warning signs and fluid management for dengue infection · 2019. 11. 19. · dengue and dengue...
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Warning Signs and Fluid Management
for Dengue Infection
Leonard Nainggolan
Div. Tropical and Infectious Disease Dept. Internal Medicine
Faculty of Medicine Universitas Indonesia
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Pathogenesis and Patophysiology
of Dengue Infection:
Virulence and viral load
Immune complex disease
T-cell-mediated
ADE
Complement
Autoimmune disease
Apoptosis
Innate immunity
Cytokine Tsunami
Genetic
CAPILLARY
ENDOTHELIUM
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Lei HY et al. Immunopathogenesis of Dengue infection. J Biomed 2001
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Lei HY et al. Immunopathogenesis of Dengue infection. J Biomed 2001
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Leakage of intravascular fluids into the extravascular space*,**
due to widening of the endothelial gaps#,## hypovolemia,
hemoconcentration, weakness, edema, and visceral congestion. *. Vaughn DW.et al. J Infect Dis.1997;176:322-30.
**. Duane J. Gubler. Clin Microbiol Rev. 1998 July; 11(3): 480–496.
#. McDonald DM, Thurston G, Baluk P. Microcirculation 1999;6(1): 7-22.
##. Dejana E. J Clin Invest 1997;100(11):S7-S10.
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Hematocrit ↑
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Right Pleural effusion is prominent in Right Lateral decubitus position compare to the Anterior-Posterior Chest X-ray.
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Pleural-Effusion Index (PEI)
# PEI at time of admission had the most critical role to predict
shock in DHF
# PEI > 6% at time of admission had significant correlations with
the occurance of shock
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Pleural Effusion
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A. PANORAMIC IMAGING (SIESCAPE) show a sagital sonography section with
massive pleural effusion (69), subhepatic (9) anechoic ascites (68)
inundating intestinal loop (46).
B. B. SAGITAL IMAGES show fluid collection of ascites.
A B
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A. The evaluation of the gall bladder should be done preprandially. The
normal thickness of GB wall should not exceed 3 mm.
B & C. SAGITAL & TRANSVERSE IMAGES of hypoalbuminemia show marked
thickening of the gallbladder wall with a small lumen.
A B C
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Patient with pericardial effusion (PE).
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Dengue Diagnostic
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WHO 2011
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Dengue Case Management
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Dengue guidelines for diagnosis, treatment, prevention, and control.
World Health Organization, UNICEF, UNDP. New Edition 2009.
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Fluid Replacement Therapy
Bed rest
Anti-pyretics (avoid aspirin and NSAIDs)
Monitor Blood Pressure, haematocrite, platelets level, and level of consciousness
Dengue Case Management
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Guidelines WHO 2011
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Fluid Replacement Therapy:
Intravenous Fluid Drip?
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A) Gases and nutrients
diffuse from capillary to
interstitial fluid
B) Forces responsible for the
direction and amount of fluid
crossing capillary walls
(Hydrostatic and Osmotic
pressure).
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Arteriole Venule
Hydrostatic Pressure Oncotic Pressure
pre-Capillary Hydr. Pr > Onc. Pr
post-capillary Onc. Pr > Hydr. Pr
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Lactated Ringer’s
Ringer Acetate
Normal Saline
Ringerfundin
Fluid Replacement Therapy
Colloids
Albumin
PPL
Dextran
solutions
HES
solutions
Gelatin
solutions
Crystalloids
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Size, Electricity charge
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“Repelling Effect”:
Negative charges of endothelial
cells will repel with negative
charges of MFG molecules
Result:
Strong Volume effect, Longer
Duration effect
& minimalism chloride
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Resuscitation
Management
Nutrition Crystalloid
Replace acute loss (hemorrhage, GI loss, Third
compartment)
1. Normal requirements (IWL + urine+ faeces) 2. Nutritional Support
Fluid Replacement
Coloid
Electrolyte
Repair
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Dengue Case Management
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Suspect DHF
Spontaneous 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 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
Fluid Replacement on Probable Dengue Infection in Wards
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Management of DHF with Increase of Haematocrite >20%
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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 min) . Evaluate BP, PP, pulse & diuresis after 15 – 30 minutes
Response*
Not Response Not Response, shock still happen
Response
Crystalloid 7 mL/kg BW in 1 h
Crystalloid 5 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 Response Response*
Colloid until max 30 mL/kg BW
Not Response Response*
CVP Stop infusion
Response
Crystalloid 3 mL/kg BW in 1 h
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 Normovolemic
Monitoring crystalloid
for 10-15 min
Not Response
Acid-base & electrolyte
disturbance, hypoglycemia, anemia, secondary infection
correction
Inotropic, Vasopressor,
drug
Vasopressor gradual
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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Thank You