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DENGUE HEMORRHAGIC FEVER

Fazria Nasriati
Tatalaksana Tersangka DBD
Demam mendadak tinggi, <7 hari, sakit kepala, pegal, atralgia, nyeri retro-orbital, di
lingkungan sekitar ada penduduk yang menderita DBD

Ada kedaruratan Tidak ada kedaruratan

Syok
Kejang
Kesadaran menurun
Perdarahan
Komorbid Demam ≥3 hari Demam < 3 hari
Asupan oral inadekuat
Ht cenderung naik
Hb, Ht, leukosit, trombosit
Rawat inap

Rawat jalan
Trombosit Trombosit
kontrol tiap hari
≤100.000/ul >100.000/ul
sp demam reda
 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

PROTOCOL 3
Management of DHF with Increase of Haematocrite >20%
 Protocol 5
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
 Protocol 5…(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
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 hypoglycem
ia, 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
Protokol 4
Penatalaksanaan Perdarahan Spontan
pada DBD Dewasa
KASUS DBD :
Perdarahan Spontan dan Masif : - Epistaksis tidak terkendali - Gross hematuria
- Hematemesis dan atau melena - Hematoskezia
- Perdarahan otak
Syok (-)

Hb, Ht, Trombo, Leuko, Pemeriksaan Hemostasis (KID)

Golongan darah, uji cocok serasi

KID (+) KID (-)

Transfusi komponen darah : Transfusi komponen darah :
* PRC (Hb<10 g/dL) * PRC (Hb<10 g %)
* FFP * FFP
* TC (Tromb.<100.000) * TC (Tromb.<100.000)
** Heparinisasi 5000-10000/24 jam drip * Pemantauan Hb, Ht, Tromb. Tiap 4-6 jam
* Pemantauan Hb, Ht, Tromb. Tiap 4-6 jam * Ulang pemeriksaan hemostasis 24 jam
* Ulang pemeriksaan hemostasis 24 jam kemudian kemudian
Cek APTT tiap hari, target 1,5-2,5 kali kontrol
Massive Bleeding Management in Dengue

Conditio Actio
Hbn
< 10 g/dL nPRC Transfusion

DIC (+) Heparinization 5000-10.000/24 hours

Platelet <100.000/uL Thrombocyte concentrate

APTT > 1.5 times FFP 10 – 15 cc/kgBW/8 hours

Fibrinogen < 100 mg/dL Cryoprecipitate 10 U/kgBW/8 hours

Terapi Cairan
1. Kristaloid
 Lactated Ringer’s
 Ringer Acetate
 Normal Saline
 Ringerfundin
2. Koloid
 Albumin
 Gelatin
 HES
 Dextran
On 23 October 2013, the Coordination Group for Mutual Recognition and Decentralised Procedures
– Human (CMDh)*, endorsed by majority the recommendations of the European Medicines Agency’s
Pharmacovigilance Risk Assessment Committee (PRAC), which concluded that HES solutions must
no longer be used to treat patients with sepsis (bacterial infection in the blood) or burn injuries or
critically ill patients because of an increased risk of kidney injury and mortality.

HES solutions may continue to be used in patients to treat hypovolaemia (low blood volume) caused
by acute (sudden) blood loss, where treatment with alternative infusions solutions known as
‘crystalloids’ alone are not considered to be sufficient. In order to minimise potential risks in these
patients, HES solutions should not be used for more than 24 hours and patients’ kidney function
should be monitored after HES administration. In addition to updating the product information,
further studies should be carried out on the use of these medicines in elective surgery and trauma
patients.

19 December 2013
EMA/809470/2013