Curriculum

 Vitae  
Mulya  Rahma  Karyan',  MD,  MSc  
Staff  member  of  Faculty  of  Medicine,  University  of  Indonesia    

•  Educa'on  
–  General  Prac**oner  graduated  from  Faculty  of  Medicine,  University  of  
Indonesia,  1994  
–  Pediatrician  graduated  from  Faculty  of  Medicine,  University  of  
Indonesia,  2004  
–  Fellowship  in  Pediatric  Tropical  Infec*ous  Diseases  from  Faculty  of  
Medicine,  University  of  Indonesia,  2005  
–  Training  on  tropical  Infec*ous  disease  on  public  health,  WHO-­‐SEARO,  
April  2009  
–  Master  Clinical  Epidemiology,  Utrecht  University  2009-­‐2011  
–  Consultant  Infec*on  and  Tropical  Pediatrics,  2011  
 
•  Organisasi    
–  Treasurer  of  Na*onal  Indonesia  Pediatric  Society  2008-­‐2010  
–  Member  Asian  Society  of  Pediatric  Infec*ous  Disease  (  ASPID  )    
–  Chair  of  Pediatric  Pharmacy,  Indonesia  Pediatric  Society  2015-­‐2017  
Update  diagnosis  and  management    
of  dengue  infec*on    

Dr.  Mulya  Rahma  Karyan',  SpA(K),  MSc    

Division  of  Infec'on  and  Tropical  Pediatric,    

Department  of  Child  Health,  Cipto  Mangunkusumo  Hospital,  
University  of  Indonesia,  Jakarta  
 Outline  topics  
•  Epidemiology  dengue  in  Indonesia  
•  Consensus  for  Dengue  Na'onal  Guideline  
•  Update  criteria  dengue  diagnosis  
•  Update  dengue  management    
•  Triage  
The  ten  highest  dengue  endemic  countries  

Average  annual  number  dengue  cases  

reported  to  WHO  from  most  highly  
endemic  countries  2004  -­‐  2010  

World  Health  Organiza'on.  (2012).  Global  Strategy  for  Dengue  Preven3on  and  Control  
2012  -­‐  2020.  Geneva:  World  Health  Organiza'on.  

4  
 IR(cases/100000personyears)      
 

0  
10  
20  
30  
40  
50  
60  
70  
80  
90  
1968  
1969  
1970  
1971  
1972  
1973  
1974  
1975  
1976  
1977  
1978  
1979  
1980  
1981  
1982  
1983  
1984  
1985  
1986  
1987  
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1990  
1991  
1992  
1993  

Year  
1994  
1995  
1996  
1997  
1998  
1999  
2000  
2001  
2002  
2003  
2004  
2005  
2006  
2007  
2008  
2009  
2010  
Directorate General DC&EH, Ministry of Health, Indonesia

2011  
Source : Sub directorate of Arbovirosis - Directorate of VBDC,

2012  
2013  
2014  
Incidence  of  DHF  in  Indonesia  1968  -­‐  2016  

2015  
2016  
Incidence  of  DHF  over  the  past  45  years  in  Indonesia  increased  rapidly    
IR  
 CRF  

0  
5  
10  
15  
20  
25  
30  
35  
40  
45  
1968  
1969  
1970  
1971  

1966
WHO
1972  
1973  
1974  
1975  
1976  

1975
WHO
1977  
1978  
1979  
1980  
1981  
1982  
1983  
1984  
1985  
1986  
1987  

1986
1988  
1989  
WHO
1990  
1991  
1992  
1993  

Year  
1994  
1995  
1996  
1997  
1998  
1997
1968-­‐2016  

WHO

1999  
2000  
2001  
2002  
2003  
2004  
2005  
2006  
2007  
2008  
2009  
2009
WHO

2010  
Directorate General DC&EH, Ministry of Health, Indonesia

2011  
Source : Sub directorate of Arbovirosis - Directorate of VBDC,
2011

2012  
WHO

2013  
Case  Fatality  Rate  of  DHF  in  Indonesia  

2014  
2015  
2016  
Dengue case mortality is reduced significantly within 45 years
CFR  
DHF  cases  based  on  age  group  1993-­‐2013  

DHF  cases  are  increasing  in  older  age  group  (>  15  years  old)  
 DENV  Serotypes  in  Indonesia  
Past  and  present  serotype  distribu0on  

2010  (1)  
Medan  

1994  (17)  

2010  (7)  
2010  (6)  
1998  (77)   Samarinda   Jayapura  
Palembang   Kendari  
Makassar  
Jakarta   2010  (1)  
Surabaya  
Bandung   Bali  
2010  (9)   2004  (28)   Yogyakarta   Merauke  

2001  (1)  

2002  (53)        1996  (162)     2010  (19)          2010  (13)        2010  (118)  
4 1
3 2

Ong  2008,  Osman  2009,  Kalayanarooj  2007,  Ito  2010,  Schreiber  2009,  Sasmono  2011     Serotype Legend
Guideline  of  Diagnosis  and  therapy  of  
Dengue  Infec*on  in  Children  

Pedoman     Written by
Diagnosis  dan  Tata  laksana  
Infeksi  Dengue  pada  Anak   Infection & Tropical Pediatric Group
Indonesian Pediatric Society

Published by
Badan Penerbit
Penyun'ng  
Sri  Rezeki  Hadinegoro  
Ismoedijanto  P  Moedjito  

Indonesian Pediatric Society

Alex  Chairulfatah  

Jakarta, 2014  
UKK  Infeksi  dan  Pediatri  Tropis  IDAI  
 Dengue  Classifica*on  

Source:  Comprehensive  guideline  for  preven'on  and  control  of  dengue  and  dengue  haemorrhagic  fever.    
Revised  and  expanded  edi'on.  Regional  office  for  South-­‐East  Asia,  New  Delhi,  India  2011.  
 
Diagnosis  criteria  of  dengue  infec*on  
 Clinical  Diagnosis    
Dengue  Infec*on    
Na*onal  Guidelines,  adopted  WHO  2011  

•  Acute  high  fever  within  2-­‐7  days,  suddenly,  

con'nue,  biphasic  
•  Hemorrhagic  manifesta'ons:  spontaneous  or  
petechiae,  purpura,  ecchymosis,  epistaxis,  gum  
bleeding,  hematemesis,  melena,  or  posi've  
tourniquet  test  
•  Headache,  myalgia,  arthralgia,  retro-­‐orbital  pain.  
•  Detected  dengue  cases  either  at  surrounding  
house  or  school  
•  Leucopenia  <4.000/mm3  
UKK  IPT  2014,  WHO  2011  
 Clinical  Diagnosis    
Dengue  Fever    
Na*onal  Guidelines,  adopted  WHO  2011  
Fever  with  2  of  following:   Laboratory  findings:  
•  Headache   •  Leucopenia  (wbc  <  4000  
•  Retro-­‐orbital  pain   cells/mm3)  
•  Myalgia   •  Thrombocytopenia  
(Platelet  count  <  100,000  
•  Artralgia/  bone  pain  
cells/mm3)  
•  Rash  
•  No  evidence  of  plasma  
•  Haemorrhagic   loss  
manifesta'ons  
•  No  evidence  plasma  
leakage  

Fever  with    >  2  signs  or  clinical  manifesta*ons  

UKK  IPT  2014,  WHO  2011  
 Clinical  Diagnosis    
Dengue  Haemorrhagic  Fever    
Na*onal  Guidelines,  adopted  WHO  2011  
•  Clinical  manifesta'ons  
–  suddenly  high  fever  2-­‐7  days  
–  Bleeding  manifesta'on  
–  hepatomegaly  
–  circulatory  failure  (hypovolemic  shock)  
•  Laboratory  findings  
–  Thrombocytopenia  <  100.000/mm3  
–  Hemoconcentration  >  20%  or  plasma  leakage  proven  
–  Probable  dengue  by  serology    
–  Confirmed  dengue  by  hemaglu'na'on  inhibi'on  test/  PCR  

Fever  with    2  clinical  manifesta*ons  with  

 laboratory  findings  
 Important:  how  to  differen*ate  between    
DF  and  DHF  
•  DF has no plasma leakage, no hypovolemic shock
•  DF has good outcome
•  Bleeding in DF is usually mild
•  Key to differentiate between DF and DHF is monitoring at the early
shock phase (day 3-5 of illness)

Time of fever Dengue Fever

defervescence Aker  fever  ceased,    
(fever ceased) •         good  clinical  condi'ons,    
•         good  appe'te  
Dengue Hemorrhagic Fever
Aker  fever  ceased,    
•         worst  clinical  condi'ons,            
•         followed  by  hypovolemic  shock  
Days of illness: 0 1 2 3 4 5 6 7 8 9 10
Phases of dengue: Febrile Critical Recovery
6 Key features:  
40
1. Temperature
38

Potential
Dehydration Reabsorption
clinical issues Fluid overload
Shock
2. Oral intake
3. Urine output Bleeding

Capillary permeability

Organ Impairment
Laboratory
changes Platelet

4. WBC WBC
5. Platelet
Haematocrit
6. HCT

IgM/IgG
Viraemia

Virology and Serology

Adapted from WCL Yip, 1980 by Hung NT, Lum LCS, Tan LH
Differen'al  diagnosis  of  DHF  febrile  phase  
•  Influenza,
•  Measles
Flu-like •  Chikungunya
syndromes
•  Febrile convulsion
•  Encephalitis

CNS Febrile Acute

infections phase exanthema

•  Rubella, measles
•  Scarlatina
•  Meningococcal infections
•  Enteric infection Diarrhoeal •  Chikungunya,
•  Rotavirus diseases •  Drug fever
 “Warning  Signs”  
•  No  clinical  improvement  at   •  Bleeding  tendency:  
a-­‐febrile  phase     epistaxis,  black  stool,                      
•  Refused  oral  intake   hematemesis,  menorrhagia  
•  Recurrent  vomi'ng     haemoglobinuria  or  
hematuria  
•  Severe  abdominal  pain  
•  Giddines  
•  Lethargy,  change  of  
behavior     •  Decreased  diuresis  within  
4-­‐6  hours  
•  Pale,  cold  hand  and  foot  
 

Early  shock  detec'on  

 Dengue  complica*ons    
according  to  course  of  illness  
Febrile  phase   Cri'cal  phase   Convalescence  
•  Dehydra'on   •  Hypovolemic   •  Hypervolemia  
•  Febrile   shock   •  Acute  lung  
convulsion   •  Massive  bleeding   edema  
•  Organs  
involvement  

Warning  signs!   Plasma  reperfusion  

 Dengue Shock Syndrome (DSS)

Compensated   Decompensated  
Profound  shock  
shock   shock  
•  Tachycardia •  Tachycardia •  Unpalpable pulse,
•  Tachypnea •  Hypotensive •  Undetectable blood
•  Pulse rate <20 mmHg •  Narrow of pulse rate pressure
•  Capillary refill time > 2 sec
•  Hyperpnea or
•  Cold skin
Kussmaul
•  Decreased urine output
•  Cyanosis
•  Restless
•  Cold and clamp skin
 Dengue Shock Syndrome (DSS)
Hours Minutes Cardiovascular collaps

•  Tachycardia •  Severe
•  Diastolic Decom •  Prolonged metabolic
Compen increased hypotension Profound acidosis
sated pensated
without •  Hypoxia shock •  Multi organ
shock increased of
shock
failure
systolic

Coagulation dysfunction Massive

Thrombocytopenia bleeding (DIC)

Without prompt & good treatment, patient will die in hours

(“tsunami storm”) Hadinegoro.  Tatalaksana  Infeksi  
Dengue.  Semarang  ,2014  
 Differen'al  diagnosis  at  cri'cal  phase  

•  Acute leukemia
•  Other malignancy
Malignancy

Infections Others

•  Acute gastroenteritis, •  Acute abdomen,

•  Malaria, •  Acute appendicytis
•  Leptospirosis, •  Acute cholecystitis,
•  Typhoid fever, •  Kawasaki syndrome,
•  Viral hepatitis,
DHF •  Lactate acidosis
•  Septic shock critical
  phase  
 Complica*ons  
Con'nued  fluid  therapy  
Excessive  fluid  replacement     aker  the  period  of  plasma  
Profound/   leads  to  massive  effusions    
Prolonged   leakage  
shock    
•  Respiratory  compromise,    
•  Acute  pulmonary  conges'on    
•  Heart  failure  

•  Metabolic  acidosis    
•  Severe  bleeding  (DIC)    
Metabolic/electrolyte    
•  Mul'-­‐organ  failure  (hepa'c  &  
renal  dysfunc'on)  
disturbance  

•  hypoglycemia,     Unusual    
•  hyponatremia,   manifesta'ons,  
•  hypocalcemia   e.g.  encephalopathy  
•  hyperglycemia  
 •  Recurrent shock
Complications of •  Prolonged shock
severe profound •  Fluid overload
shock •  Severe hemorrhages
Expanded  
Dengue  
Syndrome      
(unusual or atypical
manifestations)

•  Uncommon
Unusual •  Neurological signs (encephalopathy):
manifestations convulsions, changes in consciousness,
transient paresis
•  Hepatic, renal, heart,
•  Co-morbidity
•  Underlying disease: DM, asthma, etc
Laboratory  examina*ons  in    
dengue  infec*on  
 Laboratory  examina*ons    
in  Dengue  Infec*on  

•  Hematological  parameter  
•  Virus  isola'on  
•  Virus  an'gen  detec'on  
•  Response  immune  detec'on/  an'  
dengue  serological  test  
 Other  important  laboratory  finding    
•  79%  of  dengue  infec'on   •  Increased  liver  func'on  
cases  have  WBC  <   test:  AST  in  90%  cases,  
5000/µl     ALT  in  62.8%  cases  

Posi've  Tourniqueoe  test  +  WBC  <  5000/µl  

èPPV  83%  

Leucopenia  +  rela've  lymphocytosis  +  increased  

atypical  lymphocyte  indicate  within  24  hours  fever  will  
be  subsided  and  enter  the  cri'cal  phase  
 Reporting of dengue cases
for surveillance  
•  Suspected  dengue:  clinical  dengue  with  
simple  lab  findings  of  hemoconcentra'on/  
signs  of  plasma  leakage  and  
thrombocytopenia  
•  Probable  dengue:  above  +  serology  an'body  
IgG  &  IgM  dengue  
•  Confirmed  dengue:  above  +  virology/  serology  
an'gen  dengue  NS1/ELISA  increase  4  'mes  
 Dengue  an'gen  detec'on  &  serological  test  

1                                                                  2                                                            3                                                            4                                                              5                                                          9          day  of  fever  

•  Primer  infec*on  
         IgM  detected  earlier  than  IgG  or  in  the  beginning  of  infec'on  no  IgG  was  detected  
 
•  Secondary  infec*on  
         IgG  detected  at  the  beginning  of  infec'on;  IgM  'ter  sec  infec'on  <IgM  primary  infec'on  
 Chest  x-­‐ray  

Supine position Right lateral decubitus position

•  Right  hemithorax:  more  opaque  than  lek  side  

•  Right  hillus  much  dense  than  lek  hillus  
•  Right  diaphragm  has  higher  posi'on  than  lek  side  
(>  2  intercostal  space)  
•  Right  pleural  effusion  
 Laboratory  follow  up  sheet  
Tgl   Dema Jam   Kesadaran   FN   FP   TD   Suh LP   Nyeri   Hepat Diuresis   Pendar Sesak   Hb   Ht   L     Tr   IVFD  
m  hari   u   (cm)   perut   omega ahan  
ke-­‐   li  
                                                             52            7ml/
g/hr  
                                                                           
                                                                           
                                                                           
                                                                           
                                                                           
                                                             48            7ml/
g/hr  
 
                                                                           
                                                                           
                                                                           
                                                                           
                                                                           
                                                             46            5ml/
g/hr  
 

Dengue  follow  up  sheet:    

clinical  and  laboratory  findings  every  hour  
 A-­‐B-­‐C-­‐S  Examina*on  
Abbrevia*on   Lab  exam   Note  
A  –  Acidosis   Blood  gas   Indicate  prolonged  shock,  mul'  organ  failures                
analysis       Examined:  liver  func'on,  BUN,  ureum,  
crea'nin.  
B  –  Bleeding     Hematocrit   If  Ht  dropped  compared  to  previous  value  or  
not  rising,  cross  match  for  blood  transfusion  
soon  
C  –  Calcium     Electrolyte  Ca++   Hypocalcemia  always  occur  in  all  DHF  cases  
but  asymptoma'c.  In  severe  or  complicated  
case  is  indicated.    
S  –  Blood  sugar   Blood  sugar   Most  severe  cases  have  poor  appe'te  and  
(dextros'x)   vomi'ng  
Those  with  liver  dysfunc'on  hypoglycemia.  
Some  cases  may  have  hyperglycemia.    
Note:  profound  shock  or  have  complica'ons,  and  cases  with  no  clinical  improvement  
Role  of  calcium  in  inter-­‐vascular  
 adherent  junc'on  
 C-­‐calcium  
•  The  role  of  calcium  
–  take  part  of  vascular  endothelial-­‐junc'on  regula'on,  
–  in  the  increased  of  vascular  permeability,  monitor  of  
calcium  serum  is  mandatory.  
–  severe  or  complicated  case  giving  the  calcium  is  indicated    
 
•  Dose  of  Ca  gluconate    
–  1mg/kgBW  diluted  twice,  intravenous  slowly  
–  could  be  repeated  every  6  hours  if  needed    
–  maximal  dose  is  10ml  
 S-­‐sugar  
•  Serum  blood  sugar  should  be  monitored  since  
beginning  of  the  illness  
•  Decreased  of  appe'te,  recurrent  vomi'ng  will  
cause  hypoglycemia  par'cularly  in  severe  
case    
•  Correc'on  of  hypoglycemia  will  improved  
prognosis  
•  Liver  dysfunc'on  also  cause  of  hypoglycemia,  
but  in  some  cases  have  hyperglycemia  
Management  of  dengue  infec*on  
 Triage  System  
Patient with fever 2-7
days, to differentiate
whose patient has TRIAGE  
warning signs

1.  Need direct hospitalization Outpa*ent  

2.  Need closed monitor Hospitalized   care  
3.  Treat as outpatient

Emergency  +   One  Day  Care   Discharge:  

Actions: treat, monitor warning  signs   (24  hours)  for   observa*on  
& observed closed  monitor   during  fever  
Treat  properly  

•   By use the triage system (one day care=ODC),

reduced 76% hospitalization of suspected dengue cases
•  ODC is very useful in outbreak situation
Sri  Rezeki  Hadinegoro,  Tumbelaka  AR.  Sari  Ped  1998;1:1-­‐4  
 Priori*es  at  the  Front-­‐Line:  the  first  3  days  
•  Focus  should  be  on  adequacy  of  oral  fluid  intake:    
       “3  Golden  Ques'ons”:    
1.  How  much  fluid  intake?  What  types  of  fluids?  
2.  How  much  urine  passed?    
3.  What  ac'vi'es  could  pa'ent  do?  
•  Iden'fying  risk  factors  for  severe  disease:  infants,  co-­‐
morbid  condi'ons  such  as  chronic  hemoly'c  
diseases,  obesity,  life-­‐style  diseases,  pregnancy,  old  
age  

•  Home  care:  Fever  control,  Educa'on  of  warning  signs  

Priori*es  at  the  Front-­‐Line:  the  first  3  days  
Follow-­‐up  on  fever  is  important!
Time of fever defervescence

Warning signs
Better clinical manifestation
Worst in clinical
Good appetite Clinical
judgment manifestations, sign of
Good fluid intake
dehidration/
Fluid losses
hypovolemic shock
 Suspected Dengue Infection  
•  Fever  <7  days   •  Headache,  retroorbital  pain,  myalgia,  
•  Skin  rash   arthralgia  
•  Bleeding  manifesta*ons   •  Leucopenia  (≤4000/mL)  
(tourniquet  test/spontaneous)   •  Dengue  case  in  the  neighborhood  
 
Warning signs  
•  No  clinical  improvement  at  afebrile  phase     •  Bleeding  tendency:  epistaxis,  black  stool,  hematemesis,  
•  Refused  oral  intake                  menorrhagia,  black  color  urine  (haemoglobinuria)  or  
•  Recurrent  vomi*ng     hematuria  
•  Severe  abdominal  pain   •  Giddines  
•  Lethargy,  change  of  behavior     •  Pale,    cold  extrimi*es    
•  Decreased  diuresis  within  4-­‐6  hours  

No     Yes  

No   •   Co-­‐morbidity   Yes   Clinical  &  lab  follow-­‐up  

Hospitaliza*on  
•   Social  indica'on  

Send  home   Warning   DHF   DHF  with     Expanded  Dengue  

managed  at   Closed     signs     shock   Syndrome  
out  pa*ent   follow-­‐up  
•  Organ  involvement  
clinic   •  Complica'on  
•  Co-­‐morbidity  
•  Co-­‐infec'on  
 Home  care  advice  for  pa'ents  
•  Take  adequate  bed  rest  
•  Adequate  intake  of  fluids:  milk,  fruit  juice,  isotonic  electrolyte  
solu'on,  ORS.  
•  Keep  body  temperature  below  390C,  give  paracetamol  10mg/
kg/dose  every  6  hours,  avoid  aspirin,  NSAID  &  ibuprofen  

•  Take  to  hospital  soon  

                 ¤  Worst  clinical  manifesta'on  at  a-­‐febrile  phase    
                 ¤  Severe  abdominal  pain  
                 ¤  Recurrent  vomi'ng,    
                 ¤  Cold  hand  and  foot  and  clamp    
                 ¤  Lethargy    
                 ¤  Bleeding    
                 ¤  Dyspnea  
                 ¤  Convulsion  
 Who  should  get  an  IV  Fluid?  

1.  Those  with  shock  

2.  Those  with  warning  signs  during  the  cri'cal  phase  

 
3.  No  shock  and  no  warning  signs  BUT    
             “not  able  to  drink  enough  to  urinate  enough”    
             during  cri'cal  phase    
When to start and stop intravenous fluid therapy

Febrile  phase  
Limit  IV  fluids  (oral  fluid  advice)    
Early  IV  therapy  may  lead  to  fluid  overload  especially  with  
non-­‐isotonic  IV  fluid  
Cri*cal  phase    
IV  fluids  are  usually  required  for  24  –  48  hours    
NOTE:  For  pa'ents  who  present  with  shock,  IV  therapy  
should  be  <48  hours    
Recovery  phase  
IV  fluids  should  be  stopped  so  that  extravasated  fluids  can  be  
reabsorbed  
 Compensated  Dengue  Shock  Syndrome  
•   Give  oxygen  2-­‐4L/minute  
•   Check  hematocrit  
• Crystalloid  RL/RA  10-­‐20ml/kg.BW  within  60  minutes  

Yes   Shock recovered No  

IVFD  10ml/kg.BW,  1-­‐2  hours     Check  Ht,  blood  gas,  blood  glucose,      
calcium,  bleeding  (ABCS)  
Correc'on  soon  for  acidosis,  
Stabile,     hypoglycemia,  hypocalcaemia  
Decreased  IVFD  gradually  
7,  5,  3  ,  and  1,5  ml/kg.BW/ Ht  increased   Ht  decreased  
hour  
2nd  bolus  for  crystalloid  
Or  colloid  10-­‐20ml/kg.BW     Bleeding  
within  10-­‐20  minutes     Unclear  
Stop  IVFD  
maximal  48  hours    
aker  shock  recover   Colloid  10-­‐20ml/kg.BB    
within  10-­‐20menit,  if  shock   Blood  transfusion  
persist  suggested  blood  
transfusion     UKK  IPT  2014,  WHO  2011  
 Decompensated  Dengue  Shock  Syndrome  
•   Give  oxygen  2-­‐4L/minute  
•   Examine  hematocrite,  blood  gas,  blood  glucose,    calcium,  bleeding  (ABCS)  
•   Crystalloid  or  colloid  10-­‐20ml/kg.BW  within  10-­‐20  minutes  

Yes   Shock recovered No  

IVFD  10ml/kg.BW,  1-­‐2  hours     Evaluated  Ht,  blood  gas,  blood  glucose,      
calcium,  bleeding  (ABCS)  
Correc'on  soon  for  acidosis,  
Stabile,     hypoglycemia,  hypocalcaemia  
Decreased  IVFD  gradually  
7,  5,  3  ,  and  1,5  ml/kg.BW/ Ht  increased   Ht  decreased  
hour  
2nd  bolus  for  crystalloid  
Or  colloid  10-­‐20ml/kg.BW     Bleeding  
within  10-­‐20  minutes     Unclear  
Stop  IVFD  
maximal  48  hours    
aker  shock  recover   Colloid  10-­‐20ml/kg.BB    
within  10-­‐20menit,  if  shock   Blood  transfusion  
persist  suggested  blood  
transfusion     UKK  IPT  2014,  WHO  2011  
HOW MUCH & HOW FAST to run intravenous fluid?

Child  
Compensated  shock:  10  to  20  ml/kg  over  1  hour    
Decompensated  shock:  20  ml/kg  over  15  to  30  minutes    

AFTER  correc*on  of  shock:  

REDUCE  IV  infusion  rate  in  step-­‐wise  manner  whenever:  
•  Haemodynamic  state  is  stable  
•  Rate  of  plasma  leakage  decreases  towards  end  of  
cri'cal  phase/  hematocrite  decreases  2  'mes  serial  

indicated  by:  
Improving  haemodynamic  signs    
Increasing  urine  output    
Adequate  oral  fluid  intake  Haematocrit  decreases  below  
baseline  value  in  a  stable  pa'ent  
Lum  L.  Dengue  symposium,Bangkok  2014,  WHO  2011  
 When to stop intravenous fluids?

Plasma  leakage  is  self-­‐limi'ng  

Knowing  when  is  cri'cal  to  dengue  management  

Step-­‐wise  reduce  IV  infusion  rate  un'l  it  is  stopped,  same  as  
in  earlier  slide.  
Definitely  stop:    
1.  Features  of  intravascular  compartment  overload    
a.  Oedema  palpebra  
b.  Breathing  difficul'es,  pulmonary  oedema  
c.  Hypertension  with  good  volume  pulse  
2.  48  hours  aker  defervescence    
 

Lum  L.  Dengue  symposium,Bangkok  2014,  WHO  2011  

 Colloid therapy in dengue shock
                           
 
When  are  colloids  given?  
1.  Decompensated  shock1,2,3  
2.  Repeated  shock  –  2nd  or  3rd  shock  and  onwards  
3.  Aker  >20  to  30  ml/kg  of  crystalloids  
4.  HCT  does  not  decrease  aner  crystalloid  administra*on  
in  shock  state  

DOSE:  Limited  to  30  ml/kg/day  

 
 

1  Dung  NM,  Day  NP,  Tam  DT.  Clin  Infect  Dis,  1999,  29:787–794;  2  Ngo  NT,  Cao  XT,  Kneen  R.  Clin  Infect  Dis,  

2001,  32:204–213.  3  Wills  BA  et  al.  N  Engl  J  Med,  2005,  353:877–889.    
 Pearls: How to recognize severe bleeding
Determine if the patient has UNSTABLE haemodynamic status
NOTE:  If  NO  clinical  improvement  with  reduced  HCT,  think  significant  occult  bleeding  

Any ONE of the following:

1.  Abdominal distention and pain increase

2.  Massive bleeding, regardless of the HCT level
3.  A decreased HCT after fluid resuscitation, especially with colloids
4.  Decompensated shock with low/normal HCT before fluid resuscitation
5.  Refractory shock
6.  Persistent metabolic acidosis
Remember that clinical signs come as a “package”. Mostly likely,
more than one of the above will be observed.
Group  and  CROSS  MATCH  for  all  dengue  SHOCK  (esp  Decompensated)  pa'ents  at  admission  
Lum  L.  Dengue  symposium,Bangkok  2014  
 Emergency treatment
of haemorrhagic complications

Give: 5–10 ml/kg of fresh packed red blood cells or

10–20 ml/kg of fresh whole blood at appropriate rate
Reduce colloid/crystalloid infusions

What is a good clinical response?

•  Improving haemodynamic state – vital signs, peripheral
perfusion and urine output
•  Improving acid-base balance

When should you consider repeating blood transfusion?

1.  Further blood loss

2.  Unstable haemodynamic state

Lum  L.  Dengue  symposium,Bangkok  2014,  WHO  2011  

 Thrombocyte  transfusion  indica'on  
•  Severe  bleeding  (gastrointes'nal  bleeding,  
metrorrhagia)  
•  Together  with  Fresh  frozen  plasma  (+PRC  if  
necessary)  
•  Low  platelet  count  with  stable  vital  signs  not  
indicated  
•  Not  indicated  for  prophylac*c  

Sellahewa  KH.  Dengue  Bulle'n  2008;32:211-­‐8.  

Thomas  L,et  al.  Transfusion:49:1400-­‐11  
 High  risk  group  
Underlying
diseases/
comorbid Prolonged
Pregnancy
shock

Obese Significant
patients bleeding

High  
Infants, elderly risk   Encephalopathy
group  

UKK  IPT  2014,  WHO  2011  

 Fluid  management  in  dengue  infec'on  
NO  plasma  leakage   Plasma  leakage  

Dengue  fever   DHF  non-­‐shock   DHF  shock  

Oral  or  maintenance   Maintenance  +   Loading  crystalloid  of  

(Dextrose  5%:NS=3:1)   deficit  5-­‐10%   20  ml/kgBW,followed  
(crystalloid)   by  colloid  if  
necessary,  then  
reduce  by  'tra'on  
 
Adequate  fluid  therapy  gives  good  response  without  inotropics    
 Hematocrit  
Summary  of  M
IV  onitoring   And  in  Ddengue  
fluid  therapy   engue  

Inadequate   Adequate   Excessive  

Hypovolaemia   Improved  circula'on     Fluid  overload:  

and  'ssue  perfusion   •   Pulmonary  oedema  
Compensated  shock     •   Respiratory  distress  
   
• Worsening  pleural  effusion  
•   Capillary  refill  <2  seconds  
Decompensated   •   Normal  heart  rate   and  ascites  
shock   •   Normal  blood  pressure   •   Clinical  deteriora'on  
•   Normal  pulse  pressure  
•   Urine  0.5ml/kg/hr  
•   Bleeding  
•   ↓  HCT  to  normal  
•   DIC   •   Improving  acid-­‐base  
•   Mul'-­‐organ  failure  
 Criteria  to  send  home  
•  No  fever  24  hours  without  an'pyre'c  
•  Clinical  improvement  
•  Good  appe'te  
•  Thrombocyte  >  50.000/uL  
•  Hematocrit  stable  
•  No  respiratory  distress  
•  Rash  convalescense  
 Take  home  message  
•  Early  diagnosis  and  prompt  treatment  prevent  
deaths  
•  Awareness  of  warning  signs  in  dengue  cases  
before  developing  to  shock  is  important  
•  Dynamic  situa'on  means  frequent  assessment  
and  adjustment  according  to  pa'ent  response  
or  lack  of  response  
THANK  YOU