3.3. fluid treatment dengue trisakti-ok

FLUID TREATMENT CHOICE

IN DENGUE INFECTION

Djatnika Setiabudi

Child Health Department

Medical Faculty Padjadjaran University

Outline

Introduction

Dengue Classification (WHO 2011)

Patophysiology

Fluid Treatment

Resume

Burden of disease

Endemic in > 100 tropical and subtropical countries

50–100 million dengue fever infections per year globally

500,000 cases of severe dengue DHF and DSS

Average case fatality 2–5%

Indonesia (Profil Kesehatan tahun 2010):

- DHF the second most hospitalized patients

- 156,086 cases; insidence rate 65.7/100,000 /year

- Case Fatality Rate (CFR): 0.87%

Dengue Infection

New GuidelinesWHO /SEARO,

2011

Important notes:

1. Clinical spectrum added:expanded dengue syndrome

2. If fever and significant plasma leakage: DHF clinical diagnosis is most likely even if there is no bleeding manifestation or thrombocytopenia

Manifestations of dengue virus infection (WHO, 2011)

WHO classification of dengue infections and grading of severity of DHF (2011)

DENGUE VIRUS INFECTION

FEVER

ANOREXIA

VOMITING

BLEEDING

MANIFESTATION

HEPATOMEGALY INCREASE

VASCULAR

PERMEABILITY

TROMBOCYTOPENIA

Plasma leakage :

Hemoconcentration

Hipoproteinemia

Pleural effusion

Ascites

Hypovolemia

Shock

Anoxia

Death

AcidosisG.I. bleeding

DIC

Dehydration

Suchitra (1993)

The course of Dengue illness

Perjalanan penyakit Demam Dengue

Hari sakit

emp

Time of fever defervescence

(Saat suhu reda)

Suhu reda, klinis membaik,

nafsu makan membaik

Perjalanan penyakit DBD

Hari sakit

emp

Klinis memburuk, lemah, gelisah,

tangan kaki dingin, nafas cepat,

diuresis berkurang,

tidak ada nafsu makan

Fase syokFase demam Fase konvalesens

Time of fever defervescence

Principle of dengue management

1. Fluid replacementVascular permeability increase Plasma leakage hemoconcentration hypo-volemic shock

2. Early detection and managememnet of circulatory disturbance: Clinically and serial Blood laboratory exam

3. Detection and management of bleeding manifestation: Clinically and laboratory exam

4. Supportive and symptomatic treatment

Fluid treatment: Principle of “4-J”

Jalan/jalur pemberian : per oral – intravena ?

Jenis cairan :

oralit- jus buah - kristaloid – koloid ?

Jumlah cairan :

rumatan – dehidrasi atau hemokonsentrasi?

Syok atau tidak syok

Jadwal pemberian :

bolus - per jam – per hari ?

Indication for intravenous fluid

- (Persistent) vomiting

- Nausea and anorexia (small drinking)

- Abdominal pain and tenderness

- Impaired concioussness

- Increasing Haematocrit value

- Circulatory disturbance

Choice of fluids

Suspected dengue and Dengue Fever:

- isotonic crystalloid : normal saline, Ringer’s

lactate, Ringer’s acetate, Ringer’s dextrose

Dengue hemorrhagic Fever (DHF I and II):

- isotonic crystalloid : glucose contained solution?

DSS: crystalloid versus colloid ?

TANDA VITAL TIDAK STABIL

Penurunan jumlah urine output

Tanda-tanda syok

DBD derajat III*

Perbaikan

Oksigen melalui face mask atau kanula hidung

Penggantian volume secara cepat: inisiasi terapi IV

10 ml/kg/jam larutan isotonik kristaloid selama 1-2 jam

Tidak ada perbaikan

Perbaikan lebih lanjut

Pengurangan dari10 ml/kg/jam

menjadi 7, 5, 3, 1.5 ml/kg/jam

sesuaikeadaan klinis dan hasil

pemeriksaan hematokrit

Menghentikan terapiIV

selama 24-48 jam

Peningkatan hematokrit Penurunan hematokrit

Periksa ABCS

(Acidosis, Bleeding, Calcium,

Sugar), dan koreksi

Koloid IV

(Dextran 40 atau HES)

Transfusi darah :

FWB10 ml/kg

atau PRC 5 ml/kg

Perbaikan

Pengurangan dari10 ml/kg/jam

menjadi 7, 5, 3, 1.5 ml/kg/jam

tergantung keadaan klinis dan

hematokrit . Hentikan terapi IV

selama 24-48 jam

* Dalam kasus dengan syok yang lebih berat (DBD derajat IV) laju IV adalah 10 ml/kg selama 10-

15 menit atau 20 mL/kg dalam 30 menit, selanjutnya dikurangi menjadi 10 ml/kg/jam

Tatalaksana DSS (DBD III dan IV)

Randomised Controlled Trials

of Fluid Management in DSS

Dung NM, Day NP, Tam DT, Loan HT, Chau HT, Minh LN, et al.

Fluid replacement in dengue shock syndrome: a randomized, double-blind

comparison of four intravenous-fluid regimens.

A pilot study involving 50 children with DSS

Children were randomised to receive:

crystalloid : normal saline (n=12), Ringer’s lactate (n=13)

colloid : dextran 70 (n=12) or 3% gelatin (n=13)

Result:

- colloid group had significantly greater increases in mean

haematocrit (P=0·01), blood pressure (P=0·005), pulse

pressure (P=0·02)

Overall : showed minor differences in the immediate

clinical responses to different fluids

Clin Infect Dis. 1999;29:787–94

Ngo NT, Cao XT, Kneen R, Wills B, Nguyen VM, Nguyen TQ, et al.

Acute management of dengue shock syndrome: a randomized double-blind

comparison of 4 intravenous fluid regimens in the first hour.

A larger study: 230 DSS children , compared the same four fluids

Result:

- comparisons between all other solutions were not significant (However,

pulse pressure at presentation was identified as a potential confounder)

- in severe patients (pulse pressure < 10 mmHg) differences were found

Conclusion:

- mild-to-moderate DSS patients have respond well to crystalloid treatment

- more severe: may require more aggressive management with colloids

- However, this study was statistically underpowered

- Recommendation:

further large-scale studies, stratified for admission pulse pressure,

Clin Infect Dis. 2001;32:204–13.

Wills BA, Nguyen MD, Ha TL, Dong TH, Tran TN, Le TT, et al.

Comparison of three fluid solutions for resuscitation in dengue shock

syndrome.

largest randomised study ,stratified for presenting pulse pressure.

Group 1: Moderately shock (pulse pressure >10 to 20 mmHg, n=383)

were randomised to receive Ringer’s lactate (n=128), 6% dextran 70

(n=126) or 6% HES 200/0·5 (n=129).

Group 2: severe shock (pulse pressure 10 mmHg) were randomised to

receive one of the colloids – dextran 70 (n=67) or HES (n=62)

Result:

- Group 1: RL was found to be as effective as colloid therapy

- Group 2: - both colloid preparations performed equally result.

- dextran more adverse events than HES (allergic-reactions)

- no differences in severe adverse events

(significant bleeding or clinical fluid overload)

N Engl J Med. 2005;353:877–89.

Characteristics of three Vietnam Studies

Author, Year Population Intervention: Study fluids

Dung et al.,

1999

50 Vietnamese child with

clinical DSS;

5-15 years old

Lactated Ringer’s solution, isotonic

saline, dextran, gelatin

Fluid rate :20mL/kg for 1 hr, then

10mL/kg for the 2nd hour

Nhan et al.,

2001

230 Vietnamese children

clinically diagnosed DHF

DHF grade III = 222

DHF grade IV = 8

1-15 years old

Lactated Ringer’s solution, isotonic

saline, dextran, gelatin

Fluid rate :

DHF grade III: 20mL/kg for 1 hr

DHF grade IV: 20ml/kg for 15min,

then 20mL/kg over the following hour

Willis et al.,

2005

512 Vietnamese children

with clinical DSS

Moderate shock = 383

Severe shock = 129

2-15 years old

Lactated Ringer’s solution, starch,

dextran

Fluid rate:

15mL/kg for 1 hr, then 10mL/kg for

the 2nd hr

Kalayanarooj S.

Choice of colloidal solutions in dengue hemorrhagic fever patients.

A study of 104 DHF patients with severe plasma leakage who

had failed to respond to crystalloids and required fluid

resuscitation

compared bolus doses of two colloids, 10% dextran 40 (n=57)

and 10% HAES-steril (n=47)

Objective: compare their effectiveness, impact on renal function

and haemostasis and any complications.

Result:

- HAES-steril was found to be as effective as dextran 40.

- Both colloidal solutions were safe in these patients (no allergic

reactions, interference with renal function or haemostasis)

J Med Assoc Thai. 2008;91(suppl. 3):S97–103.

SYSTEMATIC REVIEW

The Use of Colloids and Crystalloids in Pediatric

Dengue Shock Syndrome:

a Systematic Review and Meta-analysis*

Jalac SLR, de Vera M and Alejandria MM.

Philippine Journal of Microbiology and Infectious Diseases

2010;39(1):14-27

Objectives:

to compare the therapeutic effects of colloids

versus crystalloids of children with DSS in

reducing:

1. the recurrence of shock

2. the requirement for rescue fluids

3. the need for diuretics

4. the total volume of intravenous fluids given

5. the haematocrit level and pulse rates

6. mortality rates

Results:

Colloids and crystalloids did not differ significantly in

decreasing:

1. t:he risk for recurrence of shock (RR 0.92, 95% CI 0.62 - 1.38)

2. the need for rescue fluids (RR 0.90, 95% CI 0.70 - 1.16)

3. mortality rates

4. total volume of intravenous fluids given

5. the need for diuretics (RR=1.17, 95% CI 0.84 to 1.64)

significant improvements from baseline in the haematocrit

levels and pulse rates of patients who were given colloids

Allergic type reactions were seen in patients given colloids

Conclusion:

no significant advantage was found colloid over

crystalloids in reducing the recurrence of shock,

the need for rescue colloids, the total amount of

fluids, the need for diuretics, and in reducing

mortality

Colloids decreased the haematocrit and pulse rates

of children with DSS after the first two hours of

fluid resuscitation

Resume

These studies show that the majority of DSS children can

be treated successfully with isotonic crystalloid solutions

If a colloid is considered necessary:

- rely on personal experience

- familiarity with particular products

- local availability and cost

A medium-molecular-weight preparation : optimal choice

- good initial plasma volume support

- good intravascular persistence and

- acceptable tolerability profile

Characteristics of colloids

used for plasma volume support

Initial volume

expansion

(%)*

Duration of

volume effect

(hrs)

Adverse effect

on coagulation

Allergic

potential

Other

significant

side-effects

3% Gelatine

(MW = 35,000)60–80 3–4 +/− ++

10% Dextran 40

(MW = 40,000)170–180 4–6 ++ +

Renal failure in

hypovolaemic

patients

6% Dextran 70

(MW = 70,000)100–140 6–8 ++ +

6% Hydroxy-ethyl

starch = HES

(MW = 200,000/0·5)

100–140 6–8 + +/−

6% HES

(MW = 400,000)80–100 12–24 ++ +

Management of dengue; Wills B. Halstead SB (Ed.) : 2008 Imperial College Press. Note: *Infused volume; MW, molecular weight

Countries and areas at risk of dengue transmission, 2008

Dengue Classification........

Without haemorrhage

With unusualhaemorrhage

No shock Dengue shock syndrome

Undifferentiated febrile illness

(viral syndrome)

Dengue Fever syndrome

Dengue hemorrhagic fever(plasma leakage)

Asymptomatic Symptomatic

Dengue virus infection

Clinical Spectrum of Dengue Viral Infection, WHO 1997

WHO, 1997

Ditjen Yanmed

Ditjen P2PL

WHO/TDR Guidelines 2009

These guidelines are not intended toreplacenational guidelines but to assist in the development of national or regional guidelines

Suggested dengue classification and level of severity

WHO, 2009

Tata laksana DBD derajat I & IICairan awal : Rumatan + 5%

(7ml/kgBB/jam)

Tetesan dikurangi

5ml/kgBB/jam

3ml/kgBB/jam

1,5 mL/kg/jam

Stop dalam 24-48jam

Monitor tanda vital

Hb,Ht,trombo tiap 6-12jam

Perbaikan

Gelisah

Distres nafas

Frek nadi naik

Ht tinggi

Tek nadi <20mmHg

Diuresis kurang

Evaluasi 12-24jam

Tidak ada perbaikan

Tetesan dinaikkan

10 ml/kgBB/jam

Tanda vital tidak stabilTatalaksana DSS

Tidak gelisah

Nadi kuat

Tek drh stabil

Ht turun

Diuresis 2ml/kgBB/jam

Jumlah Cairan :

Rumatan : Halliday & Segar

BB (Kg) Jumlah cairan / 24 jam

< 10 100cc/kg BB10 – 20 1000 + 50cc/kg BB untuk tiap kelebihan > 10 kg>20 1500 + 20cc/kg BB untuk tiap kelebihan > 20 kg

Kehilangan cairan : DHF dianggap dehidrasi sedang = 5-8%,

setiap 1% = 10cc/kg BB

DBD derajat I dan II

Contoh : berat badan 18 kg

Rumatan = (10 x 100) + (8x50) = 1400 cc

Kehilangan cairan = 18 x 5 x 10 cc = 900 cc

Jumlah : 2300 cc/24 jam

Order untuk kebutuhan tiap jam ( + 100cc /jam)

selanjutnya cairan disesuaikan bergantung pada

hasil monitoring Hematokrit dan klinis

DBD derajat I dan II