Demam Berdarah Dengue - Dr. H. Rustam Siregar Sp. A

7/25/2019 Demam Berdarah Dengue - Dr. H. Rustam Siregar Sp. A

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RUSTAM SIREGARDIVISI INFEKSI DAN PENYAKIT TROPIK

BAGIAN ILMU KESEHATAN ANAK

FK UNS/RSUD DR. MOEWARDISURAKARTA2014

D I A G N O S I S DA N

TATA L A K S A N A

D E M A M B E R DA R A H

D E N G U E


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D E F I N I S I

DBD merupakan suatu penyakitdemam akut yang disebabkan

oleh virus genus Flavivirus, famili

Flaviviridae

Mempunyai 4 jenis serotipe :Den-1, Den-2, Den-3, Den-4,

melalui perantara nyamuk aedes

aegypti

Mempunyai kecenderungan

terjadinya perdarahan


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E P I D E M I O L O G I

1953

pertama kali di AsiaTenggara, di Filipina

1968 pertama kali di

Indonesia di Surabaya,konfirmasi virologi 1970

1969 Jakarta, Bandung&

1972 Yogyakarta

1974epidemi di Bali,

Sumatera, Sulawesi dan

NTB

1993Menyebar ke seluruh propinsi di Indonesia


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E P I D E M I O L O G I


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PETA INSIDENS DBDMENURUT PROVINSI DI INDONESIA

TAHUN 2009


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INCIDENCE RATE DEMAM BERDARAHPROVINSI JAWA TENGAH TAHUN 2012


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CASE FATALITY RATE DEMAMBERDARAH DENGUE PROVINSI JAWA

TENGAH TAHUN 2012


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MASAINKUBASI5 9 HARI

MASA AKUT1 4 HARI

MASA KRITIS1 2 HARI

MASAPENYEMBUHAN

1 2 HARI

Hari ke - 1

KURVA DEMAM PADA DEMAMBERDARAH DENGUE

36

3738

39

40

2 3 4 5 6 7 8


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AKBAR dkk, 2008

Pemeriksaan virus dengue, pada periodelarva-

nyamuk dewasa menggunakan teknik RT-PCR

Larva nyamuk sudah terdeteksi virus dengue

Larva nyamuk dewasa dapat menyebarkan virusdengue tanpa perlu menggigit penderita infeksi

dengue


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PATOFISIOLOGI


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TRANSMISI VIRUS DENGUE OLEHNYAMUK AEDES AEGYPTI


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PATOFISIOLOGI

Demam Dengue (Infeksi Primer) dan DBD (InfeksiSekunder)

Virulensi virus dengue

Perembesan plasma

Gangguan hemostasis


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PATOGENESIS


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PATOGENESIS


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MENGHITUNG HARI DEMAM

HARI

SENIN SELASA RABU KAMIS JUMAT

12.00 12.00 12.00 12.00 12.00

1 2 3 4 5


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FASE FASE DEMAM BERDARAHDENGUE & MANIFESTASINYA


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1997 2009 2011

T i t l e

Guideline for treatment of DFand DHF in small hospitals WHO Searo 1999

Dengue Guidelines fordiagnosis, treatment,prevention and control WHO TDR 2009

Comprehensive guideline forprevention and control ofDengue and DHF WHOSearo 2011

P a g e s

33 160 212

C o n t e n t

Clinicalmanifestation,

diagnosis, casemanagement

Chapters : (6)Epidemiology andburden of disease,clinical management,vector management, labdiagnostic tests,surveillance andemergency response,

new avenues

Chapters : (15)Epidemiology, diseaseburden,clinical manifestationand diagnosis, lab diagnosis,management, surveillance,vector, vector management,IVM, Combi, PHC approach,case investigation, monitoring,strategic plan (bi-regionalplan)

D E N G U E G U I D E L I N E S


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DIAGNOSIS & CLASSIFICATION

1997 2009 2011Dengue fever Dengue without warning

signsDengue fever

DHF grade I Dengue with warning signs DHF grade IDHF grade II DHF grade II

DHF grade III Severe dengue( severe plasma leakage,severe hemorrhage,severe organ involvement)

DHF grade III

DHF grade IV DHF grade IV

* Expanded denguesyndrome

Adult management Adult management


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Probable an acute febrile illness with two or more of the followingmanifestations:

HeadacheRetro-orbital painMyalgiaArthralgiaRashHaemorrhagic manifestationsLeukopenia;

andSupportive serology (a reciprocal HI antibody titre 1280, acomparable IgG ELISA titre or a positive IgM antibody test on a lateacute or convalescent-phase serum specimen );

orOccurence at the same location and time as other confirmed ases ofdengue fever.

Confirmed a case confirmed by laboratory criteria

Reportable any probable or confirmed case should be reported


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Grade Sign and Symptomps Laboratory

DF DHF without plasma leakage

DHF I Fever with non-specific constitutionalsymptoms; the only hemorrhagicmanifestation is a positive tourniquettest &/or easy bruising

evidence of plasma leakage

Thrombocytopenia (plateletcount100,000/ L)

II DHF grade I plus spontaneousbleeding

III Circulatory failure manifested by arapid, weak pulse, narrowing of pulsepressure, or hypotension, cold &clammy skin, restlessness

IV Profound shock with undetectableblood pressure


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WHO Dengue Classification 1997

DF DHF1. Fever 2-7 days + +2. Bleeding tendency

Positive tourniquet test orSpontaneous bleeding +/- +

3. Thrombocytopaenia

100,000/mm +/- +4. Plasma leakage

Pleural effusion /ascites /hypoproteinaemia 20% increase in HCT from baseline - +


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Lancet Inf Dis 2006; 6: 297-302

Lancet 2006; 368: 170-173

KITA PERLU KLASIFIKASIBARU YANG LEBIH AKURAT

UNTUK MENDIAGNOSADEMAM BEDARAH DENGUE.


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DENGUE WITHOUT WARNINGSIGNS

Probable denguelive in /travel to dengue endemic area.

Fever and 2 of the following criteria: Nausea, vomiting Rash Aches and pains Tourniquet test positive Leucopenia Any warning sign


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DENGUE WITH WARNING SIGNS

Warning signsAbdominal pain or tendernessPersistent vomitingClinical fluid accumulationMucosal bleedLethargy, restlessnessLiver enlargement >2 cm

Increase in HCT concurrent with rapid decrease inplatelet count


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S E V E R E D E N G U E

Severe plasma leakage leading to: Shock (DSS) Fluid accumulation with respiratory distress

Severe bleeding as evaluated by clinicianSevere organ involvement

Liver:AST or ALT 1000CNS: Impaired consciousnessHeart and other organs


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Dengue virus infection

Asymptomatic Symptomatic

Undefferentiatedfever

(viral syndrome)

Dengue Fever(DF)

Dengue HaemorrhagicFever (DHF)

(with plasma leakage)

Withouthaemorrhage

With unusualhaemorrhage

DHF non shock DHF with shockDengue Shock

Syndrome (DSS)

Expanded Denguesyndrome/isolated

organophaty (unusualmanifestation)

2011

WHO CLASSIFICATION OF DENGUE I NFECTIONS


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DF/

DHF Grade Signs and Symptoms LaboratoryDF Fever with two of the following:

Headache Retro-orbital pain Myalgia Athralgia/bone pain

Rash Haemorrhagic manifestations No evidence of plasma leakage

Leucopenia (WBC


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A D M I S S I O N C R I T E R I A


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1997 2009 2011

Signs of significantdehydration (>10%normal body weight)

- Any warning sign- Coexisting conditions:infancy, pregnancy, oldage, obesity, diabetesmellitus, renal failure,

hypertension, chronichemolytic disease etc.- Social circumstances:living alone, living farfrom health facility,

without reliable means oftransport.

- Shock: Resuscitation andadmission.-Hypoglycemic patientswithout leucopeniaand/or

thrombocytopenia-Those with warning signs.- High-risk patients withleucopenia andthrombocytopenia

1997 2009 2011

No Yes Yes

HOME CARE CARD

A D M I S S I O N C R I T E R I A

WARNING SIGNS 2009 & 2011


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WARNING SIGNS 2009 & 20112009 2011

Abdominal pain + severe + or tenderness

Persistent vomiting, + + , lack of water intake

Clinical fluid accumulaton + -

Bleeding Mucosalbleed

Epistaxis, black stool, haematemesis, excessivemenstrual bleeding, dark-coloured

urine (haemoglobinuria) or haematuria.

Lethargy and/or restlessness + + , sudden behavioural changes

Liver enlargement > 2 cm + -

Increase in Hct concurrent with rapiddecrease in platelet count

+ -

No clinical improvement orworsening of the situation

- +

Giddiness - +

Pale,cold, a clammy hands and feet - +

Less/no urine output for 4 6 hours - +


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F L U I D M A N A G E M E N T

1997 2009 2011DHF grade I-II Dengue with warning

signsDHF grade I-II

6-7 ml/kg/hour 5ml/kg/hour 3ml/kg/hour stopafter 24-48 hours

isotonic solutions suchas 0.9% saline, Ringerslactate, or Hartmannssolution. Start with 5 7ml/kg/hour for 1 2

hours, then reduce to3 5 ml/kg/hr for 2 4hours, and then reduceto 2 3 ml/kg/hr or lessaccording to the clinicalresponse

maintenance (for oneday) + 5% deficit (oraland IV fluid together),to be administeredover 48 hours


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CONT

1997 2009 2011DSS Severe Dengue-

compensated shockDHF grade III

10-20 ml/kgBB bolus,repeat if necessary

algorithm

isotoniccrystalloidsolutions at 5 10ml/kg/hour over onehour. reassess

10 ml/kg in children or300 500 ml in adultsoverone hour or by bolus, ifnecessaryFurther, fluidadministration should

follow the graph


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Cont

2009 2011Severe Dengue hypotensive shock DHF grade IV

Start with crystalloid or colloid solution(if available) at 20 ml/kg as a bolusgiven over 15 minutes to bring thepatient out of shock as quickly aspossible.

10 ml/kg of bolus fluid (10-15 min)

When the blood pressure is restored,further intravenous fluid may be given asin Grade 3.

If shock is not reversible after the first 10ml/kg, a repeat bolus of 10 ml/kg andlaboratory results should be pursued andcorrected as soon as possible.


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Transfusion in Severe Bleeding

2009 2011Give 5 10ml/kg of fresh-PRC or 10 20ml/kg of FWB at an appropriate rate

and observe the clinical response.

10 ml/kg of FWB or 5 ml/kg of freshlyPRC

Reassess, repeat if necessary


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R AT E O F I N F U S I O N I N D S S( 2 0 1 1 )


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1997


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IgM IgG Interpretation

- - Tidak terinfeksi virus dengue,tetapi tidak tertutup kemungkinanterjadi false negative

+ - Infeksi primer virus dengue

- + Pernah terinfeksi virus dengue

+ + Pernah terinfeksi virus dengue,tetapi saat ini sedang mengalamiinfeksi virus dengue sekunder

D I S C H A R G E C R I T E R I A


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D I S C H A R G E C R I T E R I ACriteria 1997 2009 2011

Absence of fever 24 hourswithout the useof anti-fever

therapy

48 hours 24 hourswithout theuse of anti-

fevertherapy

Clinical improvement + + (general well-being, appetite,hemodynamic status, urine output,

no respiratory distress)

+

Return of appetite + - +

Good urine output + - +

Stable hematocrit + + (without intravenous fluids) +Elapse from shock

recoveryAt least 2 days - At least 2-3

days

No respiratorydistress

+ - +

Platelet count > 50,000/ L Increasing trend > 50,000/ L


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Summary

Dengue disease burden is significantly increasedacross continentsCase management is relatively simple andinexpensive could saves the lives of patientsRevised guidelines ( 2009 and 2011) are availableProposed National guideline ?

Changes might be slowly, difficult but inevitable


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S I G N S O F S I G N I F I C A N T


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S I G N S O F S I G N I F I C A N TD E H Y D R AT I O N

- Tachychardia- Increased capillary refill time (>2 second)- Cool, mottled or pale skin- Diminished peripheral pulses- Changes in mental status- Oliguria- Sudden rise in haematocrit or continously elevated

haematocrit despite administration of fluids- Narrowing of pulse pressure (< 20 mmHg)- Hypotension (a late finding representing uncorrected shock)

back


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Warning signs (2011)

No clinical improvement or worsening of the situation justbefore or during theTransition to afebrile phase or as the disease progresses.Persistent vomiting, not drinking.Severe abdominal pain.Lethargy and/or restlessness, sudden behavioural changes.Bleeding: Epistaxis, black stool, haematemesis, excessivemenstrual bleeding, darkcoloured urine (haemoglobinuria) or

haematuria.Giddiness.Pale, cold and clammy hands and feet.Less/no urine output for 4 6 hours.

back

Admission criteria 2009 p 47 back


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Admission criteria 2009 p 47 backWarning signs Any of the warning signs (Textbox C)

Signs & symptomsrelated to hypotension(possible plasmaleakage)

Dehydrated patient, unable to tolerate oral fluidsGiddiness or postural hypotensionProfuse perspiration, fainting, prostration during deferescenceHypotension or cold extremities

Bleeding Spontaneous bleeding, independent of the platelet count

Organ impairment Renal, hepatic neurological or cardiac- enlarged, tender lier, although not yet in shock- Chest pain or respiratory distress, cyanosis

Findings through furtherinvestigation

Rising hematocritPleural effusion, ascites or asymptomatic gall bladder thickening

Co-existing conditions PregnancyCo-morbid conditions, such as diabetes mellitus, hypertension pepticulcer, hamolitic anemias and othersOverweight or obese (rapid venous access difficult in emergency)Infancy or old age

Social circumstances Living alone, living far from healt facility, without reliable means of

transport


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High-risk patients (2011)infants and the elderly,obesity,pregnant women,peptic ulcer disease,

women who have menstruation or abnormal vaginal bleeding,haemolytic diseases such as glucose-6-phosphatase dehydrogenase(G-6PD) deficiency,thalassemia and other haemoglobinopathies,congenital heart disease,chronic diseases such as diabetes mellitus, hypertension, asthma,ischaemic heart disease,chronic renal failure, liver cirrhosis,patients on steroid or NSAID treatment, andothers

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Demam Berdarah Dengue - Dr. H. Rustam Siregar Sp. A