DIAGNOSIS AND

MANAGEMENT OF
DHF AND DSS
____________________
T.H. RAMPENGAN

Department of Child Health

Medical School Sam Ratulangi University
R.D.Kandou Hospital Manado

10/30/2019 1
 INTRODUCTION
- DHF relatively new disease 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 %
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DIAGNOSIS WHO 1975 /1986
Based 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%
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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 : DHF
III+IV : DSS

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 DHF : - ↑ permeability
- Fever ↓ → crisis
 DHF I, II :
- Crisis days III >
- IVFD 12 - 24 hours
- PCV ↑, Tr ↓ < 50 000
- Health center / >

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Fever phase

- Oral fluid : 50 ml/kgBW for 4-6 hours

- IVFD maintenance : 80-100 ml/kg/days
- Antipyretic : Paracetamol 10 mg/kgBW/time
- Convulsion : Phenobarbital 5 mg/kgBW/days
- Critical Ill : Days 3-5

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SUBSTITUTION FLUID IN DHF
Maintenance + 5 - 8%
 Vomiting every time
 Cannot drink
 ↑ fever
 PCV ↑ periodically
 Acidosis : NaBic
 PCV ↑ > 20% → IVFD : GED mild - mod

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Table 1. Fluid need for
moderate dehydration
Body Weight Amount of fluid
(Kg) (ml/kgBW/day)

<7 220
7-11 165
12-18 132
>18 88

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 Table 2. Fluid need for maintenance
Body Weight (kg) Amount of fluid
(ml/kgBW/day)

<10 100/kgBW
10-20 1000 + 50/kgBW(>10kg)
>20 1500 +20/kgBW(>20 kg)

Example : 40 Kg = 1500 +(20x20) = 1900 ml

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 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 : Dextran L40
Plasma

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DSS
 Shock→ emergency - fluid →recovery 48 hours
 Replacement of plasma volume
- Crystalloid: 20 ml/kgBW/30 min
- Still Shock : Colloid 10-20 ml/kgBW/h
Maximal 30 ml/kgBW
- Improvement : Crystalloid 10-20 ml/kgBW/h
- Still shock, PCV↓ → bleeding → blood
- PCV > 40 → blood 10 ml/kgBW/h
- Massive bleeding → blood 20 ml/kgBW/h
- Improvement → Crystalloid

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 Figure 1. Management of suspect DHF
Suspect DHF

Sudden high fever

continuously <7 d
URTI (-)

Emergency (+) Emergency (-)

Shock
Torniquet (+) Torniquet (-)
Vomit
Convulsion
Consiousness ↓ Trombocyte Trombocyte
Ambulatory
Hematemesis < 100000/µl > 100000/µl
Paracetamol
Melena
Control until fever ↓
Hospitalization Ambulatory

Follow up clinical & lab

Attention for parents Much drink
while days 3th fever (+)
Shock sign Paracetamol
Control until fever (-)
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 Figure 2. Management of DHF (Grade II)
Initial Fluid RL/NaCl 0.9% / RLD5/NaCl 0.9% + D5
(6-7 ml/kgBW/H)

Improvement (+) Monitoring vital sign / Improvement (-)

PCV and Trombocyte / 6H
Restlessness (-) Restlessness
Strong pulse Resp Distres
Stable BP Vital sign decrease Pulse rate ↑
Diuresis 2 ml/kbBW/H PCV ↑ BP ≤ 20 mmHg
PCV ↓ 2x exam Diuresis ↓/-

Decreased IV drip Improvement Increased IV drip

5 ml/kgBW/H 10 ml/kgBW/H
Evaluation 12-24 H
Step by step
Improvement (+)
15 ml/kgBW/H
3 ml/kgBW/H
Resp Distres Unstable vital sign PCV ↓
PCV ↑
IVFD Stop (24-48)
Colloid Fresh WB
If Vital Sign / PCV
/ Diuresis stable 20-30 ml/kgBW/H 10 ml/kgBW

Improvement
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Figure 3. Management of DSS (Grade III and IV)
1. Oxygenation
DHF Gr III 2. Plasma volume replacement DHF Gr IV
RL/NaCl  20 ml/kgBW immediately (bolus 30 min)

Shock (-) Evaluation 30 min Shock (+)

Follow up vital sign every 10 min
Improvement consiousness Record fluid balance Decrease consiousness
Strong pulse Weak pulse /not palpable
BP > 20 mmHg BP ≤ 20 mmHg
No RDS / cyanosis RDS / cyanosis (+)
Warm extremities Cold extremities
Diuresis > 1ml/kgBW/H Diuresis < 1ml/kgBW/H
Examine blood sugar
Reduce IVFD (10ml/kgBW/H) Shock (-)
Strict Evaluation IVFD ↑ (15-20 ml/kgBW/H)
Vital sign
Koloid/Plasma
Bleeding sign Shock (+)
(10-20 max 30 ml/kgBW/H)
Diuresis
Correction acidosis
Hb, PCV, Tr
PCV ↓ Evaluation 1 H
Stable 24 H
Fresh WB 10ml/kgBW PCV ↑
 5 ml/kgBW/H
Can repeated Koloid 20ml/kgBW

3 ml/kgBW/H IVFD stop ≤ 48 H 14

COMPLICATIONS
 Electrolyte Imbalance
 Hyponatremia
 Hypocalcemia
 Fluid overload
 Early IVFD
 Hypotonic Solution
 Not ↓ IVFD
 Not use colloidal Sol/Plasma
 Not give blood transf
 Not Calculate IVFD
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 COMPLICATIONS

Signs and Symptoms of fluid overload

 RDS, Dyspnea and Tachypnea
 Massive ascites
 Rapid pulse
 ↓ Pulse pressure
 Crepitation / Ronchi
 Poor tissue perfusion

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 COMPLICATIONS

Management of fluid overload

 Change IV to Dextran 40
 Urinary Catheter
 Furosemide 1 mg/kgBW, IV
 Still shock → Dextran 40, 10 ml/kgBW in 10-15 min
 Record Urine output
 Furosemide may repeat if still RDS
 CVP if not Response furosemide
 Ventilatory support
 Pleural/ peritoneal tapping
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 COMPLICATIONS

Unsual manifestation of DHF

- Less than 5 % of patient
- Encephalopathy/encephalitis
- Hepatic failure
- Renal failure
- Dual infections
- Underlying conditions

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 COMPLICATIONS
Common causes of encephalopathy
 Hepatic encephalopathy
 Severe shock
 Inborn error of metab
 Hepatotoxic drugs
 Underlying liver diseases
 Electrolyte imbalance
 Metabolic distrubance (hypoglycemia)
 Intracranial bleeding
 Cerebral thrombosis / ischemia

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 COMPLICATIONS
Management of DHF hepatic encephalopathy
 Maintain oxygenation
 Prevent ↑ intracranial press:
 Restrict IV
 Furosemidea+/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
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 COMPLICATIONS

DHF patients with renal failure

 Prolonged shock
 Acute hemolysis + Hburia
 G6PD Defficiency
 Hemoglobinopathy
 Management of acute hemolysis + Hb uria
 Transfusion PRC or FWB
 IVFD according the stage
 Alkalinize urine

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 COMPLICATIONS
Dual infections
 Associate:
 GI, Salmonella
 RI, Pneumonia
 Urinary infections
 Skin + Soft tissure Inf
 Nosocomial
 Thrombophlebitis
 Pneuomonia
 UTI (catheter)
 Others
 Transfusion reaction
 Hepatitis
 Massive GI Hem
 Drugs reactions

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 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
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CAUSES OF DEATH

 Prolonged shock
 Fluid overload
 Massive bleeding
 Unusual manifestation

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