UPDATNG OF

DENGUE SHOCK MANAGEMENT

Djatnika Setiabudi
DEPARTMENT OF PEDIATRICS
HASAN SADIKIN GENERAL HOSPITAL
BANDUNG

Introduction (1)

Dengue infection : Public Health Problem in

Tropics & Sub-tropics

Guiness World Records 2002 :

most important viral hemorrhagic fever &
most geographically wide-spread of
Arbovirus diseases

DSS : causes a significant number of

childhood deaths

Introduction (2)

Mortality rate

Indonesia
- 1968 : 41,3 % - 1984 : 3,0 %
- 1998 : 1,9 % - 2003 : + 2,0 %
Queen Sirikit National Institute of Child
Health (Children Hospital) Bangkok :
- 1970 : 10 %
- 1984 :
2 %
- 1990 : 0.2 %
Target of WHO : < 1 %

Clinical spectrum of
Dengue Virus infection
Dengue virus infection

Asymptomatic

Undifferentiated
febrile illness

Symptomatic

Dengue Fever

Without
Hemorrhage

With unusual
Hemorrhage

Dengue Hemorrhagic Fever

Shock (-)

Shock (+)
DSS

PATHOGENESIS

1.
2.
3.

4.

IMMUNOPATHOLOGY THEORY
ANTIGEN- ANTIBODY THEORY
ANTIBODY DEPENDENT
ENHANCEMENT (ADE) THEORY
MEDIATOR THEORY

DENGUE VIRUS INFECTION

FEVER
ANOREXIA
VOMITING

BLEEDING
MANIFESTATION

HEPATOMEGALY

INCREASE
VASCULAR
PERMIABILITY

TROMBOCYTOPENIA

Plasma leakage :
Hemoconcentration
Hipoproteinemia
Pleural effusion
Ascites

Dehydration

Hypovolemia

DIC
G.I. bleeding

Suchitra (1993)

Shock
Anoxia
Death

Acidosis

PATHOPHYSIOLOGY OF DSS

Plasma leakage

Hypovolemia

Circulatory
disturbance

Bleeding

Four Grades of DHF

Grade 1

(1)

Fever and nonspecific constitutional

symptoms
Positive tourniquet test is only
hemorrhagic manifestation

Grade 2

Grade 1 manifestations +
spontaneous bleeding

Four Grades of DHF

Grade 3

(2)

Signs of circulatory failure

- rapid and weak pulse
- narrow pulse pressure : < 20 mmHg
- cold/clammy skin
- hypotension by age
- oliguria, restlessness

Grade 4 : Profound shock

(undetectable pulse and blood pressure)
DSS = DHF grade 3 & 4

Principles of DSS
management
Early detection
Prompt and adequate fluid
replacement
Closed monitoring

Warning Signs for Dengue Shock

Four
FourCriteria
Criteriafor
forDHF:
DHF:
Fever
Fever
Hemorrhagic
Hemorrhagicmanifestations
manifestations
Excessive
Excessivecapillary
capillary
permeability
permeability
3
100,000/mm
100,000/mm3platelets
platelets

Warning Signs for Dengue Shock

Four
FourCriteria
Criteriafor
forDHF:
DHF:
Fever
Fever
Hemorrhagic
Hemorrhagicmanifestations
manifestations
Excessive
Excessivecapillary
capillary
permeability
permeability
3
100,000/mm
100,000/mm3platelets
platelets
Initial
InitialWarning
WarningSignals:
Signals:
Disappearance
Disappearanceof
offever
fever
Drop
Dropininplatelets
platelets
Increase
Increaseininhematocrit
hematocrit

Warning Signs for Dengue Shock

Four
FourCriteria
Criteriafor
forDHF:
DHF:
Fever
Fever
Hemorrhagic
Hemorrhagicmanifestations
manifestations
Excessive
Excessivecapillary
capillary
permeability
permeability
3
100,000/mm
100,000/mm3platelets
platelets
Initial
InitialWarning
WarningSignals:
Signals:
Disappearance
Disappearanceof
offever
fever
Drop
Dropininplatelets
platelets
Increase
Increaseininhematocrit
hematocrit

AlarmSignals:
Signals:
Alarm
Severeabdominal
abdominalpain
pain
Severe
Prolongedvomiting
vomiting
Prolonged
Abruptchange
changefrom
fromfever
fever
Abrupt

tohypothermia
hypothermia
to
Changeininlevel
levelof
of
Change
consciousness(irritability
(irritability
consciousness

or somnolence)

Warning Signs for Dengue Shock

Four
FourCriteria
Criteriafor
forDHF:
DHF:
Fever
Fever
Hemorrhagic
Hemorrhagicmanifestations
manifestations
Excessive
Excessivecapillary
capillary
permeability
permeability
3
100,000/mm
100,000/mm3platelets
platelets
Initial
InitialWarning
WarningSignals:
Signals:
Disappearance
Disappearanceof
offever
fever
Drop
Dropininplatelets
platelets
Increase
Increaseininhematocrit
hematocrit

AlarmSignals:
Signals:
Alarm
Severeabdominal
abdominalpain
pain
Severe
Prolongedvomiting
vomiting
Prolonged
Abruptchange
changefrom
fromfever
fever
Abrupt

tohypothermia
hypothermia
to
Change
Change
inlevel
level
of
When
in
of
When
Patients
Develop
Patients Develop
consciousness
(irritability
consciousness
(irritability
DSS:
DSS:
to66days
daysafter
afteronset
onsetof
of
33to

or somnolence)

Warning Signs for Dengue Shock

Four
FourCriteria
Criteriafor
forDHF:
DHF:
Fever
Fever
Hemorrhagic
Hemorrhagicmanifestations
manifestations
Excessive
Excessivecapillary
capillary
permeability
permeability
3
100,000/mm
100,000/mm3platelets
platelets
Initial
InitialWarning
WarningSignals:
Signals:
Disappearance
Disappearanceof
offever
fever
Drop
Dropininplatelets
platelets
Increase
Increaseininhematocrit
hematocrit

AlarmSignals:
Signals:
Alarm
Severeabdominal
abdominalpain
pain
Severe
Prolongedvomiting
vomiting
Prolonged
Abruptchange
changefrom
fromfever
fever
Abrupt

tohypothermia
hypothermia
to
Change
Change
inlevel
level
of
When
in
of
When
Patients
Develop
Patients Develop
consciousness
(irritability
consciousness
(irritability
DSS:
DSS:
to66days
daysafter
afteronset
onsetof
of
33to

or somnolence)

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 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 !

SHOCK

Body weight measurement, ABC resuscitation (+Oxygen),

vascular access and blood sampling, urine catheter
Fluid resuscitation 10-30 ml/kgBW/6-10 minute (bolus)

IMPROVEMENT
Crystalloid10ml/kgBW/hour

NOIMPROVEMENT
Repeatbolus

Monitoringvitalsign,diuresis
PCV,Thrombocyte
NOIMPROVEMENT
Maintenance
Stabilfor1224hour
Colloid20ml/kgBW/hour

Crystalloid5ml/kgBW/hour
Stabilfor612hour

Crystalloid3ml/kgBW/hour

StopIVfluid
(nomorethan48hour)

IMPROVEMENT

SHOCK

Body weight measurement, ABC resuscitation (+Oxygen),

vascular access and blood sampling, urine catheter
Fluid resuscitation 10-30 ml/kgBW/6-10 minute (bolus)

IMPROVEMENT
Crystalloid10ml/kgBW/hour

NOImprovement
Repeatbolus

Monitoringvitalsign,diuresis
PCV,Thrombocyte
NOIMPROVEMENT

IMPROVEMENT

Maintenance
Stabilfor1224hour
Colloid20ml/kgBW/hour

Crystalloid5ml/kgBW/hour
Stabilfor612hour

- IMPROVEMENT
NO

- PCV low Bleeding Blood transfusion

Crystalloid3ml/kgBW/hour

StopIVfluid
(nomorethan48hour)

- 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 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, 2002

Pitfalls 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, 2002