Dr Djatnika - DSS Update-2

UPDATNG OFUPDATNG OFDENGUE SHOCK MANAGEMENTDENGUE SHOCK MANAGEMENT

UPDATNG OFUPDATNG OFDENGUE SHOCK MANAGEMENTDENGUE SHOCK MANAGEMENT

Djatnika SetiabudiDjatnika Setiabudi

DEPARTMENT OF PEDIATRICSDEPARTMENT OF PEDIATRICS

HASAN SADIKIN GENERAL HOSPITALHASAN SADIKIN GENERAL HOSPITAL

BANDUNGBANDUNG

Djatnika SetiabudiDjatnika Setiabudi

DEPARTMENT OF PEDIATRICSDEPARTMENT OF PEDIATRICS

HASAN SADIKIN GENERAL HOSPITALHASAN SADIKIN GENERAL HOSPITAL

BANDUNGBANDUNG

Introduction Introduction (1)(1)

Dengue infection : Dengue infection : Public Health Problem in Public Health Problem in Tropics & Sub-tropicsTropics & Sub-tropics

Guiness World Records 2002 :Guiness World Records 2002 : most important viral hemorrhagic fever & most important viral hemorrhagic fever &

most geographically wide-spread of most geographically wide-spread of Arbovirus diseasesArbovirus diseases

DSS : DSS : causes a significant number of causes a significant number of childhood deathschildhood deaths

Introduction Introduction (2)(2)

Mortality rateMortality rate Indonesia Indonesia - 1968 : 41,3 % - 1984 : 3,0 %- 1968 : 41,3 % - 1984 : 3,0 % - 1998 : 1,9 % - 2003 : - 1998 : 1,9 % - 2003 : ++ 2,0 % 2,0 % Queen Sirikit National Institute of Child Queen Sirikit National Institute of Child

Health (Children Hospital) Bangkok : Health (Children Hospital) Bangkok : - 1970 : 10 % - 1970 : 10 % - 1984 : 2 %- 1984 : 2 % - 1990 : 0.2 %- 1990 : 0.2 % Target of WHO : < 1 %Target of WHO : < 1 %

WithoutHemorrhage

WithoutHemorrhage

With unusual

Hemorrhage

With unusual

HemorrhageShock (-)Shock (-) Shock (+)

DSS

Shock (+)

DSS

Undifferentiated Undifferentiated febrile illnessfebrile illness

Undifferentiated Undifferentiated febrile illnessfebrile illness

Dengue FeverDengue FeverDengue FeverDengue Fever Dengue Hemorrhagic FeverDengue Hemorrhagic FeverDengue Hemorrhagic FeverDengue Hemorrhagic Fever

AsymptomaticAsymptomaticAsymptomaticAsymptomatic SymptomaticSymptomaticSymptomaticSymptomatic

Dengue virus infectionDengue virus infectionDengue virus infectionDengue virus infection

Clinical spectrum of

Dengue Virus infection

PATHOGENESISPATHOGENESIS

1.1. IMMUNOPATHOLOGY THEORYIMMUNOPATHOLOGY THEORY

2.2. ANTIGEN- ANTIBODY THEORYANTIGEN- ANTIBODY THEORY

3.3. ANTIBODY DEPENDENT ANTIBODY DEPENDENT ENHANCEMENT ENHANCEMENT (ADE) (ADE) THEORYTHEORY

4.4. MEDIATOR THEORYMEDIATOR THEORY

DENGUE VIRUS INFECTION

FEVERANOREXIAVOMITING

BLEEDINGMANIFESTATION

HEPATOMEGALY INCREASEVASCULAR

PERMIABILITY

TROMBOCYTOPENIA

Plasma leakage :

HemoconcentrationHipoproteinemiaPleural effusionAscites

Hypovolemia

Shock

Anoxia

Death

AcidosisG.I. bleeding

DIC

Dehydration

Suchitra (1993)

Plasma leakage

Hypovolemia

Circulatorydisturbance

+ Bleeding

PATHOPHYSIOLOGY OF DSS

Four Grades of DHF Four Grades of DHF (1)(1)

Grade 1Grade 1 Fever and nonspecific constitutional Fever and nonspecific constitutional

symptomssymptoms Positive tourniquet test is only Positive tourniquet test is only

hemorrhagic manifestationhemorrhagic manifestation

Grade 2Grade 2 Grade 1 manifestations + Grade 1 manifestations +

spontaneous bleedingspontaneous bleeding

Grade 1Grade 1 Fever and nonspecific constitutional Fever and nonspecific constitutional

symptomssymptoms Positive tourniquet test is only Positive tourniquet test is only

hemorrhagic manifestationhemorrhagic manifestation

Grade 2Grade 2 Grade 1 manifestations + Grade 1 manifestations +

spontaneous bleedingspontaneous bleeding

Four Grades of DHF Four Grades of DHF (2)(2)

Grade 3Grade 3 Signs of circulatory failure Signs of circulatory failure

- rapid and weak pulse- rapid and weak pulse

- narrow pulse pressure : < 20 mmHg- narrow pulse pressure : < 20 mmHg

- cold/clammy skin- cold/clammy skin

- hypotension by age- hypotension by age

- oliguria, restlessness- oliguria, restlessness

Grade 4 : Profound shock Grade 4 : Profound shock (undetectable pulse and blood pressure)(undetectable pulse and blood pressure)

DSS = DHF grade 3 & 4DSS = DHF grade 3 & 4

Grade 3Grade 3 Signs of circulatory failure Signs of circulatory failure

- rapid and weak pulse- rapid and weak pulse

- narrow pulse pressure : < 20 mmHg- narrow pulse pressure : < 20 mmHg

- cold/clammy skin- cold/clammy skin

- hypotension by age- hypotension by age

- oliguria, restlessness- oliguria, restlessness

Grade 4 : Profound shock Grade 4 : Profound shock (undetectable pulse and blood pressure)(undetectable pulse and blood pressure)

DSS = DHF grade 3 & 4DSS = DHF grade 3 & 4

Principles of DSS Principles of DSS managementmanagement

Early detectionEarly detection

Prompt and adequate fluidPrompt and adequate fluid

replacementreplacement

Closed monitoringClosed monitoring

Warning Signs for Dengue ShockWarning Signs for Dengue Shock

Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets

Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets

Warning Signs for Dengue ShockWarning Signs for Dengue Shock

Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit

Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit

Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets

Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets

Warning Signs for Dengue ShockWarning Signs for Dengue Shock

Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit

Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit

Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)

Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)

Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets

Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets

Warning Signs for Dengue ShockWarning Signs for Dengue Shock

When Patients Develop DSS:• 3 to 6 days after onset of symptoms

When Patients Develop DSS:• 3 to 6 days after onset of symptoms

Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit

Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit

Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)

Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)

Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets

Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets

Warning Signs for Dengue ShockWarning Signs for Dengue Shock

When Patients Develop DSS:• 3 to 6 days after onset of symptoms

When Patients Develop DSS:• 3 to 6 days after onset of symptoms

Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit

Initial Warning Signals:• Disappearance of fever• Drop in platelets• Increase in hematocrit

Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)

Alarm Signals:• Severe abdominal pain• Prolonged vomiting• Abrupt change from fever to hypothermia• Change in level of consciousness (irritability or somnolence)

Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets

Four Criteria for DHF:• Fever• Hemorrhagic manifestations• Excessive capillary permeability• 100,000/mm3 platelets

Treatment of DSS

Therapetic objectives in the treatment of hypovolemic shock:

- normalize blood volume

- regulate blood pressure

- stabilize cardiac function

- improve tissue perfusion

- raise oxygen delivery

Treatment of DSS (1)

- Body-weight measurement

- ABC resuscitation

- Vascular access

- Blood sampling

- Fluid resuscitation

- Urine catheter

Sumber: Majalah Tempo

Treatment of DSS (2)

Body-weight measurement

- Important for baseline

- determine the volume of fluid needed

- important for monitoring (overload?)

Treatment of DSS (3)

ABC resuscitation

- Basic life support

- most important thing : OXYGEN

- Preventing and correcting hypoxemia

- Maintenance O2 saturation 95-100%

Treatment of DSS (4)

Vascular access and blood sampling

- Complete blood count

!! PCV, thrombocyte

- blood group , cross-match !

- Gas analysis and electrolyte

- Ureum, creatinine

- serologic studyserologic study

Treatment of DSS (5)

Fluid resuscitation

- Rapid and aggressive

- increasing preload and cardiac output

- restore effective circulation

- restore oxygen-carrying capacity

- correcting metabolic and electrolyte

disturbance

Treatment of DSS (6)

Urine Catheter

- monitor diuresis

keep urine output > 1 ml/kgBW/hour

- urinalysis : ! Specific gravity !

Repeat bolus

Crystalloid 3 ml/kgBW/hour

Stop IV fluid(no more than 48 hour)

Colloid 20 ml/kgBW/hour 

-    

Maintenance Stabil for 12 – 24 hour

Crystalloid 5 ml/kgBW/hour Stabil for 6 – 12 hour

SHOCK

Body weight measurement, ABC resuscitation (+Oxygen),vascular access and blood sampling, urine catheter

Fluid resuscitation 10-30 ml/kgBW/6-10 minute (bolus)

IMPROVEMENTCrystalloid 10 ml/kgBW/hour

Monitoring vital sign, diuresisPCV, Thrombocyte

NO IMPROVEMENT

NO IMPROVEMENT IMPROVEMENT *

Repeat bolus

Crystalloid 3 ml/kgBW/hour

Stop IV fluid(no more than 48 hour)

Colloid 20 ml/kgBW/hour 

-    

Maintenance Stabil for 12 – 24 hour

Crystalloid 5 ml/kgBW/hour Stabil for 6 – 12 hour

SHOCK

Body weight measurement, ABC resuscitation (+Oxygen),vascular access and blood sampling, urine catheter

Fluid resuscitation 10-30 ml/kgBW/6-10 minute (bolus)

IMPROVEMENTCrystalloid 10 ml/kgBW/hour

Monitoring vital sign, diuresisPCV, Thrombocyte

NO Improvement

NO IMPROVEMENT IMPROVEMENT *

NO IMPROVEMENT

- PCV low Bleeding Blood transfusion

- CVP : > 10 mmHg resuscitation drug

- Correcting acidosis & electrolyte

- Overload : diuretic

- ARDS: ventilation

Acute management of DSS:

A randomized, Double-blind Comparison of 4 Intravenous Fluid Regiments in the First Hour

- Setting: ICU of Dong Nai Pediatric Hospital, Vietnam

- Time : September 1996 – September 1997

- Subject: 230 pediatric patients (1-15 year) with DSS

222 DHF grade III – 8 DHF grade IV

- Regimen fluid :

Normal saline – RL – gelatin 3% - Dextran 70

- Dosing : DHF grade III : 20 ml/kgBW/hour

DHF grade IV : 20 ml/kgBW/15 minutes then

20 ml/kgBW/hour

Acute management of DSS:

A randomized, Double-blind Comparison of 4 Intravenous Fluid Regiments in the First Hour

Results :

- All the children survived

- No clear advantage to using any of the 4 fluids

- The most significant factor determining clinical response

was the pulse pressure at presentation

- Colloid fluid was more benefit in children presenting

with lower pulse pressure

Nhan NT, Phuong CXT, Kneen R, et al. Clin Inf Dis 2001

Treatment of DIC

- Massive bleeding , Hb / PCV low

Fresh whole blood : 10 – 20 ml/kgBW

- If NO Blood component transfusion

Thrombocyte : 1 Unit (Bag)/ 5 kgBW

Fresh Frozen Plasma : 10 - 15 ml/ kgBW

Cryoprecipitate ( if fibrinogen < 100 mg/dl)

1 bag / 3 kgBW : infant

1 bag / 6 kgBW in older children

Pearls in managementPearls in management

• Early recognition of sign of shock can modify

the severity of DHF patients

• The period of plasma leakage/shock is short :

24-48 hours

• DSS can be successfully resuscitated by using

crystalloid only : + 60%

plus colloidal : 20%

need blood/component transfusion: + 15%

Suchitra, 2002Suchitra, 2002

Pitfalls in managementPitfalls in management

• Use hypotonic solution and delay to use colloidal

during critical period of plasma leakage

• Failure to monitoring the rate/volume of replace

ment fluid: massive pleural effusion/ascites

pulmonary edema

• Failure to recognize concealed internal bleeding

prolonged shock, fluid over load, death

• Over use of platelet transfusion as prophylaxis

for bleeding in all shock cases

Suchitra, 2002Suchitra, 2002