Warning Signs and Fluid Management

for Dengue Infection

Leonard Nainggolan

Div. Tropical and Infectious Disease Dept. Internal Medicine

Faculty of Medicine Universitas Indonesia

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

Lei HY et al. Immunopathogenesis of Dengue infection. J Biomed 2001

Lei HY et al. Immunopathogenesis of Dengue infection. J Biomed 2001

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.

Hematocrit ↑

Right Pleural effusion is prominent in Right Lateral decubitus position compare to the Anterior-Posterior Chest X-ray.

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

Pleural Effusion

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

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

Patient with pericardial effusion (PE).

Dengue Diagnostic

WHO 2011

Dengue Case Management

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

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

Fluid Replacement Therapy

Bed rest

Anti-pyretics (avoid aspirin and NSAIDs)

Monitor Blood Pressure, haematocrite, platelets level, and level of consciousness

Dengue Case Management

Guidelines WHO 2011

Fluid Replacement Therapy:

Intravenous Fluid Drip?

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).

Arteriole Venule

Hydrostatic Pressure Oncotic Pressure

pre-Capillary Hydr. Pr > Onc. Pr

post-capillary Onc. Pr > Hydr. Pr

Lactated Ringer’s

Ringer Acetate

Normal Saline

Ringerfundin

Fluid Replacement Therapy

Colloids

Albumin

PPL

Dextran

solutions

HES

solutions

Gelatin

solutions

Crystalloids

Size, Electricity charge

(-)

(-)

(-)

(-)

(-)

(-)

(-)

(-)

(-)

(-)

(-)

(-) (-)

(-)

(-)

(-)

(-)

(-)

(-)

“Repelling Effect”:

Negative charges of endothelial

cells will repel with negative

charges of MFG molecules

Result:

Strong Volume effect, Longer

Duration effect

& minimalism chloride

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

Dengue Case Management

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

Management of DHF with Increase of Haematocrite >20%

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

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)

Thank You