Paediatrica Indonesiana

VOLUME 52 NUMBER 4 July 2O12

Original Article
Paediatr Indones, Vol. 52, No. 4, July 2012 239
The relationship between pleural effusion index and
mortality in children with dengue shock syndrome
Novrianti Hawarini
1
, Muhammad Sholeh Kosim
1
, M Supriatna
1
, Yusrina Istanti
1
, Eddy Sudijanto
2
Abstract
Background Den,ue shock svndrome (DSS) mortalitv rate is still
hi,h. 1he extent of plasma effusion in den,ue shock svndrome
can be identified in the right lateral decubitus position on chest
x-rav, and quantified bv the pleural effusion index (Pll). lt is
thought that Pll value can be used to predict DSS mortalitv in
children. Pleural effusion in DSS patients can cause respiratorv
failure and death.
Objective 1o determine the relationship between Pll and
mortalitv in children with DSS.
Methods This cross-sectional, retrospective study was held in the
Dr. Kariadi Hospital, Semaran,, lndonesia. Data was taken from
medical records of pediatric intensive care unit (PlCU) patients
with DSS from Januarv 2OO9 to Januarv 2O11. DSS dia,nosis
was confirmed bv clinical and radiolo,ical manifestations. Pll
diagnosis was established by the presence of fluid in the pleural
cavitv on pulmonarv radiolo,ical examinations. X-ravs were
interpreted bv the radiolo,ist on dutv at the time. Chi square and
logistic regression tests were used to analyze the data.
Results There were 1o subjects with DSS, consistin, of 1o males
(37.5 '), and 3O females (62.5'). 1wentv-nine subjects (6O.1')
survived and 19 (39.6') died. ne patient (2.1') had Pll <6',
1 (o.3') had Pll 6-15', 17 (35.1') had Pll 15-3O', and
26 (51.2') had Pll > 3O' on their x-ravs. 1he mortalitv rate
of DSS with Pll 15-3O' was 11.o' (95' Cl O.O21 to O.561,
P<O.OO5) and Pll >3O' was 65.1 ' (95' Cl 3,5o1 to 99,612,
P <O.OO5).
Conclution Pll >15' was a risk factor for mortalitv in children
with DSS. [Paediatr Indones. 2012;52:239-42].
Keywords: pleural effusion index, mortality in
dengue shock syndrome
lrom Department of Child Health, Dipone,oro Universitv Medical
School, Dr. Kariadi Hospital, Semaran,, lndonesia
1
. Department of
Radiolo,v, lacultv of Medicine, Dipone,oro Universitv, Dr. Kariadi
Hospital Semaran,, lndonesia
2
Reprint requests to: Novrianti Hawarini, Department of Child Health,
Dipone,oro Universitv Medical School, Dr. Kariadi Hospital, Jl. Dr.
Soetomo no 16, Semaran,, lndonesia, 5O231. l-mail: novrianti_dr@
yahoo.com
1his paper was presented at the Asia ceania Societv for Pediatrics
Radiolo,v Con,ress in Kuta, Bali, lndonesia, November 11-12, 2O11.
D
engue hemorrhagic fever is an important
cause of morbidity in Asian children,
and den,ue shock svndrome causes a
significant number of childhood deaths.
DSS is characterized bv a massive increase in
svstemic capillarv permeabilitv with consequent
hypovolemia.
1
WH defines DSS as DHl plus si,ns of
circulatorv failure manifested bv rapid and weak pulse,
narrow pulse pressure ( 2O mmH,) or hvpotension
for age, prolonged capillary refill, cold and clammy
skin and restlessness. nset of shock is acute and
occurs at the time of defervescence, usually after
2-5 davs of fever. Durin, shock, patients mav have
subnormal bodv temperature, cold and clammv skin,
as well as rapid and feeble pulse. Pleural effusion and
ascites measurements may be used to predict the
development of DSS.
2-5
Novrianti Hawarini et al: Pleural effusion index and mortalitv in den,ue shock svndrome
240 Paediatr Indones, Vol. 52, No. 4, July 2012
Pleural effusion occurs in the phase of plasma
leaka,e, causin, decreased chest compliance and
reduced functional residual capacity. Furthermore,
pleural effusion causes hypoxemia and increased
breathing effort. Clinical manifestations caused by
pleural effusion depend upon the volume of pleural
fluid, in addition to lung parenchymal pathology, such
as acute respiratory distress syndrome.
6
Right lateral decubitus position on chest x-ray
is used to evaluate pleural effusion. The degree of
plasma leaka,e mav be quantified bv the Pll. Pll
is calculated to be 1OO' times the maximum width
of the right pleural effusion, divided by the maximal
width of the right hemithorax.
7
The objective of this study was to evaluate
the use of Pll values to predict mortalitv in DSS in
children.
Methods
The retrospective, cross-sectional study was held in
the Dr. Kariadi Hospital, Semaran,, lndonesia from
Januarv 2OO9 to Januarv 2O11. Data was taken from
medical records of children with DSS in the PlCU
who fulfilled the inclusion criteria. Eligible subjects
were children a,ed 1-11 vears with dia,noses of
den,ue svndrome (DS) accordin, to WH criteria,
and were not havin, septic or shock condition. DSS
diagnosis was confirmed by clinical and radiological
manifestations. Pll was assessed from lateral decubitus
position on chest x-rays and calculated by the formula
A / B x 1OO' (Figure 1).
8
Radiological examination results were reviewed
bv the on-dutv radiolo,ist. We analvzed data usin,
Chi square and lo,istic re,ression analvses with SPSS
software version 17.O.
Results
1here were 1o PlCU cases of DSS from Januarv 2OO9
to Januari 2O11, consistin, of 1o males (37.5') and 3O
females (62.5'). 1wentv-nine subjects survived (6O.1'),
and 19 died (39.6'), as shown in Table 1. Table 2 shows
the Pll ,roupin,s based on x-rav findin,s.
1he relationship of Pll to death was observed
in Pll values of ,reater than 15', with a statisticallv
si,nificant association in the two hi,hest Pll
cate,ories, 15-3O' and > 3O' (Table 3).
Discussion
This study was conducted to determine the relationship
of plasma leaka,e severitv, as measured bv Pll, to
mortalitv in DSS patients.
Subjects' ,enders in our studv were 37.5' male
and 62.5' female. A 19o7 Sin,aporean studv
1O
reported a higher number of cases of men than
women with a ratio of 1.9 : 1, while a 1993 1hai
11
studv reported ,irls to be two times more frequentlv
hospitalized due to dengue.
1O
ln a 199O lndonesian
studv, cited from Supriatna MS, there was no
significant difference between males and females in
the number of DHl cases and shock events.
1O,12
lrom a total of 1o DSS patients, 19 died (39.6')
and 29 lived (6O.1'). Nationallv, DHl mortalitv rate
was reported to be low (2.5' in 1997) and remains to
be below 3%.
13
ln Semaran, in 2OO1, there were 1621
den,ue cases with an incidence rate of 11.o per 1O,OOO
population and a case fatalitv rate of O.13'. DSS
mortalitv in the Dr. Kariadi Hospital PlCU decreased
from 12' in 2OO2 to 1O.o' in 2OO1.
12
Figure 1. Pleural effusion index calculation
8
Table 1. Characteristics of subjects
Characteristics n = 48 %
Sex
Male
Female
18
30
37.5
62.5
Mortality status
Survived
Died
29
19
60.4
39.6
Novrianti Hawarini et al: Pleural effusion index and mortalitv in den,ue shock svndrome
Paediatr Indones, Vol. 52, No. 4, July 2012 241
DSS is defined as DHl with si,ns of circulatorv
failure, includin, narrow pulse pressure (2O mm H,),
hvpotension, or frank shock. 1he pro,nosis in DHl/
DSS depends on prevention or earlv reco,nition and
treatment for shock. ln hospitals with experience in
treatin, DSS, the case fatalitv rate in DHl mav be as
low as O.2'. nce shock has set in, the fatalitv rate
mav be much hi,her (12' to 11').
11
1he presence of plasma leaka,e can be observed
by the presence of pleural effusion, hemoconcentration,
and hypoalbuminemia. In some studies, significant
pleural effusion has been associated with shock and
mortality.
15
ln our studv, DSS patients had varvin, Pll
measurements: Pll <6 ' (2.1'), Pll 6-15' (o.3'),
Pll 15-3O' (35.1'), and Pll >3O' (51.2'). ln a
1hai studv in DSS patients, pleural effusion was found
in 22 of 26 DSS cases with an avera,e of Pll of 1.1'.
16
1he avera,e Pll from our hospital in 2OO1 was 1o.29'
(DSS) and 1.75' (non-DSS).
15
A limitation of our study was that we could not
use a Kappa test for radiolo,ists' assessment of x-rav
findings, since this was a retrospective study.
Our study revealed a significant relationship
between mortalitv rate from DSS and Pll. ln
conclusion, Pll >15' was a risk factor for mortalitv
in children with DSS.
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PEI Death
n (%)
OR 95% CI P
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>30% 17 (65.4) 18,889 3,581 to 99,642 <0.005
Table 2. PE groupings based on chest x-ray ndings
PEI n = 48 %
< 6%
6-15%
15-30%
>30%
1
4
17
26
2.1
8.3
35.4
54.2
Novrianti Hawarini et al: Pleural effusion index and mortalitv in den,ue shock svndrome
242 Paediatr Indones, Vol. 52, No. 4, July 2012
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