Simposium Penatalaksanaan Dbd

7/25/2019 Simposium Penatalaksanaan Dbd

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PENATALAKSANAANDEMAM BERDARAH

DENGUE

PADA DEWASA

Deden Djatnika, RSUD Bekasi18 April 2015


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Definisi

DF /DHF adalah penyakit infeksi yangdisebabkan oleh virus dengue dengan

manifestasi klinis demam, nyeri otot

dan/nyeri sendi yang disertailekopeni,ruam dan limadenopati,

trombositopeni dan diatesis hemoragik


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Epidemiologi

Data 2013 :

Jumlah kasus DBD = 101.218

Insidece rate 41,25/100.000 penduduk

Case fatality rate 0,7 %

Jumlah propinsi : 33 (100 %)

Jumlah kabupaten/kota : 436 (87,73%)


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Manifestasi klinis

Asimptomatik

Demam yang tidak jelas

Demam dengue

Demam Berdarah Dengue

DSS (Dengue Syok Sindrome)


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Diagnosis

Masa inkubasi sekitar 4-6 hari

Timbul gejala prodormal yang tidak khas

seperti nyeri kepala, nyeri tulang belakang,

dan perasaan lelah


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Ag

/Ab

level

Day

IgMIgG

Immune Response

SymptomNS1 Ag

DAY -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

AntibodyBite

NS1 Ag

ACUTE

PHASE

CONVALESENCE

PHASE

CRITICAL

PHASE


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Demam Dengue

Demam 2-7 hari dengan 2 atau lebihmanifestasi klinis sbb :

Nyeri kepala

Nyeri periorbita Myalgia /atralgia

Ruam kulit

Manifestasi perdarahan Leukopenia

Dan Serologi dengue positif


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DBD

WHO 1997 :

Demam 2-7 hari minimal satu dari :

Uji bendung Positif

Petekie, ekimosis atau purpura

Perdarahan mukosa

Hematemesis melena

Trombositopenia

Plasma leakage positip


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Plasma Leakage

Peningkatan HT >20 %

Penurunan hematokrit >20%

Adanya asites,efusi pleura,

hipoproteinemia dan hiponatremia.


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Perbedaan

DB : Tidak ditemukan Plasma leakage

DBD : Ditemukan adanya plasma leakage


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DSS

Gejala dan tandanya seperti DBD disertaikegagalan sirkulasi dengan manifestasi nadi

yang cepat dan lemah,

Tekanan Darah : hipotensi dengan standarsesuai umur.

Kulit dingin dan lembab serta gelisah


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PPV = 70 - 80%

Dengue Diagnostic


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Pemeriksaan Laboratorium

Darah rutin (Hb,HT,Leukosit,Trombosit) Isolasi Virus Dengue / antibodi spesfik : IgM-IgG Hemostasis (PT, APTT,Fibrinogen,D-Dimer/FDP ) Ethanol Gelation Test

Protein, Albumin SGOT/SGPT Ureum ,Creatinin Uji HI

Analisa Gas Darah Elektrolit Golongan Darah


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Dengue guidelines for diagnosis, treatment, prevention, and control.

World Health Organization, UNICEF, UNDP. New Edition 2009.


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Tatalaksana

Tidak ada yang spesifik

Prinsip utama adalah suportif

Penanganan tepat oleh dokter dan perawat

>> menyelamatkan pasien Dengan terapi suportif adekuat angka

kematian dapat diturunkan hingga kurang

dari 1 %. Pemeliharaan volume cairan sangat penting

Asupan cairan hrs dipertahankan


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Protokol penatalaksanaan

Protokol 1Penanganan tersangka tanpa syok

Protokol 2Pemberian cairan pd tersangka DBD di ruang rawat

inap Protokol 3

Penatalaksanaan DBD dgn HT>20%

Protokol 4

Penatalaksanaan perdarahan spontan padaDBDdewasa

Protokol 5Tata laksana DSS


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17

Tatalaksana Tersangka DBD

Demam tinggi, mendadak 100.000/ul

Rawat jalan

kontrol tiap harisp demam reda

Demam menetap >3 hari

Periksa Hb, Ht, leukosit, trombosit

Rawat inap


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Suspect DHFSpontaneous and Massive Bleeding( - )

Shock (-)

- Hb, Ht (n)- Platelets< 100.000- Crystalloid infusion *- Hb, Ht, Plt every 24 hours

- Hb, Ht increase 10-20%- Platelets< 100.000- Crystalloid Infusion *- Hb, Ht, Plt every 12 hours **

- Hb, Ht increase > 20%- Platelets< 100.000

Protocol Fluid ReplacementDHF with increased Ht > 20%

* Daily crystalloid volume required:According to formula : 1500 + 20 x (body weight in kg20))

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 2Fluid replacement on Probable Dengue Infection in

wards


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Hematokrit


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Resuscitation Management

NutritionCrystalloid

Replace acute loss(hemorrhage, GI loss, Third

compartment)

1. Normal requirements(IWL + urine+ faeces)

2. Nutritional Support

Fluid Replacement

Colloid Electrolyte

Repair


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PROTOCOL 3

Management of DHF with increase of hematocrite

>20%

P l 5


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Protocol 5

Management of Dengue Shock SyndromeAirway

Breathing : O21-2 L/min with nasal cannuls, higher use a simple mask

Circulation : crystalloid / colloid 10-20 mL/kg BW loading (If possible less than 10 min) .

Evaluate BP, PP, pulse & diuresis after 15 30 minutes

Response*

Worsening Not Response, shock still happen

Response

Crystalloid 7 mL/kg BW in 1 h


Consider for nutrition after

12 h (Dx 5 % If no

contraindication)

Within 24-48 h after shock

controlled, vital signs/Ht stable,

urine output increasing

Crystalloid 20-30 mL/kg BW loading for 20-30 min

Not Response

Ht increase Ht decrease

Colloid 10-20 mL/kg BW loading for 10-15 min Blood transfusion 10 mL/kg

BW can be repeated if

necessary

Not ResponseResponse*

Colloid until max 30 mL/kg BW

Not ResponseResponse*

CVPStop infusion

Response


Response


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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

Monitoring

crystalloid

for 10-15 min

Not Response

Acid-base &

electrolyte

disturbance,

hypoglycemi

a, anemia,

secondary

infectioncorrection

Inotropic,

Vasopressor

Vasopressorgradual

increment

Colloid &crystalloid

combination

Response*

Response:

1. Systolic BP 100 mmHg

2. PP > 20 mmHg

3. Heart Rate < 100 x/mnt, adequate vol

4. Warm extremities

5. Diuresis 0,5-1 cc/kgBW/hour

Protocol 5(Continued)


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Lactated Ringers

Ringer Acetate

Normal Saline

Volume Replacement Therapy

olloids

Albumin

PPL

Dextran

solutions

HES

solutions

Gelatin

solutions

Crystalloids


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Penutup

Menegakkan dan menatalaksana infeksidengue tidaklah mudah , untuk itu perlu

dipahami perjalanan penyakit agar tercapai

terapi yang rasional dalam rangkamengurangi mortalitas


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Terima Kasih

Simposium Penatalaksanaan Dbd

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