Terapi Cairan pada

Syok Dengue.

Uun Sumardi
 Objektif.

•
Klasifikasi: Infeksi Dengue.
•
Kebocoran Plasma (“Plasma Leakage”).
•
Perjalanan Klinis Infeksi Dengue.
•
Terapi Cairan pada Infeksi Dengue (SOSD).
•
Kasus DSS.
•
Ringkasan.
 Revised Dengue Classification, WHO 2009.

Dengue ± Warning Sign Severe Dengue

1. Severe plasma leakage

Without With
Warning Sign Warning Sign* 2. Severe haemorrhage
3. Severe organ impairment

Warning signs*
Probable Dengue : 1. Severe plasma leakage leading to:
•Live
Abdominal
in / travel to pain
dengue orendemic
tenderness
area. * Shock (DSS)
Fever and 2 of the
• Persistent vomiting following criteria:
• Nausea, vomiting * Fluid accumulation with respiratory
•• Rash
Clinical fluid accumulation
•• Aches
Mucosal bleed
and pains
distress
•• Tourniquet
Lethargy,test positive
restlessness 2. Severe haemorrhage as evaluated by
• Leukopenia
•• Any
Liver enlargment
warning sign >2 cm clinician
• Laboratory: increase in HCT 3. Severe organ involvement:
concurrent with rapid decrease
* Liver: AST or ALT ≥ 1000
in platelet count
*(requiring strict observation and medical intervention)* CNS: Impaired consciousness
* Heart and other organs
*Laboratory-confirmed dengue (important when no sign of plasma leakage)
Demam Dengue dan Demam Berdarah Dengue
Demam Dengue Demam Berdarah Dengue

Critical Critical
Phase Phase

Anon Srikiatkhachorn. Plasma leakage in dengue haemorrhagic fever. Thromb Haemost 2009; 102: 1042–1049.
 “Plasma Leakage”.

Uun Sumardi, Erni J. Nelwan. Retinal Hemorrhage in Dengue Hemorrhagic Fever. www.inaactamedica.org/archives/2011/21339548.pdf
Meta Michels, Uun Sumardi, Quirijn de Mast, Hadi Jusuf, Mita Puspita, Intan Mauli Warma Dewi et al. The Predictive Diagnostic Value of Serial Daily Bedside Ultrasonography
for Severe Dengue in Indonesian Adults. PLOS Neglected Tropical Diseases.2013,7,;6.
 Kebocoran Plasma pada Infeksi Dengue.
(Plasma Leakage)

Paracellular pathways Transcellular pathways

Peter Vervaeke, Kurt Vermeire, Sandra Liekens. Endothelial dysfunction in dengue virus pathology. Rev. Med. Virol. 2015; 25: 50–67.
Suhendro Suwarto, R Tedjo Sasmono, Robert Sinto, Eppy Ibrahim, Maulana Suryamin. Association of Endothelial Glycocalyx and Tight and Adherens Junctions With Severity of Plasma Leakage in
Dengue Infection. JID 2017;215:992-999.
Leonard N. Pengembangan Sistem Skor Sebagai Prediktor Kebocoran Plasma pada Demam Berdarah Dengue: Peran sTNFR-1, VEGF, sVE-CADHERIN dalam Patofisiologi Kebocoran Plasma. 2012.
 Perjalanan Klinis Infeksi Dengue.

24 - 48 H
Febris Critical Recovery

Severe Dengue

Plasma
Leakage
370C

Shock Compensated
(Pulse Pressure narrowing, Gagal Sirkulasi = DHF gr.III)
Med.Rec.Doc.2011.
Yacub S, Wertheim H, SimmonsC P, Screaton G, Will B. Cardiovascular Manifestation of Emerging Dengue Pandemic. Nature Rev.Cardiol.2014,11:335-3455
Tanda Peringatan untuk Syok Dengue.
Kapan DSS terjadi?
•
3 - 5 hari setelah onset demam
Tanda Bahaya:
•
Nyeri perut hebat
•
Muntah berkepanjangan, perdarahan
•
Perubahan dari demam, menjadi hipotermi

•
Perubahan kesadaran (iritabilitas atau somnolence)

•
Nadi cepat dan lemah
•Tanda Peringatan Awal:
Tekanan nadi < 20 mmHg, Hipotensi
• Menurunannya demam
•
Akral dingin
•
Menurunnya trombosit
•
Peningkatan Hematokrit
PPK Infeksi Dengue Dewasa
Tariff Magnitude of Dengue Patients Managed with Clinical
Pathway-Case mix in Dr.Hasan Sadikin Hospital as
Compared to INA-DRG’s in five days hospitalization.

Misriani, Uun S, Bachti A, Elsa PS, Hadi J,2010.

 Terapi Cairan pada Infeksi Dengue.
5R adalah resuscitation, routine maintenance, replacement,
“salvage, optimization, stabilization, de-escalation” (SOSD)
redistribution, dan reassessment.
Terapi Cairan Optimization,
RESUSITASI
Salvage RUMATAN
Stabilization

Kristaloid Koloid NUTRISI Elektrolit

Tidak
Kombinasi Adroque Formula:
25 Kcal/Kg BB.
(Koreksi Na/K).

Air Streril ditambah 1. Rumatan + IWL

Larutan Kristaloid ditambah 2. Dukungan nutrisi
elektrolit = true solution
Subtansi Koloid yang tidak
dapat bergerak bebas melintas
membrane semipermeabel
De-escalation
Stop
Mengganti kehilangan akut
(perdarahan, kehilangan melalui sal. cerna, rongga ke3)
 Komposisi Cairan Kristaloid dan Koloid.
Lakta Glukos Osmolalit Lain-
Cairan Ph Na+ Cl- K+ Ca++
t a as lain
Onc.Pres
7.35- 135- 94- 2.2- s.
Plasma 3.5-5 1-2 <100mg 291 25
7.45 145 111 2.6
mmHg.
NS 0.9% 5.0 154 154 0 0 0 0 308 0
RL 6.5 130 109 4-5 1.5 28 273
27mmol
Acetate
Plasmalite 7.4 140 98 5 0 0 0 294 23mmol
Gluconat
e
Albumin
6.7-7.3 140 129 0 0 0 0 260
4%
Onc.Pres
s.
Dextran 40 3.5-7 154 154 0 0 0 0 311 168-191
100g/L
dextran
60g/L
Dextran 70 3-7 154 154 0 0 0 0 310 dextran

Urea cross-
35g/L
linked 7.4 145 145 5 6.25 0 0 293 gelatin
Gelatin
Onc.Pres
Succinylate s.
d 7.4 154 120 0 0 0 0 308 26-29
40 g/L
Gelatin gelatin
60 g/L
starch
Hetastrach 5.5 154 154 0 0 0 0 310 (amilope
ravenous (IV) fluid in various clinical situations, as blood storage, and blood transfusion, although
ctin) development of hyp
Distribusi Cairan Infus: Nutrisi, Kristaloid dan Koloid per 1 L.
Characteristics of various different colloids
used for plasma volume support.
Initial Duration
Adverse Other
Volume Volume
Colloid Effect on Side
Expantion Effect
Coagulation Effect
(%) (h)
3 % Gelatin
MW =35.000 60-80 3-4 +/-

10% Dextran 40 Renal

MW=40.000 170-180 4-6 ++
Failure
6% Dextran 70
MW=70.000 100-140 6-8 ++

6% HES
MW=200.000/0.5 100-140 6-8 +

6% HES
(Hydroxyethylstarch) 80-100 12-24 ++
MW=400.000

Scott B H. Dengue. 2008.

 Resusitasi Cairan kasus DSS (Perempuan 44 thn.,BB 70Kg).

Penderita, saat masuk IGD, jam 10.22 (230519).

KU: tampak sakit berat, gelisah, mimisan, akral dingin. BB=70Kg.
Tensi: 110/90 mmHg, Nadi: 112 kali/mnt, isi kurang, Pernap. 20 kali/
mnt. torako abdominal, Suhu: 36.60C, Sat. 94% (nasal kanul 3L/mnt).

Jumlah Cairan Rehidrasi (RL): 1500 + [20 x (70-20)] x 2 = 5000cc/24jam.

SHari I : - Larutan Koloid ( BM rendah), larutan koloid 500cc/1jam di IGD.

- 500cc Koloid menggantikan 1000cc Larutan Ringer.

O,S - Ringer 3000cc, diberikan selama 23 jam (diruang rawat).

- Minum 1000cc.

D
Hari II : Jumlah cairan rumatan, 2500 cc - minum 1000cc, Infus RL 1500
cc/24 jam.
 Kasus DSS .
(BB.70Kg)

Hari 5 H2
H4
3
H1

H2

MIC,Doc:2019.
 Sensitivity, Specificity, PPV and NPV of Gall Bladder Thickening
(GBT) with handheld USG for Detection Severe Dengue.

Dengue Patient Positive Predictive Negative Predictive

Sensitivity Specificity Value (PPV) Value (NPV)
(n=69)
Gall Bladder 84.40 % 65.60% 55.10 % 89.40%
Thickening (GBT)

GBT>0.55 cm, H1) (95% CI: (95% CI: 58.20- (95% CI: 45.40- (95% CI: 79.20-
69.50- 70.30 % ) 61.20 %) 95.80 % )
93.80 %)

ast, Hadi Jusuf, Mita Puspita, Intan Mauli Warma Dewi et al. The Predictive Diagnostic Value of Serial Daily Bedside Ultrasonography for Severe Dengue in Indonesian Adults. PLOS
 Ringkasan.

1. Kewaspadaan dini syok dengue: tekanan nadi.

2. Penunjang diagnostik: mudah, cepat, praktis.
3. Asupan dan pemilihan cairan hidrasi yang sesuai.
4. Clinical Pathway-Casemix,
~ Kendali Biaya dan Mutu
(“Cost Effective and High Impact”)
5. Pencegahan infeksi dengue melalui 3M++
Terimakasih