mengenali kegawatan dengue 2013
TRANSCRIPT
Kegawatan dengue: kapan dan Kegawatan dengue: kapan dan bagaimana mengatasinyabagaimana mengatasinya
Ida Safitri Laksono
Bagian IKA FK UGM/RSUP Dr. Sardjito Yogyakarta
Isi presentasiIsi presentasi
� Situasi epidemiologi infeksi Dengue
� Overview of the three guidelines
� Spektrum klinis
� Tanda peringatan dan kegawatan� Tanda peringatan dan kegawatan
� Tatalaksana
� Do and don’t
� Ringkasan
PendahuluanPendahuluanGLOBAL burden of dengue
� Global incidence of dengue has grown dramatically in recent decades
� About two fifths of the world's population are now at risknow at risk
� Dengue is found in tropical and sub-tropical climates worldwide, mostly in urban and semi-urban areas
� Dengue is the most prevalent arboviraldisease with high morbidity, mortality & socio-economical costs.
Case management� Despite its complex in pathogenesis and manifestation � management is relatively simple and inexpensive
� No specific treatment � rely on fluid management . If it is appropriately and timely management . If it is appropriately and timely implemented could saves the lives of patients
� Current situation : the most effevtive way to prevent dengue transmission is to combat disease carrying-mosquitoes
� The development of vaccines and drugs is challenging but potential to change this.
1,016,612
50
60
70
800000
1000000
1200000
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un
trie
s
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Average annual number of DF/DHF cases reported to WHO, 1955-2009
908 15,497
122,174
295,554
479,848
0
10
20
30
40
0
200000
400000
600000
1955-1959 1960-1969 1970-1979 1980-1989 1990-1999 2000-2009
Nu
mb
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un
trie
s
Nu
mb
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f ca
ses
Source: DengueNet
40
60
80
IR a
nd
CF
R
CFR
IR and CFR di INDONESIA, 1968 - 2011 IR 2010:
65,57/ 100.000 pddk
IR 2011: 22,9
/100.000pddk
CFR
0
20
19
68
19
70
19
72
19
74
19
76
19
78
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
20
06
20
08
20
10
IR a
nd
CF
R
Year IR/100.000
CFR(%)
CFR
2010:
0,87%
CFR 2011;0.84 %
Source : Kemkes RI
Monthly Dengue Cases And Death In Monthly Dengue Cases And Death In Indonesia, 2010 Indonesia, 2010 -- 20112011
150
200
250
15000
20000
25000
DeathCases
20112010
Source : Subdirectorate of Arbovirosis - Directorate of VBDC,
Directorate General DC&EH , Ministry of Health RI
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Cases 22777 22467 19538 16175 13132 11530 10790 9496 7814 7959 7497 5324 8258 6357 6289 4658 4801 4363 4291 4116 3391 3755 2393 1720
Death 213 211 181 161 126 90 82 69 54 53 57 51 52 57 45 51 32 32 32 44 36 34 23 21
0
50
100
0
5000
10000
Month
� Infeksi dengue bersifat akut, dinamis dengan spektrum klinis yang bervariasi dari asimtomatik � fatal
Kegawatan penyakit pada umumnya terjadi � Kegawatan penyakit pada umumnya terjadi pada fase kritis
� Sampai saat ini belum tersedia obat anti virus maupun vaksin untuk terapinya, tata laksana relatif bertumpu pada pemberian cairan
NEW DENGUE NEW DENGUE GUIDELINESGUIDELINESGUIDELINESGUIDELINES
Dengue guidelinesDengue guidelines1997 2009 2011
Guideline for treatment of DF and DHF in small hospitals –WHO Searo 1999
Dengue – Guidelines for diagnosis, treatment,prevention and control –WHO TDR 2009
Comprehensive guideline for preventionand control of Dengue and DHF –WHO Searo 2011
Pages : 33 160 212
Content
Clinical manifestation, diagnosis, case management
Chapters : (6)Epidemiology and burden of disease, clinical management, vector management, lab diagnostic tests, surveillance and emergency response, new avenues
Chapters : (15)Epidemiology, disease burden,clinical manifestation and diagnosis, lab diagnosis, management, surveillance, vector, vector management, IVM, Combi, PHC approach, case investigation, monitoring, strategic plan (bi-regional plan)
DDiagnosisiagnosis ClassificationClassification according to existing according to existing guidelinesguidelines1997 2009 2011
Guideline for treatment of DF and DHF in small hospitals –WHO Searo 1999
Dengue – Guidelines for diagnosis, treatment,prevention and control –WHO TDR 2009
Comprehensive guideline for preventionand control of Dengue and DHF –WHO Searo 2011
Dengue fever Dengue without warning signs
Dengue feversigns
DHF grade I Dengue with warning signs DHF grade I
DHF grade II DHF grade II
DHF grade III Severe dengue (for management it is divided into two: severe dengue with compensated shock & severe dengue with hypotensive shock)
DHF grade III
DHF grade IV DHF grade IV
* Expanded dengue
Dengue case classification by severity
Withoutwith
warning signs
1.Severe plasma leakage
2.Severe haemorrhage
3.Severe organ impairment
Severe dengueDengue ± warning signs
Probable dengueLive in/travel to dengue
endemic area. Fever and 2
of the following criteria:
• Nausea, vomiting
• Rash
• Aches and pains
• Tourniquet test positive
• Leucopenia
• Any warning sign
Laboratory confirmed dengue(important when no sign of plasma leakage)
Warning signs*• Abdominal pain or
tenderness
• Persistent vomiting
• Clinical fluid accumulation
• Mucosal bleed
• Lethargy; restlessness
• Liver enlargement >2cm
• Laboratory: Increase in HCT
concurrent with rapid
decrease in platelet count
* Requiring strict observation and medical intervention
1. Severe plasma leakage
leading to:
• Shock (DSS)
• Fluid accumulation with
respiratory distress
2. Severe bleeding
as evaluated by clinician
3. Severe organ involvement• Liver: AST or ALT>=1000
• CNS: Impaired consciousness
• Heart and other organs
Criteria for dengue ± warning signs Criteria for severe dengue
WHO
/TD
R 2
009
SPECTRUM OF CLINICAL ILLNESS SPECTRUM OF CLINICAL ILLNESS ASSOCIATED WITH DENGUE VIRUS ASSOCIATED WITH DENGUE VIRUS INFECTIONINFECTION
Inapparent
Infection
Mild FebrileMild Febrile
IllnessIllness
DengueDengue
FeverFever
Severe and FatalSevere and Fatal
InfectionInfectionInfection IllnessIllness FeverFever InfectionInfection
1 2 3 4 5 6 7 8 9 10
40
Shock Bleeding
ReabsorptionFluid overload
Dehydration
Organ Impairment
Days of illness
Temperature
Potential clinical issues
Viraemia
Course of dengue illness: Febrile Critical Recovery Phases
Laboratory
changes
Serology and virology
Platelet
Hematocrit
IgM/IgG
Adapted from WCL Yip, 1980 by Hung NT, Lum LCS, Tan LH
Apakah semua pasien tersangka Apakah semua pasien tersangka Infeksi Dengue Infeksi Dengue perlu dirawat inap?perlu dirawat inap?
� TIDAK
� hanya 1/3 kasus akan mengalami syok
� Tips’: perhatikan hari demam, apakah � Tips’: perhatikan hari demam, apakah masuk fase kritis ?
� Apabila ragu-ragu: rawat di ruang rawat sehari (one day care): observasi 24 jam, beri cairan rumatan
Kapan mencurigai dengue?Kapan mencurigai dengue?
� Presumptive Diagnosis (Probable Dengue)
� Riwayat tinggal di atau berkunjung ke daerahendemis ( laporan kasus Dengue)
Demam dan 2 dari kriteria:
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� Demam dan 2 dari kriteria:◦ Mual dan muntah◦ Rash◦ Nyeri dan sakit◦ Leukopenia◦ Tourniquet test positive◦ Tanda peringatan
What to Do ?What to Do ?PadaPada fasefase awalawal demamdemam
� Curiga Dengue bila terdapat gejala :demam
+ nyeri kepala, retro orbital, sendi, perut
+ muka kemerahan (flushing)
+ ruam kulit
� Kenali indikator Diagnosis dini
Demam & muka kemerahan (tanpa coryza)
Hari sakit Sensitivitas Spesifisitas
1 73,3 % 93,3 %
2 90,5 % 89,2 %
3 85,5 % 87,9 %
What to Do ?What to Do ?PadaPada fasefase demamdemam
� Lakukan uji bendung (Tourniquete test)
◦ Uji bendung positif + demam 1–3 hari mempunyaiPPV infeksi dengue : 63 %
◦ Bila disertai leukopenia ≤ 5000 /mL, PPV 83 %
�Kenali indikator Diagnosis dini
Uji Bendung
Hari sakit Sensitivitas Spesifisitas
1 53,3 % 75,8 %
2 90,6 % 77,8 %
3 98,7 % 74,2 %
What to Do ?What to Do ?PadaPada fasefase awawal/demamal/demam
� Perdarahan �hati-hati bila:
◦ Epistaksis pertama kali
◦ Menorrhagia pada anak remaja
� Fase iniFase ini
◦ Perdarahan tidak berat
◦ Bentuk perdarahan paling sering:
�petekie, epistaksis, hematemesis
◦ Stop / meminimalisasi perdarahan
◦ Mengurangi faktor-faktor yang dapat menimbulkanperdarahan
What to Do ?What to Do ?PadaPada fasefase awalawal demamdemam
◦ Lakukan pemeriksaan darah serial: Hb, Ht, leukosit, hitung jenis dan trombosit
◦ Perawatan di rumah:◦ Perawatan di rumah:
� Turunkan suhu, ukur suhu berkala
� Berikan sebanyak mungkin cairan oral: susu, juice, cairanelektrolit
� Berikan lingkungan yang tenang
� Penurun panas : paracetamol
What to Do ?What to Do ?PadaPada fasefase awalawal // demamdemam
� Pemeriksaan Ag NS1 perlu dikerjakan atautidak?
� Diperlukan bila gejala klinis tidak khas �demam < 72 jam
�Ag NS1 dilakukan untuk mendeteksi infeksi
virus Dengue pada fase akut
�sensitivitas bervariasi � >unggul dari kultur virus & AbIgM/IgG anti Dengue
�spesifisitas 100% ∞ gold standard: kultur virus & PCR
What to Do ?What to Do ?PadaPada fasefase awalawal/demam/demam
� Pemeriksaan Dengue blot ≥ HS 5
� Lihat gejala klinis pasien
� Interpretasi hasil pemeriksaan IgM dan IgG� Interpretasi hasil pemeriksaan IgM dan IgG
Bila hasil IgG & IgM(-) dan klinis (+), ulang pemeriksaan
Ig M Ig G Interpretasi
+ - Infeksi primer
+ + Infeksi sekunder
- + Tsk inf sekunder
- - Tdk ada infeksi
Dengue Case Management, WHO 2009
Presumptive diagnosis
Warning signs
Negative
Negative Positive
Positive
Dengue with warning signsDen without
warning signs
Severe dengue
ASSESSMENT
CLA
SSIFICATION
CO-EXISTING CONDITION/SOCIAL CIRCUMSTANCES
Group A Group B Group C
Group criteria Group criteria
or : Excisting warning signs Group criteria
Lab test Lab test Lab test Lab test
Treatment Treatment Treatment Treatment compensated shock
• if patient improves• if patient still unstable
Monitoring Monitoring Reassess clinical status & Hct Treatment of hypotensive shock•if patient improves• if patient still unstable
Reassess clinical status, Hct, IVFD
Treatment of haemorrhagic complication
Monitoring
warning signs
CLA
SSIFICATION
MANAGEMENT
PASIEN YANG DIPERBOLEHKAN RAWAT JALANPASIEN YANG DIPERBOLEHKAN RAWAT JALAN
� HARUS DIEVALUASI:
darah lengkap dan Hct setiap hari
sampai keluar dari fase kritis
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� APA YANG DIPANTAU?
◦ Perkembangan penyakit: keluhan memberat?
◦ Defervescence (saat suhu turun): ↑ Hct bersamaan ↓TROMBOSIT
◦ Munculnya tanda peringatan
Critical Phase Critical Phase –– Warning signsWarning signs
� Sekitar fase devervescene: pasien membaik/memburuk � cek warning sign (tanda awal fase kritis)
Warning Signs• Abdominal pain or tenderness• Persistent vomiting atau water intake <<• Clinical fluid accumulation• Mucosal bleed
25
25
• Mucosal bleed• Lethargy; restlessness; perubahan perilaku tiba-tiba• Liver enlargement >2cm• pening/pusing >>• Pucat, kaki tangan dingin lembab• Urine output (-)/<< selama 4-6 jam• Laboratory: Increase in HCT concurrent with rapid
decrease in platelet count
WHO 2209 & 2011
TATALAKSANA TATALAKSANA KEGAWATANKEGAWATANKEGAWATANKEGAWATAN
Indikasi rawat inap Indikasi rawat inap TTersangka DBDersangka DBD
� Terdapat tanda peringatan/tanda kegawatan
� Pada pemantauan dijumpai � Pada pemantauan dijumpai � kadar Hct tinggi/ meningkat dibanding
sebelumnya� trombosit turun� perdarahan spontan (selain petekie)
o Kondisi pasien berakibatTATA LAKSANA LEBIH KOMPLEKS, seperti:
BAYI, KEHAMILAN, USIA LANJUT,
OBESITAS, DM, GAGAL GINJAL, HIPERTENSI,
PENYAKIT HEMOLITIK KRONIK DLL.
PERTIMBANGKAN RAWAT INAP
PENYAKIT HEMOLITIK KRONIK DLL.
� Kondisi sosial seperti:� tinggal di rumah seorang diri atau� tinggal jauh dari fasilitas kesehatan atau� tidak tersedia sarana transportasi
� Bila menolak: Tanda tangan surat penolakan
Admission CriteriaAdmission Criteria
1997 2009 2011
Signs of significant dehydration (>10% normal body weight)
- Any warning sign- Coexisting conditions: infancy, pregnancy, old age, obesity, diabetes mellitus, renal failure, hypertension, chronic hemolytic disease etc.
- Shock: Resuscitation and admission. -Hypoglycemic patients without leucopenia and/or thrombocytopenia -Those with warning signs.- High-risk patients with etc.
- Social circumstances: living alone, living far from health facility, without reliable means of transport. In detail
- High-risk patients with leucopenia and thrombocytopenia
1997 2009 2011
No Yes yes
Home care card
Fluid managementFluid management
1997 2009 2011
DHF grade I-II Dengue with warning signs
DHF grade I-II
6-7 ml/kg/hour → 5 ml/kg/hour → 3 ml/kg/hour – stop after 24-48 hours
isotonic solutions such as 0.9% saline, Ringer’s lactate, or Hartmann’s solution. Start with 5–7
maintenance (for one day) + 5% deficit (oral and IV fluid together), to be administered over 48 24-48 hours solution. Start with 5–7
ml/kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response
be administered over 48 hours
Tata laksana Dengue denganWS (DBD derajat I & II)
Cairan awal 5-7ml/kgbb/jamRL atau NaCl 0,9%
Monitor tanda vital/jam
Hb, Hct, trombo tiap 6-12jamPerbaikan
GelisahDistres nafas
Tidak ada perbaikan
Tidak gelisahNadi kuat
1-2 jam
Tetesan dikurangi3-5ml/kgBB/jam
2-3ml/kgBB/jam
Stop dalam 24-48jam
Distres nafasFrek nadi naikHct tinggi Tek nadi <20mmHgDiuresis kurang
Evaluasi 1 jam
Tetesan dinaikkan
10 ml/kgBB/jam
Tanda vital tidak stabilCek Hct
Nadi kuatTek drh stabilHct turunDiuresis 1 ml/kgBB/jam
2- 4 jam
SYOK KOMPENSATA ?
Kegawatan pada fase kritisKegawatan pada fase kritis
� Dapat berlanjut ke keadaan yang berat jika:◦ Kebocoran plasma berat sampai terjadi syok dan atau akumulasi cairan/distres pernapasan
32
pernapasan
◦ Perdarahan hebat dan atau
◦ Gangguan fungsi organ yang berat (ensefalopati, ensefalitis, gagal hati, kardiomiopati dll)
� Periode kebocoran plasma berlangsung 24-48 jam
1997 2009 2011
DSS Severe Dengue-compensated shock
DHF grade III
10-20 ml/kgBB bolus, repeat if necessary
algorithm
isotonic crystalloid solutions at 5–10ml/kg/hour over one hour. →reassess
10 ml/kg in children or 300–500 ml in adults over one hour or by bolus, if hour. →reassess one hour or by bolus, if necessaryFurther, fluid administration should follow the graph
mulai dengan larutan kristaloid10-20 m/kg/jam – 1 jam
Koloid IV
PERBAIKAN*Ya tidak
periksaHCT
HCT
↓
HCT↑
tinggi
Syok kompensata(perfusi menurun tetapi tekanan sistolik
masih baik)
IV kristaloid, turunkan bertahap10 ml/kg/hr selama 1-2 jam7 mL/kg/hr selama 2 jam5 mL/kg/hr selama 4 jam3 mL/kg/jam
Koloid IV(bolus kedua)
10-20 mL/kg/jam –1jam
PikirkanperdarahantersembunyiSiapkan transfuse darah
Jika klinis membaik, turunkan tetesan cairan
Hentikan cairan setelah48jam
* Nilai ulang kondisi klinis (tanda vital , pulse, capillary refill time dan ekstremitas) dan tentukan status penderita
- IV: intravenous, HCT: hematocrit, ↑↑↑↑:meningkat, ↓↓↓↓:turun
Jika perlu bolus cairandapat diberikandalam24 -48 jam
Kurangi tetesan7-10 mL/kg/jam - 1-2 jam
PERBAIKAN*
Ya
Tdk
2009 2011
Severe Dengue – hypotensiveshock
DHF grade IV
Initiate intravenous fluid resuscitation with crystalloid or colloid solution (if available) at 20 ml/kg as a bolus given over 15 minutes to bring the patient
Ten ml/kg of bolus fluid should be given as fast as possible, ideally within 10 to 15 minutes. When the blood pressure is restored, further over 15 minutes to bring the patient
out of shock as quickly as possible.
blood pressure is restored, further intravenous fluid may be given as in Grade 3. If shock is not reversible after the first 10 ml/kg, a repeat bolus of 10 ml/kg and laboratory results should be pursued and corrected as soon as possible.
SyokSyok dekompensatadekompensata ( hipotensif)( hipotensif)
� Tatalaksana pada pasien dengan syok dekompensata/ hipotensif lebih agresif.
� Mulai resusitasi cairan intravena dengan larutan kristaloid atau koloid (bila tersedia) 20
36
kristaloid atau koloid (bila tersedia) 20 ml/kg sebagai bolus diberikan secepatnya/ dalam 15 menit untuk mengeluarkan pasien dari kondisi syok secepat mungkin.
What Not to Do ?What Not to Do ?PadaPada fasefase awalawal/ demam/ demam
� Jangan selalu mendiagnosis DD/DBD pada pasiendemam dan ISPA
�Indikator dini infeksi dengue:�Indikator dini infeksi dengue:
- Demam tinggi
-Wajah kemerahan
-Tidak tampak fokal infeksi
- Uji Tourniquet positif
- Trombositopenia atau ( Ht naik ± )
What Not to Do ?What Not to Do ?PadaPada fasefase awalawal/demam/demam
� Pemeriksaan NS1 bukan untuk mengetahui beratringannya penyakit
� Foto thoraks RLD jangan dilakukan pada semuakasus tersangka DBDkasus tersangka DBD
� Tidak boleh memberikan obat penurun panas jenisAspirin atau Ibuprofen
� Jangan memberikan antibiotik, kecuali terdapatinfeksi penyerta dengan fokus yang jelas◦ Pada ensefalopaty / ensefalitis diberikan antibiotik
� Hindari pemberian kortikosteroid tanpa indikasijelas, tidak menunjukkan adanya manfaat
What Not to Do ?What Not to Do ?PadaPada fasefase awalawal / demam/ demam
� Tidak boleh memberikan obat penurun panasjenis Aspirin atau Ibuprofen
� Jangan memberikan antibiotik, kecuali terdapatinfeksi penyerta dengan fokus yang jelas
◦ Pada ensefalopaty / ensefalitis diberikan antibiotik◦ Pada ensefalopaty / ensefalitis diberikan antibiotik
� Hindari pemberian kortikosteroid tanpa indikasijelas, tidak menunjukkan adanya manfaat
◦ hanya diberikan pada kasus ensefalopaty tanpa
perdarahan
RingkasanRingkasan
� Saat ini belum tersedia vaksin dan obat anti virus Dengue � manajemen kasus bertumpu pada tatalaksana cairan
� Mengenali gejala dan tanda, tanda � Mengenali gejala dan tanda, tanda peringatan seawal mungkin akan mengurangi risiko terjadinya kegawatan
� Ketepatan dan kecepatan pemberian pada kasus berat ( DSS) menentukan outcome penderita