dhf dss handout

8/9/2019 Dhf Dss Handout

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DIAGNOSIS AND MANAGEMENT

OF DHF AND DSS

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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 %3


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The severity of disease divided in 4 grade

• I : Fever + non spesific + RL (+)

• II : I + Other hemorrh manifest

•

III : II + mild shock• IV : III + severe shock

• Grade I + II : DHFIII + IV : 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 / >

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• 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

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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

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Table 2. Fluid need for maintenance

Body Weight

(Kg)

Amount of fluid

(ml/kgBW/day)

10 kg)

1500 + 20/kgBW(>20 kg)

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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

HAESGelofusin

Gelofundin

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Figure 1. Management of suspect DHF

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Suspect DHF

Sudden high feverContinously < 7 d

URTI (-)

Emergency (-)Emergency (+)

ShockVomit

Convulsion

Consiousness

Hematemesis

Melena Ambulatory

Paracetamol

Control until Fever

Tourniquet (+) Tourniquet (-)

Follow Up Clinical & Lab

While days 3th fever (+)

Attention for parents

Shock Sign

Trombocyte

> 100 000 / ul

Trombocyte

< 100 000 / ul

Hospitalization

Much drink

Paracetamol

Control until fever (-)

Ambulatory


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Figure 2. Management of DHF (Grade II)

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Initial Fluid RL/NaCl 0.9% / RLD5/NaCL0.9 % + D5(6-7ml/KgBW/H)

Decresed IV drip

Monitoring Vital Sign /

PCV and Trombocyte / 6 H

Restlessness (-)

Strong pulse

Stable BP

Diuresis 2 ml/kgBW/H

PCV 2 X exam

Improvement (+) Improvement (-)

Restlessness

Resp Distres

Pulse reate

BP < 20mmHg

Diuresis / -

10 ml/kgBW/H

Step by Step

15 ml/kgBW/h

Increased IV drip

Evaluation 12 – 24 h

Improvement

Unstable vital signResp Distres

PCV PCV

Coloid

20 – 30 ml/kgBW/hFresh WB

10 ml/kgBW

Improvement

Improvement

Vital sign decrease

PCV

IVFD Stop (24 – 48 h)

If Vital Sign / PCV / Diuresis

stable

5 ml/kgBW/h

3 ml/kgBW/h


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

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DHF Gr III 1. Oxygenation2. Plasma volume replacement

RL/NaCL 20 ml/kgBW imediately (bolus 30 min)

Evaluation 30 min

Follow up vital sign every 10 min

Record fluid balansShock (-) Shock (+)

DHF Gr IV

Improvement consiousness

Strong pulse

BP > 20 mmHg

No RDS / Cyanosis

Warm ExtremitiesDiuresis > 1 ml/kgBW/h

Decrese consiousness

Weak pulse / not palpable

BP < 20 mmHg

RDS / Cyanosis (+)

Cold ExtremitiesDiuresis < 1 ml/kgBW/h

Examine Glood SugarReduce IVFD (10ml/kgBW/h)

IVFD (15 -20 ml/kgBW/h)

Koloid / Plasma

(10-20 max 30 ml/kgBw/h

Correction accidosisEvaluation 1 h

Shock (+)

Shock (-)

PCV high /

Koloid 20 ml/kgBW

PCV

Fresh WB 10 ml/kgBW

Can repeated

Strict Evaluation

Vital sign

Bleeding sign

DiuresisHb, PCV, Tr

Stable max 24 h

5 ml/kgBW/h

3 ml/kgBW/h IVFD stop ≤ 48 h


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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 IVFD15


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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


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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


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Unusual manifestation of DHF

• Less than 5% of patient

•

Encephalopathy/encephalitis• Hepatic failure

• Renal failure

• Dual infections• Underlying conditions

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COMPLICATIONS


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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


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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 reactions20

COMPLICATIONS


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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


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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 22

COMPLICATIONS


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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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