Penatalaksanan intensif pasien dengan

Penyakit Tropik Berat

di ICU

Departemen Anestesiologi & Reanimasi / Instalasi

Pelayanan Intensif (ICU)
FK-USU / RSUP H.Adam Malik - Medan

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Penyakit Tropik Berat (yang sering
di ICU :
 Tetanus Berat (Severe Tetanus)
 Malaria Berat (Severe Malaria)
 DHF Grade III-IV (DSS)

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DHF GR III-IV (DSS)

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 Grading the Severity of Dengue Infection

DF/DHF Grade* Symptoms Laboratory

Fever with two or more of the Leukopenia, Occasionally,

DF following signs : headache, retro – Thrombocytopenia, may be
orbital pain, myalgia, arthalgia present, no evidence of
plasma loss

DHF I Above signs plus positive Tourniquet Thrombocytopenia, < 100,000,

test Hct rise ≥ 20 %

DHF II Above signs plus spontaneous Thrombocytopenia, < 100,000,

bleeding Hct rise ≥ 20 %

DHF III Above signs plus circulatory failure Thrombocytopenia, < 100,000,
(weak pulse, hypotension, Hct rise ≥ 20 %
restlessness)

DHF IV Profound shock with undetectable Thrombocytopenia, < 100,000,

blood presure and pulse Hct rise ≥ 20 %

* DHF Grade III and IV are also called as Dengue Shock Syndrome (DSS)
Clinical Manifestation DSS
Increase of Vascular permeability :
Haemoconcentration, Hypoalbuminemi,
Hypoproteinemia, Shock, Pleural
effusion

Thrombopathy
Hemorrhage
Coagulopathy

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PENATALAKSANAAN
Afebrile phase Manifestations Management

Duration two days In addition to the manifestations of
after febrile stage DHF Grade II :
– Circulatory failure manifested by
rapid and weak pulse, narrowing of
pulse pressure (20 mmHg or less
or Hypotension with the presence
of cold clammy skin and restless
ness
–Capillary relief time more than two
seconds
–Check haematocrits/platelet
–Initiate IV Therapy (5% D/NSS) 10 ml/kg/h
–Check Haematocrit , vital signs, urine output every hour.
–If patient improves IV fluids should be reduced every
hour from 10 to 6 and from 6 to 3 ml/kg/h which can be
maintained up to 24 to 48 hours.
–If patients has already received one hour treatment of
20 ml/kg/hr of IV fluids and vital signs are not stable
check haematocrit again and
–If haematocrit is increasing change IV fluid to colloidal
solution preferably Dextran or plasma at 10 ml/kg/h
every hr.
–If haematocrit is increasing from initial value give fresh
whole blood transfusion, 10 ml/kg/h and continue fluid
therapy at 10 ml/kg/h and reducing it stepwise bring
down the volume to 3 ml/kg/h and maintain it up to 24 –
48 hours.
–Initial IV therapy (5% D/NSS) 20 ml/kg as a bolus one or
two times
–Oxygen therapy should be given to all patients.
–In case of continued shock colloidal fluids (Dextran or
Plasma) should be given at 10 – 20 ml/kg/hr.
 Afebrile phase Manifestation Management

Profound shock with undetectable
Pulse and blood pressure
- If shock still persists and the haemotocrit level
continues declining give fresh whole blood 10
ml/kg as a bolus
- Vital signs should be monitored every 30 – 60
minutes
- In case of severe bleeding gives fresh whole blood
20 ml/kg as a bolus
- Give platelet rich plasma transfusion exceptionally
when platelet counts are below 5.000 – 10.000 / mm3
- After blood transfusioncontinues fluid therapy at 10
ml/kg/h and reduce it stepwise to bring it down to 3
ml/kg/h and maintain in for 24 – 48 hrs

Con Phase Manifestation Management

- 6 – 12 hours after critical/shock

stage some symptoms of
respiratory distress (pleural
effusion or arcites) - Rest for 1 – 2 days
- 2-3 days after critical stage , - Normal diet
strong pulse, normal blood - No need for medication
pressure.
- Improved general
Duration 2 – 3 days condition/return of appetite.
After recovery from - Good urine output
critical/shock stage - Stable haematocrit
- Pletelet count > 50.000 per mm3
- Patient could bedischarged from
hospital 2 – 3 days after critical
stage
- Bradycardia/arrhytmia
- Asthenia and depression (few
weeks) in adult
 Fluid Therapy in DSS

The policy of initial fluid therapy in DSS

according to the Department of Health
and WHO until 2003 :
Crystalloid (Lactate Ringer), followed
with colloid (Dextran) if not responded

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 Department of Health
Indonesian Intensive Care Association
Indonesian Anesthesiology Ass
Indonesian Paed. Ass (2004)

Review on the management of DHF

Change the protocol
Include colloid MMW-6% HES as alternative as
initial fluid resuscitation in DSS

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 Volume Replacement Therapy

Crystalloids Colloids

Lactated Ringer's
Normal Saline

Albumin Gelatin Dextran HES

PPL solutions solutions solutions
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 Crystalloid (RL, RA, NaCL)

Distributed to the interstitial space

Very short period in the intravascular space
Need more fluid to maintain intravascular
volume  risk for interstitial edema /
pulmonary edema

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 Colloid

– HES: ( MW 100.000-300.000 kD ): Sealing

effect +, good intravascular volume effect,
longer duration in the intravascular space, 
DO2, VO2
– Dextran : LMW colloid (40.000-70.000 kD)
with good preservation volume effect, no
sealing effect, increase anaphylactic
reaction
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 Hydroxyethyl Starch (HES)
- Effective and safe plasma substitute HES → broad
range of MW, from very small until several hundred
thousand Dalton
- Classification of HES (by in vitro) according to MW :
- HIGH MOLECULAR WEIGHT (HMW) → 450 K Da
- MEDIUM MOLECULAR WEIGHT (MMW) → 200 K Da
- LOW MOLECULAR WEIGHT (LMW) → 70 K Da

Sealing effect : HES with 100–300.000 D MW

Effect of HES on Blood Coagulation

HMW-HES  more effect on blood coagulation

(vWF, factor VIII)

LMW (HES 70/0.5/4)/MMW(HES 200/0.5/6)  did

not affect on blood coagulation

Possible dilutional coagulation effect : PT, aPTT

(significant prolongation after HMW-HES 480)
Fluid Resuscitation in DSS
Primary importance in the management
of hypoperfusion state

Goal of therapy
 Tissue DO2
 Blood Pressure Colloid
MMW
 VO2
Reversing Lactic Acidosis
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Study on DSS using colloid (HES )
as initial fluid resuscitation

Tatty E. Setiati Different

(2000) RESULT
Different
Herminia L. Cifra method of
(2001) H study

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 RL group Colloid group
(HAES Steril 6%)

Duration of
shock 7.9+/- 2.6 2.3 +/- 2
( Hour)

Ventilators days 8 +/- 1.1 4.0 +/- 0.71

Pleural effusion 30 _
M2/Mod7/S21

ALI /PaO2/FiO2=200-250 4 1

ARDS 6 2
PaO2/FiO2 < 200
 Conclusion
Evidenced showed that endothelial dysfunction
lead to vascular leakage and hemostatic
disturbances occurred in DSS
MMW which has a sealing effect could
minimizing vascular leakage, good preservation
volume effect, and lowering mortality
MMW HES can be used as alternative for initial
fluid resuscitation in DSSS

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 What not to do in DSS
Do not give Aspirin or Ibuprofen for treatment of fever.
Avoid giving intravenous therapy before there is evidence
of haemorrhage and bleeding.
Avoid giving blood transfusion unless indicated, reduction
in haematocrit or severe bleeding.
Avoid giving steroids. They do not show any benefit.
Do not use antibiotics
Do not change the speed of fluid rapidly, i.e. avoid rapidly
increasing or rapidly slowing the speed of fluids.
Insertion of nasogastric tube to determine concealed
bleeding or to stop bleeding (by cold lavage) is not
recommended since it is hazardous.

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 Signs of Recovery
Stable pulse, blood pressure and breathing rate
Normal temperature
No evidence of external or internal bleeding
Return of appetite
No vomiting
Good urinary output
Stable haematocrit
Convalescent confluent petechiae rash

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Laboratory findings
Biochemistry
 Hypoglycemia < 2.2 mmol/l
 Hyperlactatemia > 5 mmol/l
 Acidosis arterial pH<7.3 venous plasma HCO3 < 15 mmol/l
 Serum creatitine >265 µmol/l
 Total bilirubin > 50 µmol/l
 Liver enzymes SGOT (AST) x 3 upper limit of normal
SGPT (ALT) x 3 upper limit of normal
5 – Nucleotidase
 Muscle enzymes CPK
Myoglobin
 Urate > 600 µmol/l

Hematology
 Leucocytosis >12.999/µl
 Severe anemia PCV < 15 %
 Coagulopathy Platelet < 50.000/µl
PT prolonged > 3 s
Prolonged PPT
Fibrinogen <200 mg/dl

Parasitology
 Hyperparasitemia > 100.000/µl - increased mortality
> 500.00/µl - high mortality
 >20% of parasites are pigment – containing trophozoites and schizonts
 >5% of neutrophils contain visible malaria pigment