Kegawatan dengue: kapan dan Kegawatan dengue: kapan dan bagaimana mengatasinyabagaimana mengatasinya

Ida Safitri Laksono

Bagian IKA FK UGM/RSUP Dr. Sardjito Yogyakarta

Isi presentasiIsi presentasi

� Situasi epidemiologi infeksi Dengue

� Overview of the three guidelines

� Spektrum klinis

� Tanda peringatan dan kegawatan� Tanda peringatan dan kegawatan

� Tatalaksana

� Do and don’t

� Ringkasan

PendahuluanPendahuluanGLOBAL burden of dengue

� Global incidence of dengue has grown dramatically in recent decades

� About two fifths of the world's population are now at risknow at risk

� Dengue is found in tropical and sub-tropical climates worldwide, mostly in urban and semi-urban areas

� Dengue is the most prevalent arboviraldisease with high morbidity, mortality & socio-economical costs.

Case management� Despite its complex in pathogenesis and manifestation � management is relatively simple and inexpensive

� No specific treatment � rely on fluid management . If it is appropriately and timely management . If it is appropriately and timely implemented could saves the lives of patients

� Current situation : the most effevtive way to prevent dengue transmission is to combat disease carrying-mosquitoes

� The development of vaccines and drugs is challenging but potential to change this.

1,016,612

50

60

70

800000

1000000

1200000

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f co

un

trie

s

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ses

Average annual number of DF/DHF cases reported to WHO, 1955-2009

908 15,497

122,174

295,554

479,848

0

10

20

30

40

0

200000

400000

600000

1955-1959 1960-1969 1970-1979 1980-1989 1990-1999 2000-2009

Nu

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f co

un

trie

s

Nu

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f ca

ses

Source: DengueNet

40

60

80

IR a

nd

CF

R

CFR

IR and CFR di INDONESIA, 1968 - 2011 IR 2010:

65,57/ 100.000 pddk

IR 2011: 22,9

/100.000pddk

CFR

0

20

19

68

19

70

19

72

19

74

19

76

19

78

19

80

19

82

19

84

19

86

19

88

19

90

19

92

19

94

19

96

19

98

20

00

20

02

20

04

20

06

20

08

20

10

IR a

nd

CF

R

Year IR/100.000

CFR(%)

CFR

2010:

0,87%

CFR 2011;0.84 %

Source : Kemkes RI

Monthly Dengue Cases And Death In Monthly Dengue Cases And Death In Indonesia, 2010 Indonesia, 2010 -- 20112011

150

200

250

15000

20000

25000

DeathCases

20112010

Source : Subdirectorate of Arbovirosis - Directorate of VBDC,

Directorate General DC&EH , Ministry of Health RI

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Cases 22777 22467 19538 16175 13132 11530 10790 9496 7814 7959 7497 5324 8258 6357 6289 4658 4801 4363 4291 4116 3391 3755 2393 1720

Death 213 211 181 161 126 90 82 69 54 53 57 51 52 57 45 51 32 32 32 44 36 34 23 21

0

50

100

0

5000

10000

Month

� Infeksi dengue bersifat akut, dinamis dengan spektrum klinis yang bervariasi dari asimtomatik � fatal

Kegawatan penyakit pada umumnya terjadi � Kegawatan penyakit pada umumnya terjadi pada fase kritis

� Sampai saat ini belum tersedia obat anti virus maupun vaksin untuk terapinya, tata laksana relatif bertumpu pada pemberian cairan

NEW DENGUE NEW DENGUE GUIDELINESGUIDELINESGUIDELINESGUIDELINES

Dengue guidelinesDengue guidelines1997 2009 2011

Guideline for treatment of DF and DHF in small hospitals –WHO Searo 1999

Dengue – Guidelines for diagnosis, treatment,prevention and control –WHO TDR 2009

Comprehensive guideline for preventionand control of Dengue and DHF –WHO Searo 2011

Pages : 33 160 212

Content

Clinical manifestation, diagnosis, case management

Chapters : (6)Epidemiology and burden of disease, clinical management, vector management, lab diagnostic tests, surveillance and emergency response, new avenues

Chapters : (15)Epidemiology, disease burden,clinical manifestation and diagnosis, lab diagnosis, management, surveillance, vector, vector management, IVM, Combi, PHC approach, case investigation, monitoring, strategic plan (bi-regional plan)

DDiagnosisiagnosis ClassificationClassification according to existing according to existing guidelinesguidelines1997 2009 2011

Guideline for treatment of DF and DHF in small hospitals –WHO Searo 1999

Dengue – Guidelines for diagnosis, treatment,prevention and control –WHO TDR 2009

Comprehensive guideline for preventionand control of Dengue and DHF –WHO Searo 2011

Dengue fever Dengue without warning signs

Dengue feversigns

DHF grade I Dengue with warning signs DHF grade I

DHF grade II DHF grade II

DHF grade III Severe dengue (for management it is divided into two: severe dengue with compensated shock & severe dengue with hypotensive shock)

DHF grade III

DHF grade IV DHF grade IV

* Expanded dengue

Dengue case classification by severity

Withoutwith

warning signs

1.Severe plasma leakage

2.Severe haemorrhage

3.Severe organ impairment

Severe dengueDengue ± warning signs

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

Laboratory confirmed dengue(important when no sign of plasma leakage)

Warning signs*• Abdominal pain or

tenderness

• Persistent vomiting

• Clinical fluid accumulation

• Mucosal bleed

• Lethargy; restlessness

• Liver enlargement >2cm

• Laboratory: Increase in HCT

concurrent with rapid

decrease in platelet count

* Requiring strict observation and medical intervention

1. Severe plasma leakage

leading to:

• Shock (DSS)

• Fluid accumulation with

respiratory distress

2. Severe bleeding

as evaluated by clinician

3. Severe organ involvement• Liver: AST or ALT>=1000

• CNS: Impaired consciousness

• Heart and other organs

Criteria for dengue ± warning signs Criteria for severe dengue

WHO

/TD

R 2

009

SPECTRUM OF CLINICAL ILLNESS SPECTRUM OF CLINICAL ILLNESS ASSOCIATED WITH DENGUE VIRUS ASSOCIATED WITH DENGUE VIRUS INFECTIONINFECTION

Inapparent

Infection

Mild FebrileMild Febrile

IllnessIllness

DengueDengue

FeverFever

Severe and FatalSevere and Fatal

InfectionInfectionInfection IllnessIllness FeverFever InfectionInfection

1 2 3 4 5 6 7 8 9 10

40

Shock Bleeding

ReabsorptionFluid overload

Dehydration

Organ Impairment

Days of illness

Temperature

Potential clinical issues

Viraemia

Course of dengue illness: Febrile Critical Recovery Phases

Laboratory

changes

Serology and virology

Platelet

Hematocrit

IgM/IgG

Adapted from WCL Yip, 1980 by Hung NT, Lum LCS, Tan LH

Apakah semua pasien tersangka Apakah semua pasien tersangka Infeksi Dengue Infeksi Dengue perlu dirawat inap?perlu dirawat inap?

� TIDAK

� hanya 1/3 kasus akan mengalami syok

� Tips’: perhatikan hari demam, apakah � Tips’: perhatikan hari demam, apakah masuk fase kritis ?

� Apabila ragu-ragu: rawat di ruang rawat sehari (one day care): observasi 24 jam, beri cairan rumatan

Kapan mencurigai dengue?Kapan mencurigai dengue?

� Presumptive Diagnosis (Probable Dengue)

� Riwayat tinggal di atau berkunjung ke daerahendemis ( laporan kasus Dengue)

Demam dan 2 dari kriteria:

16

� Demam dan 2 dari kriteria:◦ Mual dan muntah◦ Rash◦ Nyeri dan sakit◦ Leukopenia◦ Tourniquet test positive◦ Tanda peringatan

What to Do ?What to Do ?PadaPada fasefase awalawal demamdemam

� Curiga Dengue bila terdapat gejala :demam

+ nyeri kepala, retro orbital, sendi, perut

+ muka kemerahan (flushing)

+ ruam kulit

� Kenali indikator Diagnosis dini

Demam & muka kemerahan (tanpa coryza)

Hari sakit Sensitivitas Spesifisitas

1 73,3 % 93,3 %

2 90,5 % 89,2 %

3 85,5 % 87,9 %

What to Do ?What to Do ?PadaPada fasefase demamdemam

� Lakukan uji bendung (Tourniquete test)

◦ Uji bendung positif + demam 1–3 hari mempunyaiPPV infeksi dengue : 63 %

◦ Bila disertai leukopenia ≤ 5000 /mL, PPV 83 %

�Kenali indikator Diagnosis dini

Uji Bendung

Hari sakit Sensitivitas Spesifisitas

1 53,3 % 75,8 %

2 90,6 % 77,8 %

3 98,7 % 74,2 %

What to Do ?What to Do ?PadaPada fasefase awawal/demamal/demam

� Perdarahan �hati-hati bila:

◦ Epistaksis pertama kali

◦ Menorrhagia pada anak remaja

� Fase iniFase ini

◦ Perdarahan tidak berat

◦ Bentuk perdarahan paling sering:

�petekie, epistaksis, hematemesis

◦ Stop / meminimalisasi perdarahan

◦ Mengurangi faktor-faktor yang dapat menimbulkanperdarahan

What to Do ?What to Do ?PadaPada fasefase awalawal demamdemam

◦ Lakukan pemeriksaan darah serial: Hb, Ht, leukosit, hitung jenis dan trombosit

◦ Perawatan di rumah:◦ Perawatan di rumah:

� Turunkan suhu, ukur suhu berkala

� Berikan sebanyak mungkin cairan oral: susu, juice, cairanelektrolit

� Berikan lingkungan yang tenang

� Penurun panas : paracetamol

What to Do ?What to Do ?PadaPada fasefase awalawal // demamdemam

� Pemeriksaan Ag NS1 perlu dikerjakan atautidak?

� Diperlukan bila gejala klinis tidak khas �demam < 72 jam

�Ag NS1 dilakukan untuk mendeteksi infeksi

virus Dengue pada fase akut

�sensitivitas bervariasi � >unggul dari kultur virus & AbIgM/IgG anti Dengue

�spesifisitas 100% ∞ gold standard: kultur virus & PCR

What to Do ?What to Do ?PadaPada fasefase awalawal/demam/demam

� Pemeriksaan Dengue blot ≥ HS 5

� Lihat gejala klinis pasien

� Interpretasi hasil pemeriksaan IgM dan IgG� Interpretasi hasil pemeriksaan IgM dan IgG

Bila hasil IgG & IgM(-) dan klinis (+), ulang pemeriksaan

Ig M Ig G Interpretasi

+ - Infeksi primer

+ + Infeksi sekunder

- + Tsk inf sekunder

- - Tdk ada infeksi

Dengue Case Management, WHO 2009

Presumptive diagnosis

Warning signs

Negative

Negative Positive

Positive

Dengue with warning signsDen without

warning signs

Severe dengue

ASSESSMENT

CLA

SSIFICATION

CO-EXISTING CONDITION/SOCIAL CIRCUMSTANCES

Group A Group B Group C

Group criteria Group criteria

or : Excisting warning signs Group criteria

Lab test Lab test Lab test Lab test

Treatment Treatment Treatment Treatment compensated shock

• if patient improves• if patient still unstable

Monitoring Monitoring Reassess clinical status & Hct Treatment of hypotensive shock•if patient improves• if patient still unstable

Reassess clinical status, Hct, IVFD

Treatment of haemorrhagic complication

Monitoring

warning signs

CLA

SSIFICATION

MANAGEMENT

PASIEN YANG DIPERBOLEHKAN RAWAT JALANPASIEN YANG DIPERBOLEHKAN RAWAT JALAN

� HARUS DIEVALUASI:

darah lengkap dan Hct setiap hari

sampai keluar dari fase kritis

24

� APA YANG DIPANTAU?

◦ Perkembangan penyakit: keluhan memberat?

◦ Defervescence (saat suhu turun): ↑ Hct bersamaan ↓TROMBOSIT

◦ Munculnya tanda peringatan

Critical Phase Critical Phase –– Warning signsWarning signs

� Sekitar fase devervescene: pasien membaik/memburuk � cek warning sign (tanda awal fase kritis)

Warning Signs• Abdominal pain or tenderness• Persistent vomiting atau water intake <<• Clinical fluid accumulation• Mucosal bleed

25

25

• Mucosal bleed• Lethargy; restlessness; perubahan perilaku tiba-tiba• Liver enlargement >2cm• pening/pusing >>• Pucat, kaki tangan dingin lembab• Urine output (-)/<< selama 4-6 jam• Laboratory: Increase in HCT concurrent with rapid

decrease in platelet count

WHO 2209 & 2011

TATALAKSANA TATALAKSANA KEGAWATANKEGAWATANKEGAWATANKEGAWATAN

Indikasi rawat inap Indikasi rawat inap TTersangka DBDersangka DBD

� Terdapat tanda peringatan/tanda kegawatan

� Pada pemantauan dijumpai � Pada pemantauan dijumpai � kadar Hct tinggi/ meningkat dibanding

sebelumnya� trombosit turun� perdarahan spontan (selain petekie)

o Kondisi pasien berakibatTATA LAKSANA LEBIH KOMPLEKS, seperti:

BAYI, KEHAMILAN, USIA LANJUT,

OBESITAS, DM, GAGAL GINJAL, HIPERTENSI,

PENYAKIT HEMOLITIK KRONIK DLL.

PERTIMBANGKAN RAWAT INAP

PENYAKIT HEMOLITIK KRONIK DLL.

� Kondisi sosial seperti:� tinggal di rumah seorang diri atau� tinggal jauh dari fasilitas kesehatan atau� tidak tersedia sarana transportasi

� Bila menolak: Tanda tangan surat penolakan

Admission CriteriaAdmission Criteria

1997 2009 2011

Signs of significant dehydration (>10% normal body weight)

- Any warning sign- Coexisting conditions: infancy, pregnancy, old age, obesity, diabetes mellitus, renal failure, hypertension, chronic hemolytic disease etc.

- Shock: Resuscitation and admission. -Hypoglycemic patients without leucopenia and/or thrombocytopenia -Those with warning signs.- High-risk patients with etc.

- Social circumstances: living alone, living far from health facility, without reliable means of transport. In detail

- High-risk patients with leucopenia and thrombocytopenia

1997 2009 2011

No Yes yes

Home care card

Fluid managementFluid management

1997 2009 2011

DHF grade I-II Dengue with warning signs

DHF grade I-II

6-7 ml/kg/hour → 5 ml/kg/hour → 3 ml/kg/hour – stop after 24-48 hours

isotonic solutions such as 0.9% saline, Ringer’s lactate, or Hartmann’s solution. Start with 5–7

maintenance (for one day) + 5% deficit (oral and IV fluid together), to be administered over 48 24-48 hours solution. Start with 5–7

ml/kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response

be administered over 48 hours

Tata laksana Dengue denganWS (DBD derajat I & II)

Cairan awal 5-7ml/kgbb/jamRL atau NaCl 0,9%

Monitor tanda vital/jam

Hb, Hct, trombo tiap 6-12jamPerbaikan

GelisahDistres nafas

Tidak ada perbaikan

Tidak gelisahNadi kuat

1-2 jam

Tetesan dikurangi3-5ml/kgBB/jam

2-3ml/kgBB/jam

Stop dalam 24-48jam

Distres nafasFrek nadi naikHct tinggi Tek nadi <20mmHgDiuresis kurang

Evaluasi 1 jam

Tetesan dinaikkan

10 ml/kgBB/jam

Tanda vital tidak stabilCek Hct

Nadi kuatTek drh stabilHct turunDiuresis 1 ml/kgBB/jam

2- 4 jam

SYOK KOMPENSATA ?

Kegawatan pada fase kritisKegawatan pada fase kritis

� Dapat berlanjut ke keadaan yang berat jika:◦ Kebocoran plasma berat sampai terjadi syok dan atau akumulasi cairan/distres pernapasan

32

pernapasan

◦ Perdarahan hebat dan atau

◦ Gangguan fungsi organ yang berat (ensefalopati, ensefalitis, gagal hati, kardiomiopati dll)

� Periode kebocoran plasma berlangsung 24-48 jam

1997 2009 2011

DSS Severe Dengue-compensated shock

DHF grade III

10-20 ml/kgBB bolus, repeat if necessary

algorithm

isotonic crystalloid solutions at 5–10ml/kg/hour over one hour. →reassess

10 ml/kg in children or 300–500 ml in adults over one hour or by bolus, if hour. →reassess one hour or by bolus, if necessaryFurther, fluid administration should follow the graph

mulai dengan larutan kristaloid10-20 m/kg/jam – 1 jam

Koloid IV

PERBAIKAN*Ya tidak

periksaHCT

HCT

↓

HCT↑

tinggi

Syok kompensata(perfusi menurun tetapi tekanan sistolik

masih baik)

IV kristaloid, turunkan bertahap10 ml/kg/hr selama 1-2 jam7 mL/kg/hr selama 2 jam5 mL/kg/hr selama 4 jam3 mL/kg/jam

Koloid IV(bolus kedua)

10-20 mL/kg/jam –1jam

PikirkanperdarahantersembunyiSiapkan transfuse darah

Jika klinis membaik, turunkan tetesan cairan

Hentikan cairan setelah48jam

* Nilai ulang kondisi klinis (tanda vital , pulse, capillary refill time dan ekstremitas) dan tentukan status penderita

- IV: intravenous, HCT: hematocrit, ↑↑↑↑:meningkat, ↓↓↓↓:turun

Jika perlu bolus cairandapat diberikandalam24 -48 jam

Kurangi tetesan7-10 mL/kg/jam - 1-2 jam

PERBAIKAN*

Ya

Tdk

2009 2011

Severe Dengue – hypotensiveshock

DHF grade IV

Initiate intravenous fluid resuscitation with crystalloid or colloid solution (if available) at 20 ml/kg as a bolus given over 15 minutes to bring the patient

Ten ml/kg of bolus fluid should be given as fast as possible, ideally within 10 to 15 minutes. When the blood pressure is restored, further over 15 minutes to bring the patient

out of shock as quickly as possible.

blood pressure is restored, further intravenous fluid may be given as in Grade 3. If shock is not reversible after the first 10 ml/kg, a repeat bolus of 10 ml/kg and laboratory results should be pursued and corrected as soon as possible.

SyokSyok dekompensatadekompensata ( hipotensif)( hipotensif)

� Tatalaksana pada pasien dengan syok dekompensata/ hipotensif lebih agresif.

� Mulai resusitasi cairan intravena dengan larutan kristaloid atau koloid (bila tersedia) 20

36

kristaloid atau koloid (bila tersedia) 20 ml/kg sebagai bolus diberikan secepatnya/ dalam 15 menit untuk mengeluarkan pasien dari kondisi syok secepat mungkin.

What Not to Do ?What Not to Do ?PadaPada fasefase awalawal/ demam/ demam

� Jangan selalu mendiagnosis DD/DBD pada pasiendemam dan ISPA

�Indikator dini infeksi dengue:�Indikator dini infeksi dengue:

- Demam tinggi

-Wajah kemerahan

-Tidak tampak fokal infeksi

- Uji Tourniquet positif

- Trombositopenia atau ( Ht naik ± )

What Not to Do ?What Not to Do ?PadaPada fasefase awalawal/demam/demam

� Pemeriksaan NS1 bukan untuk mengetahui beratringannya penyakit

� Foto thoraks RLD jangan dilakukan pada semuakasus tersangka DBDkasus tersangka DBD

� Tidak boleh memberikan obat penurun panas jenisAspirin atau Ibuprofen

� Jangan memberikan antibiotik, kecuali terdapatinfeksi penyerta dengan fokus yang jelas◦ Pada ensefalopaty / ensefalitis diberikan antibiotik

� Hindari pemberian kortikosteroid tanpa indikasijelas, tidak menunjukkan adanya manfaat

What Not to Do ?What Not to Do ?PadaPada fasefase awalawal / demam/ demam

� Tidak boleh memberikan obat penurun panasjenis Aspirin atau Ibuprofen

� Jangan memberikan antibiotik, kecuali terdapatinfeksi penyerta dengan fokus yang jelas

◦ Pada ensefalopaty / ensefalitis diberikan antibiotik◦ Pada ensefalopaty / ensefalitis diberikan antibiotik

� Hindari pemberian kortikosteroid tanpa indikasijelas, tidak menunjukkan adanya manfaat

◦ hanya diberikan pada kasus ensefalopaty tanpa

perdarahan

RingkasanRingkasan

� Saat ini belum tersedia vaksin dan obat anti virus Dengue � manajemen kasus bertumpu pada tatalaksana cairan

� Mengenali gejala dan tanda, tanda � Mengenali gejala dan tanda, tanda peringatan seawal mungkin akan mengurangi risiko terjadinya kegawatan

� Ketepatan dan kecepatan pemberian pada kasus berat ( DSS) menentukan outcome penderita