PREDICTION AND MANAGEMENT OF

SEVERE DENGUE

LEONARD NAINGGOLAN
Division of Tropical Infectious Disease
Departement of Internal Medicine
FMUI-CM Hospital
Virulence and viral load
ADE
Innate immunity Immune system
T-cell-mediated
Complement Liver
Autoimmune disease
Apoptosis Vascular Endothelium
Cytokine Tsunami
Genetic
Lei HY et al. Immunopathogenesis of Dengue infection. J Biomed 2001
Hematocrit ↑
→
→
→
Petekie
 Case 1.

Bite
DAY -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

I had high fever from 6 days ago.

So I went to a hospital at the first day of fever

 Case 1.

Bite
DAY -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

I had high fever from 6 days ago.

So I went to a hospital at the first day of fever

They tested Dengue IgG/IgM.
 Case 1.

Bite
DAY -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

I had high fever from 6 days ago.

So I went to a hospital at the first day of fever

They tested Dengue IgG/IgM.

IgM/IgG Dengue (-)

Dr. said it is not dengue fever!!

 Case 2.

Bite
DAY -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

I had high fever from 6 days ago.

So I just took a aspirin.

But I could not get over, so I visit hospital this morning.

 Case 2.

Bite
DAY -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

I had high fever from 6 days ago.

So I just took a aspirin.

But I could not get over, so I visit hospital this morning.

They tested Dengue NS1 Ag.
 Case 2.

Bite
DAY -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

I had high fever from 6 days ago.

So I just took a aspirin.

But I could not get over, so I visit hospital this morning.

They tested Dengue NS1 Ag.

Dengue NS1 Ag (-)

Dr. said it is not dengue fever!!

VIRUS DENGUE
 Immune Response

Symptom
Bite NS1 Ag Antibody
DAY -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

ACUTE CRITICAL CONVALESENCE PHASE

PHASE PHASE
Ag/Ab level

IgG
IgM
NS1 Ag

Day
Dengue Markers
█ Response to Primary Infection
1. NS1 antigens
Day 1 after onset of fever and up to Day 9.
Not detectable once anti-NS1 IgG antibodies are produced.

2. IgM antibodies
Day 5 after onset of fever and rise
for 1-3 weeks, then for up to 60 days.

3. IgG antibodies
Day 14 after onset of fever and persists for life.
Dengue Markers
█ Response to Secondary Infection
1. NS1 antigens
Day 1 after onset of fever and up to Day 9.
Not detectable once anti-NS1 IgG antibodies are produced
(Appearance in short period )

2. IgM antibodies
Produced at low or undetectable levels or
for a shorter period than in a primary infection.

3. IgG antibodies
Rise rapidly 1-2 days after onset of symptoms.
 MENGHITUNG HARI DEMAM
• Tn A, 25 thn datang dg demam
mendadak tinggi sejak 2 hari yll.
Selain demam, pasien juga
mengeluh pegal2, atralgia.
Tetangga pasien ada yg dirawat krn
DBD.
• Tn Z, 32 thn datang dg demam
mendadak tinggi sejak 5 hari yll.
Selain demam, pasien juga
mengeluh pegal2, atralgia.
Tetangga pasien ada yg dirawat krn
DBD.
 MODEL PREDIKSI KEBOCORAN PLASMA PADA PENDERITA
INFEKSI DENGUE DENGAN DEMAM ≤ 48 JAM

Skor
Faktor prediktor Koef SE z p> |z| IK 95%

Petekie (+) 0,439 0,360 1,22 0,222 -0,266 – 1,144 14

Trombosit < 134.000 ( /µL) 0,034 0,013 2,68 0,007 0,009– 0,059 31

SGOT ≥ 48 (U / L) 0,311 0,367 0,85 0,396 -0,408 – 1,030 10

Jumlah skor Tindakan

< 24 Rawat jalan
≥ 24 Rawat inap dan pemberian cairan
infus
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

(Tatty ,2004 )
 ULTRASONOGRAPHY
• An ideal, safety, noninvasive investigation to
detect plasma leakage (pleural - pericardial
effusion & ascites), hepatomegaly,
splenomegaly.

• Abdominal & chest scanning

Detect the early mild form of DHF

• GB-wall-thickening wall thickness > 3 mm

• Pericholecystic fluid
• Minimal ascites
• Pleural & pericardial effusion
• Hepatosplenomegaly
 A B C

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.
ULTRASONOGRAPHY
Detect The Severe Form of DHF :
• Fluids in the perirenal & pararenal
region
• Hepatic & splenic subcapsular fluid
• Pancreatic enlargement
 TATALAKSANA

• Setelah diperiksa pada Tn A ditemukan keadaan umum

baik, hemodinamik baik, dapat makan dan minum dengan
baik. Mual, muntah, dan mimisan disangkal.
• Hasil pemeriksaan laboratorium menunjukkan Leukosit
4800/mm3, Hematokrit 40 vol%, Trombosit 251000/mm3.
• Diinfus?
• Dirawat?
• ???
 TATALAKSANA

• Setelah diperiksa pada Tn Z ditemukan mual, muntah, dan

mimisan.
• Hasil pemeriksaan laboratorium menunjukkan Leukosit
1900/mm3, Hematokrit 43 vol%, Trombosit 59000/mm3.
• Diinfus?
• Dirawat?
• ???
 FLUID REPLACEMENT ON PROBABLE DENGUE
INFECTION IN WARDS

Suspect DHF
Spontaneous and Massive Bleeding( - )
Shock (-)

- Hb, Ht (n)
- Hb, Ht increase 10-20% - Hb, Ht increase > 20%
- Platelets< 100.000
- Platelets< 100.000 - Platelets< 100.000
- Crystalloid infusion *
- Crystalloid Infusion *
- Hb, Ht, Plt every 24 hours
- Hb, Ht, Plt every 12 hours **
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

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.
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

Ht increase Ht 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
(CONTINUED)
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
Not Response
Response:
Monitoring Acid-base &
1. Systolic BP 100 mmHg crystalloid for electrolyte
2. PP > 20 mmHg 10-15 min disturbance,
3. Heart Rate < 100 x/mnt, adequate vol hypoglycemia
, 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