DIAGNOSIS AND MANAGEMENT

OF DHF AND DSS

INTRODUCTION

DHF relatively new diseases in Indonesia

1968 in Surabaya and Jakarta
1973 in Manado
Management divided in DHF and DSS
Mortality rate in : 1968 41.3 %
1992 2.9 %
1995 2.5 %
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DIAGNOSIS WHO 1975 / 1986

Base on 4 clinical and 2 laboratoric criteria
Clinical :

High fever 2 7 days

Hemorrhagic manifestation
Hepatomegaly
Shock

Laboratoric
Thrombocytopenia
Hemoconcentration

Dx : Minimally 2 clinical + Lab criteria

The accuracy : 75 90 %
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The severity of disease divided in 4 grade

I
II
III
IV

: Fever + non spesific + RL (+)

: I + Other hemorrh manifest
: II + mild shock
: III + severe shock

Grade I + II
III + IV

: DHF
: DSS
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 DHF : - permeability
- Fever crisis
DHF I, II :
Crisis days III >
IVFD 12 24 hours
PCV , Tr < 50 000
Health center / >

 Fever phase
Oral fluid : 50 ml/kgBW for 4 6 hours
IVFD manitenance : 80 100 ml/kg/days
Antipyretic : paracetamol 10 mg/kgBW/time
Convulsion : Phenobarbital 5 mg/kgBW/days
Critical Ill : Days 3 - 5

SUBSTITUTION FLUID IN DHF

Maintenance + 5 8 %
Vomiting every time
Cannot drink
fever
PCV periodically
Acidosis : NaBic
PCV > 20 % IVFD : GED mild - mod
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Table 1. Fluid need for moderate

dehidration.
Body Weight
(Kg)

Amount of fluid
(ml/kgBW/day)

<7
7 11
12 18
> 18

220
165
132
88
8

Table 2. Fluid need for maintenance

Body Weight
(Kg)

Amount of fluid
(ml/kgBW/day)

<10
10 20
20

100 / kgBW
1000 + 50/kgBW(>10 kg)
1500 + 20/kgBW(>20 kg)

Example : 40 Kg = 1500 + (20X20) = 1900 ml

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Temperature leakage
Reconvalescen reabsorbtion of fluid
Sign + symptom of shock hospitalization
Fluid Recommended (WHO)
Cristaloid

: RL RL-D5%
RA RA-D5%
NaCl 0.9 % - NaCl 0.9%-D5%
Colloid : Plasma
Dextran L 40
HAES
Gelofusin
Gelofundin
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DSS
Shock emergency fluid recovery 48 hours
Replacement of plasma volume
Cristaloid : 20 ml/kgBW/30 min
Still Shock : Koloid 10 20 ml/kgBW/h
Maximal 30 ml/kgBW
Improvement : Cristaloid 10 20 ml/kgBW/h
Still syok, PCV bleeding blood
PCV > 40 blood 10 ml/kgBW/h
Massive bleeding blood 20 ml/kgBW/h
Improvement Cristaloid
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Figure 1. Management of suspect DHF

Suspect DHF
Sudden high fever
Continously < 7 d
URTI (-)
Emergency (+)

Shock
Vomit
Convulsion
Consiousness
Hematemesis
Melena

Emergency (-)

Tourniquet (+)

Trombocyte
< 100 000 / ul

Hospitalization

Tourniquet (-)

Trombocyte
> 100 000 / ul

Ambulatory
Paracetamol
Control until Fever

Ambulatory
Follow Up Clinical & Lab
While days 3th fever (+)

Attention for parents

Shock Sign

Much drink
Paracetamol
Control until fever (-)

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Figure 2. Management of DHF (Grade II)

Initial Fluid
Improvement (+)
Restlessness (-)
Strong pulse
Stable BP
Diuresis 2 ml/kgBW/H
PCV 2 X exam

Decresed IV drip

RL/NaCl 0.9% / RLD5/NaCL0.9 % + D5

(6-7ml/KgBW/H)

Monitoring Vital Sign /

PCV and Trombocyte / 6 H

Restlessness
Resp Distres
Pulse reate
BP < 20mmHg
Diuresis / -

Vital sign decrease

PCV

Improvement

Increased IV drip

5 ml/kgBW/h
Evaluation 12 24 h
Improvement
3 ml/kgBW/h
IVFD Stop (24 48 h)
If Vital Sign / PCV / Diuresis
stable

Resp Distres
PCV
Coloid
20 30 ml/kgBW/h

Improvement (-)

Unstable vital sign

10 ml/kgBW/H
Step by Step
15 ml/kgBW/h

PCV
Fresh WB
10 ml/kgBW

Improvement

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Figure 3. Management of DSS (DHF III and IV)

DHF Gr III

1.
2.

Oxygenation
Plasma volume replacement
RL/NaCL 20 ml/kgBW imediately (bolus 30 min)
Evaluation 30 min
Follow up vital sign every 10 min
Record fluid balans

Shock (-)
Improvement consiousness
Strong pulse
BP > 20 mmHg
No RDS / Cyanosis
Warm Extremities
Diuresis > 1 ml/kgBW/h

Shock (-)

Strict Evaluation
Vital sign
Bleeding sign
Diuresis
Hb, PCV, Tr

3 ml/kgBW/h

Shock (+)
Decrese consiousness
Weak pulse / not palpable
BP < 20 mmHg
RDS / Cyanosis (+)
Cold Extremities
Diuresis < 1 ml/kgBW/h
Examine Glood Sugar

Reduce IVFD (10ml/kgBW/h)

Stable max 24 h
5 ml/kgBW/h

DHF Gr IV

IVFD (15 -20 ml/kgBW/h)

Koloid / Plasma
(10-20 max 30 ml/kgBw/h
Correction accidosis
Evaluation 1 h

Shock (+)

PCV
Fresh WB 10 ml/kgBW
Can repeated
IVFD stop 48 h

PCV high /
Koloid 20 ml/kgBW

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COMPLICATIONS
Electrolyte Imbalance
Hyponatremia
Hypocalcemia

Fluid overload
Early IVFD
Hypotonic Solution
Not IVFD
Not Use Colloidal Sol / Plasma
Not Give blood transf
Not Calculate IVFD
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COMPLICATIONS

Signs and Symptoms of Fluid Overload

RSD, Dyspnea and Tachypnea
Massive acites
Rapid Pulse
Pulse pressure
Crepitation/Ronchi
Porr tissue perfusion
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COMPLICATIONS

Management of fluid overload

Change IV to Dextrans 40
Urinary Catheter
Furosemide 1 mg/kgBW, IV
Still Shock Dextrans 40, 10 mg/kgBW in 10-15 min
Record Urine output
Furosemide may repeat if still RDS
CVP if not Response furosemide
Ventilatory support
Pleural/peritoneal tapping
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COMPLICATIONS

Unusual manifestation of DHF

Less than 5% of patient
Encephalopathy/encephalitis
Hepatic failure
Renal failure
Dual infections
Underlying conditions
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COMPLICATIONS

Signs and Symptoms of Fluid Overload

Prolonged shock
Acute hemolysis + Hb uria
G6PD
Hemoglobinopathy

Management of acute hemolysis + Hb Uria

Transfussion PRC of FWB
IVFD according the stage
Alkaline urine
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COMPLICATIONS
Dual Infections
Associate :
GI, Salmonella
RI, Pneumonia
Urinary infections
Skin + soft tissue inf
Nosocomial
Thrombophlebitis
Pneumonia
UTI (Catheter)
Others
Transfussion reaction
Hepatitis
Massive GI Hem
Drugs reactions

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COMPLICATIONS

Common causes of encephalopathy

Hepatic encephalopathy
Severeshock
Inborn error of metab
Hepatotoxic drugs
Underlying liver diseases

Electrolyte imbalance
Metabolic distrubance (hypoglycemia)
Intracranial bleeding
Cerebral thrombosis/ischemia
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COMPLICATIONS
Management of DHF hepatic encephalopathy
Maintain oxygenation
Prevent intracranial press :
Restrict IV
Furosemide + / dexamethasone

Amonia production
Vit K1 3-10 mg IV
Correct metab acidosis
PRC if indicated
Antibiotic
H2 Blocker if massive GI Bleeding
Avoid unnecessary drugs
Exchange tranf if needed
Dyalisis if needed
Branch chain aminoacid

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INDICATION FOR DISCHARGE

Not fever in 24 h
Good appetite
Good general condition
Diuresis
Normal PCV (38 40)
2 days after shock
No dyspnea
Platelet > 50 000/mm3
No complication
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CAUSES OF DEATH

Prolonged shock
Fluid overload
Massive bleeding
Unusual manifestation

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