dhf dr bram tangjong

8/9/2019 DHF Dr Bram Tangjong

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Penatalaksanaan DemamPenatalaksanaan DemamBerdarah Dengue padaBerdarah Dengue pada

Orang DewasaOrang Dewasa

Dr. A. TangjongDr. A. Tangjong

Bagian Penyakit DalamBagian Penyakit Dalam

FK UKI!"U FK UKIFK UKI!"U FK UKI


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Demam BerdarahMasih merupakan masalah penting dikota-kota besar, khususnya Jakarta

Ledakan kasus 5 tahunan

1988, 1993, 1998

Self LimitingDiseases


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PendahuluanPendahuluan

Virus dengue ter-mskVirus dengue ter-msk

genusgenus FlavivirusFlavivirus drdr

familifamili FlaviviridaeFlaviviridae

Ada 4 serotipe:Den1-4Ada 4 serotipe:Den1-4 Patogenesis masihPatogenesis masih

kontroversikontroversi

Penelitian masihPenelitian masih

diperlukandiperlukan


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Replication and TransmissionReplication and Transmission

of Dengue Virus (Part 1)of Dengue Virus (Part 1)

1. Virus transmitted

to human in mosquito

saliva

2. Virus replicates

in target organs

3. Virus infects hite !lood cells and

l"mphatic tissues

#. Virus released and

circulates in !lood

3

4

1

2


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Patogenesis DBDPatogenesis DBD

Teori virulensiTeori virulensi

virusvirus

TeoriTeori infectioninfectionenhancingenhancing

antibody antibody


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$"pothesis on Pathogenesis$"pothesis on Pathogenesis

of D$% (Part 1)of D$% (Part 1)

Persons ho have e&perienced a denguePersons ho have e&perienced a dengue

infection develop serum anti!odies that caninfection develop serum anti!odies that can

neutrali'e the dengue virus of that sameneutrali'e the dengue virus of that same

((homologoushomologous) serot"pe) serot"pe


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Neutralizing antibody to Dengue 1 virus

1

1

Dengue 1 virus1

$omologous nti!odies %orm$omologous nti!odies %orm

on*infectious +omple&es on*infectious +omple&es

Non-neutralizing antibody

1

1 Complex formed by neutralizing antibody and virus


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$"pothesis on Pathogenesis$"pothesis on Pathogenesisof D$% (Part 2)of D$% (Part 2)

,n a su!sequent infection- the pre*e&isting,n a su!sequent infection- the pre*e&istingheterologousheterologous anti!odies form comple&esanti!odies form comple&es

ith the ne infecting virus serot"pe- !utith the ne infecting virus serot"pe- !ut

do not neutrali'e the ne virusdo not neutrali'e the ne virus


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Non-neutralizing antibody to Dengue 1 virus

Dengue 2 virus

2 2

2

2

2

$eterologous nti!odies %orm$eterologous nti!odies %orm

,nfectious +omple&es,nfectious +omple&es

Complex formed by non-neutralizing antibodyand virus

2


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$"pothesis on Pathogenesis$"pothesis on Pathogenesis

of D$% (Part 3)of D$% (Part 3) nti!od"*dependent enhancementnti!od"*dependent enhancement is theis the

process in hich certain strains of dengue process in hich certain strains of dengue

virus- comple&ed ith non*neutrali'ingvirus- comple&ed ith non*neutrali'ing

anti!odies- can enter a greater proportionanti!odies- can enter a greater proportion

of cells of the mononuclear lineage- thusof cells of the mononuclear lineage- thus

increasing virus productionincreasing virus production


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2

2

2

2

2

2

2

2

2

2

$eterologous +omple&es nter /ore$eterologous +omple&es nter /ore

/onoc"tes- 0here Virus Replicates/onoc"tes- 0here Virus Replicates

Non-neutralizing antibody

Dengue 2 virus2

Complex formed by non-neutralizing

antibody and Dengue 2 virus

2


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$"pothesis on Pathogenesis$"pothesis on Pathogenesisof D$% (Part #)of D$% (Part #)

,nfected monoc"tes release vasoactive,nfected monoc"tes release vasoactive

mediators- resulting in increased vascularmediators- resulting in increased vascular

permea!ilit" and hemorrhagic permea!ilit" and hemorrhagic

manifestations that characteri'e D$% andmanifestations that characteri'e D$% and

DD


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Manifestations of dengue infection

engue !irus

infection

"symptomatic #ymptomatic

$ndi%erentiated fe!er

engue fe!ersyndrome

&ithouthaemorrhage

&ith unusualhaemorrhage

enguehaemorrhagi

c fe!er

'o shock engueshocksyndrome

engue

fe!er

engue

haemorrhagicfe!er


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Non-speifi onstitutional s!mptoms o"servedNon-speifi onstitutional s!mptoms o"served

in haemorrhagi fever patients #ith denguein haemorrhagi fever patients #ith dengue

$riteria$riteria D%&'()D%&'()

*n+eted phar!n,*n+eted phar!n, ./0./0

VomitingVomiting //

$onstipation$onstipation 3/3/

A"dominal painA"dominal pain //

%eadahe%eadahe 44/.44/.5enerali6ed l!mphadenopath!5enerali6ed l!mphadenopath! 4/4/

$on+untival in+etion$on+untival in+etion 32/032/0

$ough$ough 21/21/

7hinitis7hinitis 12/012/0

8aulopapular rash8aulopapular rash 12/112/1

8!algia9arthralgia8!algia9arthralgia 12/12/,anthema,anthema 0/3 0/3

A"normal refle,A"normal refle, ./ ./

DiarrheaDiarrhea ./4 ./4

Palpa"le spleenPalpa"le spleen ./3 ./3

$oma$oma 3/ 3/


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The follo#ing lassifiations are proposed :

; Probable- an aute fe"rile illness #ith t#o or more ofthe follo#ing manifestations :

< headahe

< retro-or"ital pain

< m!algia

< arthralgia

< rash

< haemorrhagi manifestations

< leukopenia

< serolog! '=) or D& ourrene at the same loation 9

time


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(riteria iagnosis ) *&+ 199.

emam, atau ri/ayat demam akut, antara 0- hari, biasanyabifasik

erdapat minimal satu dari manifestasi perdarahan berikut ini2 $i tourni4uet positif

etekie, ekimosis, atau purpura

erdarahan mukosa, saluran cerna, bekas suntikan atau ditempat lain

+ematemesis atau melena

rombositopenia *6 177777mm3.

erdapat minimal satu dari tanda-tanda plasma leakage olehkarena peningkatan permeabilitas kapiler berikut2

+ematokrit meningkat : 07; dibandingkanhematokrit rata-rata pada usia, enis kelamin, dan

populasi yang sama

+ematokrit turun hingga : 07; dari hematokrita/al, setelah pemberian cairan

erdapat efusi pleura, asites , hiponatremia,hi oalbuminemia


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CENTERS !R D"SE#SE C!NTR!$ #ND %RE&ENT"!N

%our rades of D$%%our rades of D$%

rade 1rade 1 %ever and nonspecific constitutional s"mptoms%ever and nonspecific constitutional s"mptoms

Positive tourniquet test is onl" hemorrhagic manifestationPositive tourniquet test is onl" hemorrhagic manifestation

rade 2rade 2 rade 1 manifestations 4 spontaneous !leedingrade 1 manifestations 4 spontaneous !leeding

rade 3rade 3

igns of circulator" failure (rapid5ea6 pulse- narroigns of circulator" failure (rapid5ea6 pulse- narro

pulse pressure- h"potension- cold5clamm" s6in) pulse pressure- h"potension- cold5clamm" s6in)

rade #rade #

Profound shoc6 (undetecta!le pulse and 7P)Profound shoc6 (undetecta!le pulse and 7P)


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Viral Ris6 %actorsViral Ris6 %actors

for D7D Pathogenesisfor D7D Pathogenesis

Virus strain (genot"pe)Virus strain (genot"pe)

8 pidemic potential9 viremia level- infectivit"pidemic potential9 viremia level- infectivit"

Virus serot"peVirus serot"pe

8 D7D ris6 is greatest for D*2- folloed !"D7D ris6 is greatest for D*2- folloed !"

D*3- D*# and D*1D*3- D*# and D*1


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Treatment of Dengue %ever Treatment of Dengue %ever

%luids%luids

RestRest

ntip"retics (avoid aspirin and non*steroidalntip"retics (avoid aspirin and non*steroidal

anti*inflammator" drugs)anti*inflammator" drugs)

/onitor !lood pressure- hematocrit- platelet/onitor !lood pressure- hematocrit- platelet

count- level of consciousnesscount- level of consciousness


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Suspek DBD

( Demam 2-7 hari)

Hb, Ht,

Trombo N

Hb, Ht

normal/meningkatTrombo

< !"#"""

Hb, Ht

meningkat ($!")

Trombo normal

%ulang

&a'at &a'at

&a'at Sesuai

%rotokol

Sok /

%erarahan

Observasi Penderita suspek DBD dewasa di IGD pada keadaan wabah(KLB)

*ontrol

poli

%rotokol %enatalaksanaan

DBD De'asa


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:; uspe6 D7D

Perdarahan pontan /asif (*)

"o6 (*)

$!-$t (n)5

Trom!.=.===

*R? # @am56olf

*$!-$t-Trom!. tiap 2# @am

$!-$t (n)5

Trom!.A1==.===

*R? # @am56olf

*$!-$t-Trom!. tiap 12 @am

$!-$t- (n)

Trom!. < 1==.===

2# @am sta!il

:linis mem!uru6 9

TD - - Diuresis

*R? # @am56olf atau

*Pertim!ang6an 9

Bcairan 6oloid ( plasma expander )

Bma& 1*1-> ltr 5 2# @am

(lihat proto6ol D7D dengan s"o6)

$!-$t (n)5

Trom!.A1==.===

*R? # @am56olf

* $!-$t-Trom!. 1&12 @am

Pulang $!-$t (n)

Trom!.


24/27

CENTERS !R D"SE#SE C!NTR!$

#ND %RE&ENT"!N

:; D7D 9

Perdarahan pontan C /asif 9 *pista6sis tida6 ter6endali

*$ematemesis melena5hemartos6e'ia *Perdarahan ota6

"o6 (*)

*R? # @am56olf

*DP?-hemostase

:,D (4)

*R? # @am56olf *$eparinisasi

*Transfusi 6omponen darah 9

B%%P

BPR+ ($!A1=g)

BTr (Trom!.A1==.===)

B$!-$t-Trom!. tiap #*E @am

B;lang hemostase 2# @am 6emudian

:,D (*)

*R? # @am56olf *Transfusi 6omponen darah 9

BPR+ ($!A1=g)


B$!-$t- Trom!. tiap #*E @am


enatalaksanaan ) de/asa *dengan perdarahan < tanpa syo


25/27

CENTERS !R D"SE#SE C!NTR!$

#ND %RE&ENT"!N

D7D tadium ,,, 5 ,V 9

Perdarahan pontan C /asif 9 *pista6sis tida6 ter6endali

*$ematemesis melena5hematos6e'ia

*Perdarahan ota6

*DP?*hemostase

*nalisa gas darah

*R? 2= ml56g775@am 9 3=F*12=F

*G2 2*# liter5menit

TD - - Diuresis*+airan 6oloid ( plasma expander ) 9

1=*2= ml56g775hari tetesan cepat

ma& >== cc52 @am

1*1-> l52# @am

*R? # @am56olf

*7ila perlu**vasopresor

(Dopamin5Do!utamin5pinefrin)

:,D (4)

*R? # @am56olf

*$eparinisasi


B%%P

BPR+ ($!A1=g)


B$!-$t-Trom!. tiap #*E @am


:,D (*)

*R? # @am56olf


BPR+ ($!A1=g)


B$!-$t- Trom!. tiap #*E @am


TD sistoli6 (1== mm$g)

R? 1= ml56g775@am (E=F*12=F)

TD- (n)- Diuresis 5(n)

R? # @am56olf

enatalaksanaan ) de/asa dengan syok < perdarahanspontan


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Thank #ouThank #ou

dhf dr bram tangjong

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