cerebral
involvement or hypoglycemia,
but may be non specific
consequence of fever
Duration of symptoms Commonly several days Usually 1 2 days only
before features of severe before features of severe
disease develop
Jaundice Common Uncommon
Time from start of Usually quinine 2 4 days Usually 1 2 days
treatment to resolution
of coma in cerebral malaria
Hypoglycemia Relatively uncommon Common
Usually quinine-induced
(especially in pregnancy)
Pulmonary edema Common Rare
Renal failure Common Rare
Neurological sequelae Uncommon Occur in about 10% of cases
after cerebral malaria
Management Management
Parenteral antimalarials.
IV fluid administration.
Vital signs monitoring every 4 hours.
Blood check up for malaria parasite every
day until disappearance of parasitemia. day until disappearance of parasitemia.
Monitoring clinical signs and symptoms of
severe malaria that may occur later.
Record conscious level every 4 hours and
urine output every 8 hours.
51 51
Antimalarial drug doses in severe malaria
Hospital
ICU
Health Clinic :
No Intravenous
Infusion Possible
Rural health clinic :
No injection facilities
Chloroquine-resistant
P falcipanum
Quinine
Quinine dihydrochloride
7 mg salt/kg infused over
30 min followed by
Immediately 10 mg/kg
Over 4 h: or 20 mg salt/kg
Infused over 4 h
Maintenance dose: 10 mg
Salt/kg infused over 2-8 h
Quinine dihydrochloride
20 mg salt/kg diluted 1 : 2 with sterile
water given by split injection into both
anterior thighs. Maintenance dose : 10
mg/kg 8 hourly
Artesunate rectocap :
10 mg/kg daily
Artemisinin suppository
20 mg/kg at 0 and 4 h
Then daily
Chloroquine sensitive
P falcipanum
Salt/kg infused over 2-8 h
At 8 h intervals
Arteminisim derivative :
a) Artemether 3.2 mg/kg
Stat By im injection
Followed by 1.6 mg/kg
Daily
a) Artesunate 2.4 mg/kg stat
By iv injection followed by 1.2
mg/kg daily
Chloroquine
Chloroquine 10 mg base/kg
Infused iv at constant rate over 8 hr
followed by 15 mg base/kg over 24 hr
As for Hospital ICU :
Artesunate can also be
Given by im injection
Chloroquine 3.5 mg
Base kg 6-hourly or 2.5 mg
base/kg 4 hourly by im or sc injection.
Total dose 25 mg base/kg
Chloroquine 10 mg/kg daily
Or nasogastric chloroquine as for
oral regimen
Poor prognostic features in
severe malaria
Clinical findings
Deep Coma Deep Coma
Repeated convulsions
Respiratory distress (rapid, deep, laboured, stertorous,
breathing often with intercostals recession)
Significant bleeding
Laboratory findings
Biochemistry
Hypoglycemia < 2.2 mmol/l
Hyperlactatemia > 5 mmol/l
Acidosis arterial pH<7.3 venous plasma HCO
3
< 15 mmol/l
Serum creatitine >265 mol/l
Total bilirubin > 50 mol/l
Liver enzymes SGOT (AST) x 3 upper limit of normal
SGPT (ALT) x 3 upper limit of normal
5 Nucleotidase
Muscle enzymes CPK
Myoglobin
Urate > 600 mol/l Urate > 600 mol/l
Hematology
Leucocytosis >12.999/l
Severe anemia PCV < 15 %
Coagulopathy Platelet < 50.000/l
PT prolonged > 3 s
Prolonged PPT
Fibrinogen <200 mg/dl
Parasitology
Hyperparasitemia > 100.000/l - increased mortality
> 500.00/l - high mortality
>20% of parasites are pigment containing trophozoites and schizonts
>5% of neutrophils contain visible malaria pigment
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