Dengue Case Management

Leonard Nainggolan
Div. Tropical and Infectious Disease
Dept. Internal Medicine
Faculty of Medicine Universitas Indonesia

Pathogenesis and Patophysiology

Virulence and viral load

Immune complex disease
T-cell-mediated
ADE
Complement
Autoimmune disease
Apoptosis
Innate immunity
Cytokine Tsunami
Genetic

Lei HY et al. Immunopathogenesis of Dengue infection. J Biomed 2001

CAPILLARY
ENDOTHELIUM

Hydrostatic pressure < Oncotic

pressure

Hydrostatic pressure > Oncotic pressu

Nature Reviews Nephrology 6, 361-370 (June 2010)

The movement of material is generally accomplished via routes situated either across (i.e.,
transcellular) or in between (i.e., paracellular) the cells forming the barrier. While the
paracellular transport occurs via the intercellular junctions, there are at least three transcellular
routes described so far:
(a) water and small molecules are moved via membrane transporters that have a different
distribution/orientation on opposite fronts of a barrier cell;
(b) transcytosis, defined as the transport of macromolecular cargo from one front of a polarized
cell to the other within membrane-bounded carrier(s), and
(c) pores or channels which are patent openings through the barrier cells with or without

Lei HY et al. Immunopathogenesis of Dengue infection. J Biomed 2001

Hematokrit

Klasifikasi Dengue (WHO, 2009)

Pemeriksaan Penunjang

NS1
Protein non-struktural,
pada dengue
Sensitivitas deteksi NS1
(pada infeksi primer) >
90%
Sensitivitas menuruan
pada infeksi sekunder

(60-80%)

Peeling, R. W.et al.

Evaluation of diagnostic tests: dengue.
Nature Reviews Microbiology8,S30S37 (2010)

Dengue Case Management

Dengue guidelines for diagnosis, treatment, prevention, and control.

World Health Organization, UNICEF, UNDP. New Edition 2009.

Manifestasi Klinis
(Clinical Guidance of Dengue Virus Infection. CDC 2009)

Fluid Replacement
Resuscitation

Crystalloid

Colloid

Management

Electrolyte

Nutrition

Repair
Replace
Replace acute
acute loss
loss
(hemorrhage,
(hemorrhage, GI
GI loss,
loss, Third
Third
compartment)
compartment)

1.
1. Normal
Normal requirements
requirements
(IWL
(IWL +
+ urine+
urine+ faeces)
faeces)
2.
2. Nutritional
Nutritional Support
Support

Tatalaksana Tersangka DBD

Demam tinggi, mendadak <7 hari
Lesu, tidak ada ISPA

Ada kedaruratan
Syok
Kejang
Kesadaran menurun
perdarahan

Tidak ada kedaruratan

Uji Torniquet
negatif

positif

Trombosit
<100.000/ul

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

Rawat inap

Demam menetap >3 hari

Periksa Hb, Ht, leukosit, trombosit
22

MANAGEMENT PROTOCOL OF DENGUE

INFECTION in ADULT PATIENTS

Protocol 1: Management of Probable Dengue Infection

without Shock
Protocol 2: Fluid replacement on Probable Dengue
Infection in wards
Protocol 3: Management of DHF with increase of
hematocrite >20%
Protocol 4: Management of Spontaneous hemorrhage in
Dengue
Patients

PROTOCOL 1
Management of Probable Dengue Infection
Without Shock
Keluhan DBD
(Kriteria WHO 1997)

Hb, Ht
trombo normal

Observasi
Rawat jalan
Periksa Hb, Ht
Leuko, Tromb/24 jam

Hb, Ht normal
trombo 100.000-150.000

Observasi
Rawat jalan
Periksa Hb, Ht
Leuko, Tromb/24 jam

Hb, Ht normal
trombo < 100.000
Rawat

Hb, Ht meningkat
trombo normal/turun

Rawat

Penanganan Protokol
Rawat Inap Untuk DBD
( Protokol 2 )

PROTOCOL 2
Fluid Replacement on Probable Dengue
Infection in Wards
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%

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

Protocol 5
Management of Dengue Shock
Syndrome
Response
*

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 after 15 30 minutes
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

Crystalloid 3 mL/kg BW in 1 h

Blood transfusion 10
mL/kg BW can be repeated
if necessary

Colloid 10-20 mL/kg BW loading for 1015 min

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

Stop infusion

Response*
Consider for nutrition after
12 h (Dx 5 % If no
contraindication)

Not Response
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

Response:
1. Systolic BP 100 mmHg
2. PP > 20 mmHg
3. Heart Rate < 100 x/mnt, adequate
vol
4. Warm extremities
5. Diuresis 0,5-1 cc/kgBW/hour

Not Response
Monitoring
crystalloid
for 10-15
min

Normovolemi
c
Acid-base &
electrolyte
disturbance,
hypoglycemi
a, anemia,
secondary
infection
correction

Inotropic,
Vasopressor,
drug

Response
*

Colloid &
crystalloid
combination

Vasopressor
gradual
increment

Indikasi ICU
Syok yang tidak responsif setelah 1 jam
Syok berulang
Syok dengan perdarahan masif
Syok dengan komplikasi lainnya, mis.
respiratory distress, ensefalopati, gagal
jantung, gagal ginjal, kejang.
Departemen Kesehatan RI, IDAI, PAPDI, PDS PATKLIN, PERDICI & PPNI.2005. Pedoman
Tatalaksana Klinis Infeksi Dengue di Sarana Pelayanan Kesehatan. 2005. Jakarta : Depkes.

Human Junction