The Role of Fluid Replacement Therapy in

Dengue Hemorrhagic Fever Management:

Leonard Nainggolan
Division of Tropical-Infectious Disease
Departement of Internal Medicine
FMUI-CM Hospital
Reaksi Sistem Kekebalan Tubuh
 CAPILLARY
ENDOTHELIUM
 Pathophysiology
Arteri Vena

Hydrostatic Oncotic Pressure

Pressure

Pre Capillary
Post Capillary
Hyd. Press. > Onc.
Oncotic Pressure >
Press
Hyd. Press.
Nature Reviews Nephrology 6, 361-370 (June 2010)
Haematocrit
↑
Right Pleural effusion is prominent in Right Lateral decubitus position
compare to the Anterior-Posterior Chest X-ray.
Pleural Effusion
Patient with pericardial effusion (PE).
Evidence of plasma leakage
 Gall bladder wall oedema is associated with
plasma leakage and may precede the clinical
detection.
 A significantly decreased serum albumin >0.5
gm/dl from baseline or <3.5 gm% is indirect
evidence of plasma leakage
Dengue Diagnostic
WHO 2011
Dengue Case Management
Dengue guidelines for diagnosis, treatment, prevention, and control.
World Health Organization, UNICEF, UNDP. New Edition 2009.
 Dengue Case Management

 Fluid Replacement Therapy

 Bed rest
 Anti-pyretics (avoid aspirin and NSAIDs)
 Monitor Blood Pressure, haematocrite,
platelets level, and level of consciousness
 Fluid Replacement

Resuscitation Management

Crystalloid Coloid
Electrolyte Nutrition

Repair

Replace
Replace acute
acute loss
loss 1.
1. Normal
Normal requirements
requirements
(Hemorrhage,
(Hemorrhage, GI
GI loss,
loss, Third
Third (IWL
(IWL + + urine+
urine+ faeces)
faeces)
compartment)
compartment) 2.
2. Nutritional
Nutritional Support
Support
Guidelines WHO 2011
Tatalaksana Tersangka DBD
Demam mendadak tinggi, <7 hari, sakit kepala, pegal, atralgia, nyeri retro-orbital, di
lingkungan sekitar ada penduduk yang menderita DBD

Ada kedaruratan Tidak ada kedaruratan

Syok
Kejang
Kesadaran menurun
Perdarahan
Komorbid Demam ≥3 hari Demam < 3 hari
Asupan oral inadekuat
Ht cenderung naik
Hb, Ht, leukosit, trombosit
Rawat inap

Rawat jalan
Trombosit Trombosit
kontrol tiap hari
≤100.000/ul >100.000/ul
sp demam reda
 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%
 Protocol 5
Management of Dengue Shock
Syndrome
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
Response min) . Evaluate BP, PP, pulse & diuresis.
*
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

Colloid 10-20 mL/kg BW loading for 10- Blood transfusion 10

15 min mL/kg BW can be repeated
Crystalloid 3 mL/kg BW in 1 h
if necessary

Response* Not Response

Response

Colloid until max 30 mL/kg

Within 24-48 h after shock BW
controlled, vital signs/Ht stable,
urine output increasing Response* Not Response
Consider for nutrition after
12 h (Dx 5 % If no
Stop infusion contraindication) 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 Normovolemi
c
Not Response
Response:
Monitoring Acid-base &
1. Systolic BP 100 mmHg crystalloid electrolyte
2. PP > 20 mmHg for 10-15 disturbance,
3. Heart Rate < 100 x/mnt, adequate vol min hypoglycemi
a, anemia,
4. Warm extremities secondary
5. Diuresis 0,5-1 cc/kgBW/hour infection
correction

Inotropic,
Vasopressor,
drug

Colloid & Vasopressor

Response crystalloid gradual
* combination increment
 Volume Replacement Therapy

Crystalloids Colloids
Lactated Ringer’s
Ringer Acetate
Normal Saline
Ringerfundin

Albumin
Albumin Gelatin
Gelatin Dextran
Dextran HES
HES
PPL solutions
solutions solutions
solutions solutions
solutions
PPL
 Pathophysiology
Arteri Vena

Hydrostatic Oncotic Pressure

Pressure

Pre Capillary
Hydrostatic Pressure > Post Capillary Oncotic
Onc. Press Pressure > Hyd. Press.
Size, Electricity charge
 -- -- --

--
----
“Repelling Effect”:
----
-- -

--
(-) (-)

--
-- -

--
--

--
--
(-)

--
(-)
--
(-) --

--
-- --
-- --

--
-- --
--

--
(-) --
-- -- (-)
--
--

--
(-) Negative charges of endothelial cells will repell
--
--
--
-----
- ----
(-)
--

--
--
(-) -- with negative charges of fluid molecules.
--

--
--

--
--

--

(-) --
--
--

(-)
-- --
-- -
- --
--

- -- (-)
--
--

----
--

(-) -- Result:
--

(-) Strong Volume effect, Longer Duration effect &

--
(-)
--

-- --
----
--

----
-- --
--

(-) minimalism chloride.

--

--
--

--
--
--

(-) (-)
 Comparison of Three Fluid Solutions for
Resuscitation in Dengue Shock Syndrome
Bridget A. Wills, Nguyen M. Dung, Ha T. Loan, Dong T.H. Tam, Tran T.N. Thuy,
Le T.T. Minh, Tran V. Diet, Nguyen T. Hao, Nguyen V.Chau, Kasia Stepniewska,
Nicholas J. White, Jeremy J. Farrar

CONCLUSIONS:
Initial resuscitation with Ringer's lactate is indicated for children with
moderately severe dengue shock syndrome. Dextran 70 and 6 percent
hydroxyethyl starch perform similarly in children with severe shock, but
given the adverse reactions associated with the use of dextran, starch
may be preferable for this group.

N Engl J Med. 2005 Sep 1;353(9):877-89

On 23 October 2013, the Coordination Group for Mutual Recognition and Decentralised Procedures
– Human (CMDh)*, endorsed by majority the recommendations of the European Medicines Agency’s
Pharmacovigilance Risk Assessment Committee (PRAC), which concluded that HES solutions must
no longer be used to treat patients with sepsis (bacterial infection in the blood) or burn injuries or
critically ill patients because of an increased risk of kidney injury and mortality.

HES solutions may continue to be used in patients to treat hypovolaemia (low blood volume) caused
by acute (sudden) blood loss, where treatment with alternative infusions solutions known as
‘crystalloids’ alone are not considered to be sufficient. In order to minimise potential risks in these
patients, HES solutions should not be used for more than 24 hours and patients’ kidney function
should be monitored after HES administration. In addition to updating the product information,
further studies should be carried out on the use of these medicines in elective surgery and trauma
patients.

19 December 2013
EMA/809470/2013
 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
 Massive Bleeding Management in Dengue

Condition Action
Hb < 10 g/dL PRC Transfusion

DIC (+) Heparinization 5000-10.000/24 hours

Platelet <100.000/uL Thrombocyte concentrate

APTT > 1.5 times FFP 10 – 15 cc/kgBW/8 hours

Fibrinogen < 100 mg/dL Cryoprecipitate 10 U/kgBW/8 hours

KESIMPULAN
 Pada DBD terjadi kebocaran plasma yang
mengandung air, gula, dan elekrolit dari dalam
pembuluh darah ke jaringan sekitarnya
 Akibat kebocoran yang terjadi dapat menimbulkan
gejala penyakit yang ringan, syok bahkan kematian
 Penanganan utama kasus DBD adalah mengganti
cairan dan elektrolit yang keluar tsb.
 E N T
TIIO
O N
N
P
PRR E
EV
V E N
Terima Kasih

谢谢