dhf dss handout
TRANSCRIPT
-
8/9/2019 Dhf Dss Handout
1/25
DIAGNOSIS AND MANAGEMENT
OF DHF AND DSS
1
-
8/9/2019 Dhf Dss Handout
2/25
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 %
2
-
8/9/2019 Dhf Dss Handout
3/25
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
-
8/9/2019 Dhf Dss Handout
4/25
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
4
-
8/9/2019 Dhf Dss Handout
5/25
• DHF : - permeability
- Fever crisis
•
DHF I, II : – Crisis days III >
– IVFD 12 – 24 hours
– PCV , Tr < 50 000
– Health center / >
5
-
8/9/2019 Dhf Dss Handout
6/25
• 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
6
-
8/9/2019 Dhf Dss Handout
7/25
SUBSTITUTION FLUID IN DHF
Maintenance + 5 – 8 %
• Vomiting every time
•
Cannot drink• fever
• PCV periodically
• Acidosis : NaBic• PCV > 20 % IVFD : GED mild - mod
7
-
8/9/2019 Dhf Dss Handout
8/25
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
8
-
8/9/2019 Dhf Dss Handout
9/25
Table 2. Fluid need for maintenance
Body Weight
(Kg)
Amount of fluid
(ml/kgBW/day)
10 kg)
1500 + 20/kgBW(>20 kg)
9
Example : 40 Kg = 1500 + (20X20) = 1900 ml
-
8/9/2019 Dhf Dss Handout
10/25
• 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
10
-
8/9/2019 Dhf Dss Handout
11/25
-
8/9/2019 Dhf Dss Handout
12/25
Figure 1. Management of suspect DHF
12
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
-
8/9/2019 Dhf Dss Handout
13/25
Figure 2. Management of DHF (Grade II)
13
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
-
8/9/2019 Dhf Dss Handout
14/25
Figure 3. Management of DSS (DHF III and IV)
14
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
-
8/9/2019 Dhf Dss Handout
15/25
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
-
8/9/2019 Dhf Dss Handout
16/25
Signs and Symptoms of Fluid Overload
• RSD, Dyspnea and Tachypnea
•
Massive acites• Rapid Pulse
• ↓ Pulse pressure
• Crepitation/Ronchi• Porr tissue perfusion
16
COMPLICATIONS
-
8/9/2019 Dhf Dss Handout
17/25
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
17
COMPLICATIONS
-
8/9/2019 Dhf Dss Handout
18/25
Unusual manifestation of DHF
• Less than 5% of patient
•
Encephalopathy/encephalitis• Hepatic failure
• Renal failure
• Dual infections• Underlying conditions
18
COMPLICATIONS
-
8/9/2019 Dhf Dss Handout
19/25
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
19
COMPLICATIONS
-
8/9/2019 Dhf Dss Handout
20/25
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
-
8/9/2019 Dhf Dss Handout
21/25
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
21
COMPLICATIONS
-
8/9/2019 Dhf Dss Handout
22/25
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
-
8/9/2019 Dhf Dss Handout
23/25
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
23
-
8/9/2019 Dhf Dss Handout
24/25
-
8/9/2019 Dhf Dss Handout
25/25
25