Dengue Shock Syndrome Management

Leonard Nainggolan
Division of Tropical and Infectious Disease
Department of Internal Medicine
Faculty of Medicine Universitas Indonesia
Lei HY et al. Immunopathogenesis of Dengue infection. J Biomed 2001
Dengue Case Management
 Dengue Case Management

 Fluid Replacement Therapy

 Bed rest
 Antipyretics
 Level of Consciousness, Blood Pressure,
Diuresis, HCT, Thrombocyte Monitoring.
 Fluid Replacement

Resuscitation Management

Crystalloid Colloid Electrolyte Nutrition

Repair

Replace acute loss 1. Normal requirements

(hemorrhage, GI loss, Third (IWL + urine+ faeces)
compartment) 2. Nutritional Support
 Fluid Replacement Therapy

Crystalloids Colloids
Lactated Ringer’s
Ringer Acetate
Normal Saline

Albumin Gelatin Dextran HES

PPL solutions solutions solutions
 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

Crystalloid 7 mL/kg BW in 1 h
Crystalloid 20-30 mL/kg BW loading for 20-30 min

Response
Not Response

Crystalloid 5 mL/kg BW in 1 h

Hct increase Hct decrease

Response

Colloid 10-20 mL/kg BW loading for 10-15 min Blood transfusion 10 mL/kg
BW can be repeated if
Crystalloid 3 mL/kg BW in 1 h
necessary

Response* Not Response

Response

Colloid until max 30 mL/kg BW

Within 24-48 h after shock
controlled, vital signs/Ht stable,
urine output increasing Response* Not Response
Consider for nutrition after
12 h (Dx 5 % If no
Stop infusion contraindication) CVP
 Management of Dengue Shock Syndrome

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 Normovolemi
c
Not Response
Response:
Monitoring Acid-base &
1. Systolic BP 100 mmHg crystalloid electrolyte
2. PP > 20 mmHg for 10-15 min disturbance,
3. Heart Rate < 100 x/mnt, adequate vol hypoglycemi
a, anemia,
4. Warm extremities secondary
5. Diuresis 0,5-1 cc/kgBW/hour infection
correction

Inotropic,
Vasopressor,
drug

Colloid & Vasopressor

Response* crystalloid gradual
combination increment
The Role of Colloids in DSS
Management
 Arteriole Venule

Hydrostatic
Pressure Oncotic Pressure

pre-Capillary post-capillary
Hydr. Pr > Onc. Pr Onc. Pr > Hydr. Pr
 Molecular Shape of Semi-Synthetic Gelatins
Mw=30000 Dalton Mw=35000 Dalton

Succinylated, charged Urea-linked Polygeline

Modified Fluid Gelatin/ MFG (Haemaccel)
(-) (-)
(-) “Repelling Effect”:
(-)
(-)
Negative charges of
(-) endothelial cells will repell with
(-) negative charges of MFG molecules
(-)
Result:
(-) Strong volume effect, longer duration
(-)
effect & minimize chloride
(-) (-)

(-)
(-)
 Fluid Replacement Therapy

Crystalloids Colloids
Lactated Ringer’s
Ringer Acetate
Normal Saline

Albumin Gelatin Dextran HES

PPL solutions solutions solutions
Characteristic Modified fluid Polygelin Oxypolygelatin
gelatin (MFG)
Process Succinylated Urea-linked gelatin
gelatin
Molecule Weight 30,000 Dalton 35,000 Dalton 30,000 Dalton
Molecule shape stretched Small and globular small and globular
polypeptides molecular polypeptide chains
polypeptide chains
Charge significant multiple Less negative charge Less negative charge
negative charge
 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

Crystalloid 7 mL/kg BW in 1 h
Crystalloid 20-30 mL/kg BW loading for 20-30 min

Response
Not Response

Crystalloid 5 mL/kg BW in 1 h

Hct increase Hct decrease

Response

Colloid 10-20 mL/kg BW loading for 10-15 min Blood transfusion 10 mL/kg
BW can be repeated if
Crystalloid 3 mL/kg BW in 1 h
necessary

Response* Not Response

Response

Colloid until max 30 mL/kg BW

Within 24-48 h after shock
controlled, vital signs/Ht stable,
urine output increasing Response* Not Response
Consider for nutrition after
12 h (Dx 5 % If no
Stop infusion contraindication) CVP
 Management of Dengue Shock Syndrome

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 Normovolemi
c
Not Response
Response:
Monitoring Acid-base &
1. Systolic BP 100 mmHg crystalloid electrolyte
2. PP > 20 mmHg for 10-15 min disturbance,
3. Heart Rate < 100 x/mnt, adequate vol hypoglycemi
a, anemia,
4. Warm extremities secondary
5. Diuresis 0,5-1 cc/kgBW/hour infection
correction

Inotropic,
Vasopressor,
drug

Colloid & Vasopressor

Response* crystalloid gradual
combination increment
THANK YOU...