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DIAGNOSIS AND

MANAGEMENT OF DHF
AND DSS


Departement of Child Health
Medical School Sam Ratulangi University
General Hospital Prof.Dr.R.D.Kandou Manado
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INTRODUCTION
 DHF relatively new diseases in Indonesia
 1968 in Surabaya and Jakarta
 1973 in Manado
 Management divided in DHF and DSS
 Mortality rate in : 1968  41.3 %
1992  2.9 %
1995  2.5 %
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DIAGNOSIS WHO 1975 / 1986
 Base on 4 clinical and 2 laboratoric criteria
 Clinical :
 High fever 2 – 7 days
 Hemorrhagic manifestation
 Hepatomegaly
 Shock
 Laboratoric
 Thrombocytopenia
 Hemoconcentration
 Dx : Minimally 2 clinical + Lab criteria
 The accuracy : 75 – 90 %
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The severity of disease divided in 4
grade
 I : Fever + non spesific + RL (+)
 II : I + Other hemorrh manifest
 III : II + mild shock
 IV : III + severe shock

 Grade I + II : DHF
III + IV : DSS
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 DHF : -  permeability
- Fever   crisis

 DHF I, II :
 Crisis days III >
 IVFD 12 – 24 hours
 PCV , Tr  < 50 000
 Health center / >
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 Fever phase
 Oral fluid : 50 ml/kgBW for 4 – 6 hours
 IVFD manitenance : 80 – 100 ml/kg/days
 Antipyretic : paracetamol 10 mg/kgBW/time
 Convulsion : Phenobarbital 5 mg/kgBW/days
 Critical Ill : Days 3 - 5
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SUBSTITUTION FLUID IN DHF
Maintenance + 5 – 8 %
 Vomiting every time
 Cannot drink
  fever
 PCV  periodically
 Acidosis : NaBic
 PCV  > 20 %  IVFD : GED mild - mod

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Table 1. Fluid need for moderate
dehidration.
Body Weight
(Kg)
Amount of fluid
(ml/kgBW/day)
< 7
7 – 11
12 – 18
> 18
220
165
132
88
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Table 2. Fluid need for
maintenance
Body Weight
(Kg)
Amount of fluid
(ml/kgBW/day)
<10
10 – 20
20
100 / kgBW
1000 + 50/kgBW(>10 kg)
1500 + 20/kgBW(>20 kg)
Example : 40 Kg = 1500 + (20X20) = 1900 ml
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 Temperature    leakage
 Reconvalescen  reabsorbtion of fluid
 Sign + symptom of shock 
hospitalization
 Fluid Recommended (WHO)
 Cristaloid : RL – RL-D5%
RA – RA-D5%
NaCl 0.9 % - NaCl 0.9%-D5%
 Colloid : Plasma
Dextran L 40
HAES
Gelofusin
Gelofundin
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DSS
 Shock  emergency – fluid  recovery 48 hours

Replacement of plasma volume
 Cristaloid : 20 ml/kgBW/30 min
 Still Shock : Koloid 10 – 20 ml/kgBW/h
Maximal 30 ml/kgBW
 Improvement : Cristaloid 10 – 20 ml/kgBW/h
 Still syok, PCV   bleeding  blood
 PCV > 40  blood 10 ml/kgBW/h
 Massive bleeding  blood 20 ml/kgBW/h
 Improvement  Cristaloid
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Figure 1. Management of suspect DHF
Suspect DHF
Sudden high fever
Continously < 7 d
URTI (-)
Emergency (-) Emergency (+)
Shock
Vomit
Convulsion
Consiousness 
Hematemesis
Melena Ambulatory
Paracetamol
Control until Fever 
Tourniquet (+)
Tourniquet (-)
Follow Up Clinical & Lab
While days 3
th
fever (+)
Attention for parents
Shock Sign
Trombocyte
> 100 000 / ul
Trombocyte
< 100 000 / ul
Hospitalization
Much drink
Paracetamol
Control until fever (-)
Ambulatory
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Figure 2. Management of DHF (Grade II)
Initial Fluid
RL/NaCl 0.9% / RLD5/NaCL0.9 % + D5
(6-7ml/KgBW/H)
Decresed IV drip
Monitoring Vital Sign /
PCV and Trombocyte / 6 H
Restlessness (-)
Strong pulse
Stable BP
Diuresis 2 ml/kgBW/H
PCV  2 X exam
Improvement (+)
Improvement (-)
Restlessness
Resp Distres
Pulse reate 
BP < 20mmHg
Diuresis  / -
10 ml/kgBW/H
Step by Step
15 ml/kgBW/h
Increased IV drip
Evaluation 12 – 24 h
Improvement
Unstable vital sign
Resp Distres
PCV 
PCV 
Coloid
20 – 30 ml/kgBW/h
Fresh WB
10 ml/kgBW
Improvement
Improvement
Vital sign decrease
PCV 
IVFD Stop (24 – 48 h)
If Vital Sign / PCV / Diuresis
stable
5 ml/kgBW/h
3 ml/kgBW/h
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Figure 3. Management of DSS (DHF III and IV)
DHF Gr III
1. Oxygenation
2. Plasma volume replacement
RL/NaCL  20 ml/kgBW imediately (bolus 30 min)
Evaluation 30 min
Follow up vital sign every 10 min
Record fluid balans
Shock (-) Shock (+)
DHF Gr IV
Improvement consiousness
Strong pulse
BP > 20 mmHg
No RDS / Cyanosis
Warm Extremities
Diuresis > 1 ml/kgBW/h
Decrese consiousness
Weak pulse / not palpable
BP < 20 mmHg
RDS / Cyanosis (+)
Cold Extremities
Diuresis < 1 ml/kgBW/h
Examine Glood Sugar
Reduce IVFD (10ml/kgBW/h)
IVFD  (15 -20 ml/kgBW/h)
Koloid / Plasma
(10-20 max 30 ml/kgBw/h
Correction accidosis
Evaluation 1 h
Shock (+)
Shock (-)
PCV high / 
Koloid 20 ml/kgBW
PCV 
Fresh WB 10 ml/kgBW
Can repeated
Strict Evaluation
Vital sign
Bleeding sign
Diuresis
Hb, PCV, Tr
Stable max 24 h
 5 ml/kgBW/h
3 ml/kgBW/h IVFD stop ≤ 48 h
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COMPLICATIONS
 Electrolyte Imbalance
 Hyponatremia
 Hypocalcemia
 Fluid overload
 Early IVFD
 Hypotonic Solution
 Not  IVFD
 Not Use Colloidal Sol / Plasma
 Not Give blood transf
 Not Calculate IVFD
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Signs and Symptoms of Fluid Overload
 RSD, Dyspnea and Tachypnea
 Massive acites
 Rapid Pulse
 ↓ Pulse pressure
 Crepitation/Ronchi
 Porr tissue perfusion
COMPLICATIONS
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Management of fluid overload
 Change IV to Dextrans 40
 Urinary Catheter
 Furosemide 1 mg/kgBW, IV
 Still Shock  Dextrans 40, 10 mg/kgBW in 10-15 min
 Record Urine output
 Furosemide may repeat if still RDS
 CVP if not Response furosemide
 Ventilatory support
 Pleural/peritoneal tapping
COMPLICATIONS
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Unusual manifestation of DHF
 Less than 5% of patient
 Encephalopathy/encephalitis
 Hepatic failure
 Renal failure
 Dual infections
 Underlying conditions
COMPLICATIONS
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Signs and Symptoms of Fluid Overload
 Prolonged shock
 Acute hemolysis + Hb uria
 G
6
PD
 Hemoglobinopathy
 Management of acute hemolysis + Hb Uria
 Transfussion PRC of FWB
 IVFD according the stage
 Alkaline urine
COMPLICATIONS
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Dual Infections
 Associate :
 GI, Salmonella
 RI, Pneumonia
 Urinary infections
 Skin + soft tissue inf
 Nosocomial
 Thrombophlebitis
 Pneumonia
 UTI (Catheter)
 Others
 Transfussion reaction
 Hepatitis
 Massive GI Hem
 Drugs reactions
COMPLICATIONS
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Common causes of encephalopathy
 Hepatic encephalopathy
 Severeshock
 Inborn error of metab
 Hepatotoxic drugs
 Underlying liver diseases
 Electrolyte imbalance
 Metabolic distrubance (hypoglycemia)
 Intracranial bleeding
 Cerebral thrombosis/ischemia

COMPLICATIONS
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Management of DHF hepatic encephalopathy
 Maintain oxygenation
 Prevent ↑ intracranial press :
 Restrict IV
 Furosemide + / dexamethasone
 ↓ Amonia production
 Vit K1 3-10 mg IV
 Correct metab acidosis
 PRC if indicated
 Antibiotic
 H2 Blocker if massive GI Bleeding
 Avoid unnecessary drugs
 Exchange tranf if needed
 Dyalisis if needed
 Branch – chain aminoacid
COMPLICATIONS
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INDICATION FOR DISCHARGE
 Not fever in 24 h
 Good appetite
 Good general condition
 Diuresis
 Normal PCV (38 – 40)
 ≥ 2 days after shock
 No dyspnea
 Platelet > 50 000/mm
3

 No complication
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CAUSES OF DEATH
 Prolonged shock
 Fluid overload
 Massive bleeding
 Unusual manifestation
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