Management of

Dengue Shock Syndrome

DR. Dr. Rismala Dewi, Sp. A(K)

Emergency and Pediatric Intensive Care Division FMUI-CMH

Learning Objective

Definition and concept

Type and clinical sign of shock in children
Fluid management in shock
Algorithm for pediatric shock
The Concept

DO2
VO2 ⬇
⬇
 DO2 = cardiac output x Arterial blood oxygen

Frequency x stroke volume Hb x 1,34 x SaO2 + 0,003 x PaO2

Preload afterload
Contractility Transfusion pH O2
PCO2 MAP
Temp
Fluid Vasoactive
Inotropic
A state in which there is inadequate tissue
perfusion to meet metabolic demands

It is HYPOPERFUSION…..
 Cor
Conduit
Content

* If anything goes
wrong it must be
one of this
 Clinical features

 Heart rate ↑
 Hypoperfusion
 Capillary refill time ↑
 Diuresis ↓
 Mental status ↓
 Weak pulse
 Blood pressure ↓
Stages of Shock

Compensated

Uncompensated

Irreversible

“Whatever the cause,

the body responds in
similar way”
 Intravascular volume changes

Heart rate
Capillary refill time
Blood pressure

-20 mL/kg -40 mL/kg -60 mL/kg

Hypotension is a late
and premorbid sign
 Pediatric Shock

Reassess, Reassess, Reassess

Pediatric patients in compensated

shock “crash” quickly
Pediatric Assessment Triangle

Circulation
Management
 Initial assessment may detect shock,
but not its cause
 When in doubt, treat for hypovolemia
 The questions must be answered:

 Does the child require emergent therapy?

 What kind of fluid should be given?
 How much fluid and what rate should fluid
be given initially and then in follow-up?
Hypervolemia optimisation hypovolemia

Liberal

Goal Which
directed
(targeted)
Standard
(routine) fluid?
Restrictive
 Volume Fluid
replacement replacement
 Fluid Management Concept
Specific treatment , forpatients with volume loosess

Volume replacement
Target : intravascular space
Indication : plasma and blood losses

Colloid + crystalloid

Crystalloid

Fluid replacement
Target : tissue, interstitium
Indication : dehydration, maintenance
Basic treatment, necessary in all patients
 Total body water = 60% body weight

Intracellular water Extracellular water

40% body weight 20% body weight
300 14% 5% 1%
Osmolality – mOsm/L

200

Transcellular
SHOCK

Plasma
Interstitial
100

0
Which
fluid?
Problem to be concern

Metabolic Volume Electrolyte

acidosis overload imbalance

Fluid shift
Coagulopathy and raised
ICP
Initial fluid resuscitation with crystalloid
minimal 20 mL/Kg in children

Goal
directed
(targeted)

Consider addition of albumin in patient

requiring substantial amounts of crystalloid
to maintain adequate MAP
Normal heart rate
Normal pulses
Capillary refill time < 2 seconds
Normal blood pressure
Warm extremities
Normal mental status
Urine output >1 mL/kg/hr
 Vital sign by age
Respirations Pulse SBP
Age (breaths/min) (beats/min) (mm Hg)
Newborn: 0-1 mo 30 to 60 90 to 180 50 to 70
Infant: 1 mo-1 yr 25 to 50 100 to 160 70 to 95
Toddler: 1-3 yr 20 to 30 90 to 150 80 to 100
Preschool age: 3-6 yr 20 to 25 80 to 140 80 to 100
School age: 6-12 yr 15 to 20 70 to 120 80 to 110
Adolescent: 12-18 yr 12 to 16 60 to 100 90 to 110
Older than 18 yr 12 to 20 60 to 100 90 to 140
Don’t give too much Fluid!!

Hepatomegaly
Rales
Increased WOB
↑Jugular venous pressure
Chest X-ray
USCOM
Echocardiography
Fluid responsiveness
 Congestive heart failure

1. Redistribution

2.Interstitial edema
3.Alveolar edema
Fluid balance paradigm
 Patient with sign and symptoms of shock

Assess airway and breathing

(protecting airway-high flow O2-intubate)

Place iv/io line  20 mL/kg bolus kristaloid

Re-assess for Little or no response

Positive response
response HR, RR,
Continued re-assessment BP, pulses, cap refill
Re-assessment A/B
Administer 2nd and 3rd
IV bolus as necessary

Begin assessment of category of shock

Hypovolemic Cardiogenic Distributive Obstructive

Which drug?
β-1 β-2 α
Dobutamine +++ + +
Dopamine ++ + Vary
Epinephrine ++ ++ +
Norepinephrine ++ 0 +++
Isoproterenol +++ +++ 0
 Conclusion
Recognize compensated shock quickly-
have a high index of suspicion, remember
tachycardia is first sign and hypotension is
late and ominous
Assessment, management of fluid balance
and prescription of appropriate fluid
constitute some of challenges for clinician
CASE ILLUSTRATION
 Case

 N, ♀, 6 years old, BW 16 kg
 Admitted to ED CMH
 Chief complaint: cold and clumpsy
hands and feet 2 hours p.a
Case: History of present illness
5 d p.a. 2 h p.a.

•High fever with sudden •Restlessness

onset •Cold and clumpsy
•Nausea (+), bleeding (-) hands and feet
•Last urine: 3 hrs p.a

General practitioners: ED CMH

•respiratory infection
•antipyretic
 no improvement.
Case: Physical examination
Alert
Blood pressure (BP) 90/70 mmHg
Pulse rate 168x/mnt, weak
Respiratory rate 32 tpm, regular, no
nasal flare nor retraction
Temperature 37.1°C (axilla)
Extremities cold, CRT 4 seconds
Working diagnosis
• Hypovolemic shock ec DSS.

Management
• O2 through nasal cannula 1 L/minute
• Crystalloid loading 20 mL/kgBW via 2 venous access
in 10 minutes or as soon as possible.
• Urine catheter
• Lab: complete blood count
Case: Management
After 1st loading
•BP: 90/60 mmHg
•Pulse: 148x/min, reg, weak
•T: 36,5 ºC
•RR: 28x/min, reg, adequate
•Cold extremities
•CRT 3 s
Partial response
2nd loading: crystalloid 20
mL/kgBB & colloid 20
mL/kgBB via 2 venous
access as soon as possible.
After 2nd loading
•BP: 90/60 mmHg
•Pulse: 110x/min, reg, adequate
•RR: 26x/min, reg, adequate
•Warm extremities
•CRT 2 s
•Diuresis 1,6 mL/kgBW/hour
Shock treatment successful
PICU
 Case: Follow-up

1st day 1st day 3rd day 4th day

• Chest X-ray
Admitted to PICU Dobutamine &
Pleural effusion, pulmonary
edema dopamine stoppedto pediatric
•Transfer
Shock  crystalloid 20 ml/kgBB &
ward
colloid 20 mL/kgBB
Shock was not resolved
• RDT: anti dengue IgM (-) & IgG (+)

• Ronchi (+)

Dobutamine & Dopamine

•Chest X-rays
 Case: Follow up

Date 1st day 2nd day 3rd day 4th day

Hb 13,5 11,1 14,4 12,3

(gr/dL)
Ht 42 32 39,4 38,3
(%)
Leucocyte 2.600 2.300 2.300 4.400
(/µL)

Trombocyte 35.000 10.000 52.000 74.000

(/µL)