FLUID TREATMENT CHOICE
IN DENGUE INFECTION
Djatnika Setiabudi
Child Health Department
Outline
Introduction
Dengue Classification (WHO 2011)
Patophysiology
Fluid Treatment
Burden of disease
Endemic in > 100 tropical and subtropical countries 50–100 million dengue fever infections per year globally 500,000 cases of severe dengue DHF and DSS
Average case fatality 2–5%
Indonesia (Profil Kesehatan tahun 2010):
- DHF the second most hospitalized patients
- 156,086 cases; insidence rate 65.7/100,000 /year - Case Fatality Rate (CFR): 0.87%
New Guidelines WHO /SEARO,
2011
Important notes:
1. Clinical spectrum added:
expanded dengue syndrome
2. If fever and significant
plasma leakage: DHF clinical diagnosis is most likely even if there is
no bleeding manifestation or thrombocytopenia
Manifestations of dengue virus infection (WHO, 2011)
WHO classification of dengue infections and grading of severity of DHF (2011)
DENGUE VIRUS INFECTION FEVER ANOREXIA VOMITING BLEEDING MANIFESTATION HEPATOMEGALY INCREASE VASCULAR PERMEABILITY TROMBOCYTOPENIA Plasma leakage : Hemoconcentration Hipoproteinemia Pleural effusion Ascites Hypovolemia Shock Anoxia Death Acidosis G.I. bleeding DIC Dehydration Suchitra (1993)
Perjalanan penyakit Demam Dengue
Hari sakit
emp
Time of fever defervescence
(Saat suhu reda)
Suhu reda, klinis membaik, nafsu makan membaik
Perjalanan penyakit DBD
Hari sakit
emp
Klinis memburuk, lemah, gelisah, tangan kaki dingin, nafas cepat,
diuresis berkurang, tidak ada nafsu makan
Fase syok
Fase demam Fase konvalesens Time of fever defervescence
Principle of dengue management
1.
Fluid replacement
Vascular permeability increase Plasma leakage
hemoconcentration hypo-volemic shock
2.
Early detection and managememnet of
circulatory disturbance:
Clinically and serial Blood laboratory exam
3.
Detection and management of bleeding
manifestation:
Clinically and laboratory exam
Fluid treatment: Principle of “4-J”
J
alan/jalur pemberian :
per oral – intravena ?
J
enis cairan :
oralit- jus buah - kristaloid – koloid ?
J
umlah cairan :
rumatan – dehidrasi atau hemokonsentrasi?
Syok atau tidak syok
J
adwal pemberian :
Indication for intravenous fluid
-
(Persistent) vomiting
-
Nausea and anorexia (small drinking)
-Abdominal pain and tenderness
-
Impaired concioussness
-
Increasing Haematocrit value
-Circulatory disturbance
Choice of fluids
Suspected dengue and Dengue Fever:
- isotonic crystalloid : normal saline, Ringer’s
lactate, Ringer’s acetate, Ringer’s dextrose
Dengue hemorrhagic Fever (DHF I and II):
- isotonic crystalloid : glucose contained solution?
TANDA VITAL TIDAK STABIL Penurunan jumlah urine output
Tanda-tanda syok DBD derajat III*
Perbaikan
Oksigen melalui face mask atau kanula hidung Penggantian volume secara cepat: inisiasi terapi IV 10 ml/kg/jam larutan isotonik kristaloid selama 1-2 jam
Tidak ada perbaikan
Perbaikan lebih lanjut Pengurangan dari 10 ml/kg/jam
menjadi 7, 5, 3, 1.5 ml/kg/jam sesuai keadaan klinis dan hasil
pemeriksaan hematokrit
M enghentikan terapi IV selama 24-48 jam
Peningkatan hematokrit Penurunan hematokrit Periksa ABCS
(Acidosis, Bleeding, Calcium, Sugar), dan koreksi
Koloid IV
(Dextran 40 atau HES)
Transfusi darah : FWB10 ml/kg atau PRC 5 ml/kg
Perbaikan
Pengurangan dari 10 ml/kg/jam menjadi 7, 5, 3, 1.5 ml/kg/jam tergantung keadaan klinis dan hematokrit . Hentikan terapi IV
selama 24-48 jam
* Dalam kasus dengan syok yang lebih berat (DBD derajat IV) laju IV adalah 10 ml/kg selama 10-15 menit atau 20 mL/kg dalam 30 menit, selanjutnya dikurangi menjadi 10 ml/kg/jam
Randomised Controlled Trials
of Fluid Management in DSS
Dung NM, Day NP, Tam DT, Loan HT, Chau HT, Minh LN, et al. Fluid replacement in dengue shock syndrome: a randomized, double-blind
comparison of four intravenous-fluid regimens.
A pilot study involving 50 children with DSS Children were randomised to receive:
crystalloid : normal saline (n=12), Ringer’s lactate (n=13) colloid : dextran 70 (n=12) or 3% gelatin (n=13)
Result:
- colloid group had significantly greater increases in mean haematocrit (P=0·01), blood pressure (P=0·005), pulse
pressure (P=0·02)
Overall : showed minor differences in the immediate
clinical responses to different fluids
Ngo NT, Cao XT, Kneen R, Wills B, Nguyen VM, Nguyen TQ, et al. Acute management of dengue shock syndrome: a randomized double-blind
comparison of 4 intravenous fluid regimens in the first hour.
A larger study: 230 DSS children , compared the same four fluids Result:
- comparisons between all other solutions were not significant (However, pulse pressure at presentation was identified as a potential confounder)
- in severe patients (pulse pressure < 10 mmHg) differences were found Conclusion:
- mild-to-moderate DSS patients have respond well to crystalloid treatment - more severe: may require more aggressive management with colloids
- However, this study was statistically underpowered - Recommendation:
further large-scale studies, stratified for admission pulse pressure,
Wills BA, Nguyen MD, Ha TL, Dong TH, Tran TN, Le TT, et al.
Comparison of three fluid solutions for resuscitation in dengue shock syndrome.
largest randomised study ,stratified for presenting pulse pressure.
Group 1: Moderately shock (pulse pressure >10 to 20 mmHg, n=383) were randomised to receive Ringer’s lactate (n=128), 6% dextran 70 (n=126) or 6% HES 200/0·5 (n=129).
Group 2: severe shock (pulse pressure 10 mmHg) were randomised to receive one of the colloids – dextran 70 (n=67) or HES (n=62)
Result:
- Group 1: RL was found to be as effective as colloid therapy
- Group 2: - both colloid preparations performed equally result.
- dextran more adverse events than HES (allergic-reactions) - no differences in severe adverse events
(significant bleeding or clinical fluid overload)
Characteristics of three Vietnam Studies
Author, Year Population Intervention: Study fluids
Dung et al., 1999
50 Vietnamese child with clinical DSS;
5-15 years old
Lactated Ringer’s solution, isotonic saline, dextran, gelatin
Fluid rate :20mL/kg for 1 hr, then 10mL/kg for the 2nd hour
Nhan et al., 2001 230 Vietnamese children clinically diagnosed DHF DHF grade III = 222 DHF grade IV = 8 1-15 years old
Lactated Ringer’s solution, isotonic saline, dextran, gelatin
Fluid rate :
DHF grade III: 20mL/kg for 1 hr DHF grade IV: 20ml/kg for 15min, then 20mL/kg over the following hour Willis et al., 2005 512 Vietnamese children with clinical DSS Moderate shock = 383 Severe shock = 129 2-15 years old
Lactated Ringer’s solution, starch, dextran
Fluid rate:
15mL/kg for 1 hr, then 10mL/kg for the 2nd hr
Kalayanarooj S.
Choice of colloidal solutions in dengue hemorrhagic fever patients.
A study of 104 DHF patients with severe plasma leakage who had failed to respond to crystalloids and required fluid
resuscitation
compared bolus doses of two colloids, 10% dextran 40 (n=57) and 10% HAES-steril (n=47)
Objective: compare their effectiveness, impact on renal function and haemostasis and any complications.
Result:
- HAES-steril was found to be as effective as dextran 40.
- Both colloidal solutions were safe in these patients (no allergic reactions, interference with renal function or haemostasis)
SYSTEMATIC REVIEW
The Use of Colloids and Crystalloids in Pediatric
Dengue Shock Syndrome:
a Systematic Review and Meta-analysis*
Jalac SLR, de Vera M and Alejandria MM.
Philippine Journal of Microbiology and Infectious Diseases 2010;39(1):14-27
Objectives:
to compare the therapeutic effects of colloids
versus crystalloids of
children with DSS
in
reducing:
1.
the recurrence of shock
2.
the requirement for rescue fluids
3.the need for diuretics
4.
the total volume of intravenous fluids given
5.the haematocrit level and pulse rates
Results:
Colloids and crystalloids did not differ significantly in decreasing:
1. t:he risk for recurrence of shock (RR 0.92, 95% CI 0.62 - 1.38) 2. the need for rescue fluids (RR 0.90, 95% CI 0.70 - 1.16)
3. mortality rates
4. total volume of intravenous fluids given
5. the need for diuretics (RR=1.17, 95% CI 0.84 to 1.64)
significant improvements from baseline in the haematocrit
levels and pulse rates of patients who were given colloids
Conclusion:
no significant
advantage was found colloid over
crystalloids in reducing the
recurrence of shock,
the need for rescue colloids
,
the total amount of
fluids, the need for diuretics, and in reducing
mortality
Colloids decreased the haematocrit and pulse rates
of children with DSS after the first two hours of
fluid resuscitation
Resume
These studies show that the majority of DSS children can
be treated successfully with isotonic crystalloid solutions
If a colloid is considered necessary:
- rely on personal experience
- familiarity with particular products - local availability and cost
A medium-molecular-weight preparation : optimal choice
- good initial plasma volume support - good intravascular persistence and - acceptable tolerability profile
Characteristics of colloids
used for plasma volume support
Initial volume expansion (%)* Duration of volume effect (hrs) Adverse effect on coagulation Allergic potential Other significant side-effects 3% Gelatine (MW = 35,000) 60–80 3–4 +/− ++ 10% Dextran 40 (MW = 40,000) 170–180 4–6 ++ + Renal failure in hypovolaemic patients 6% Dextran 70 (MW = 70,000) 100–140 6–8 ++ + 6% Hydroxy-ethyl starch = HES (MW = 200,000/0·5) 100–140 6–8 + +/− 6% HES (MW = 400,000) 80–100 12–24 ++ +
Management of dengue; Wills B. Halstead SB (Ed.) : 2008 Imperial College Press. Note: *Infused volume; MW, molecular weight
Without
haemorrhage haemorrhageWith unusual No shock Dengue shock syndrome
Undifferentiated febrile illness (viral syndrome)
Dengue Fever
syndrome Dengue hemorrhagic fever(plasma leakage)
Asymptomatic Symptomatic Dengue virus infection
Ditjen Yanmed
WHO/TDR Guidelines 2009
These guidelines
are not intended toreplace national guidelines but to
assist in the development of national or regional
Suggested dengue classification and level of severity
WHO, 2009
Tata laksana DBD derajat I & II
Cairan awal : Rumatan + 5% (7ml/kgBB/jam)
Tetesan dikurangi 5ml/kgBB/jam
3ml/kgBB/jam 1,5 mL/kg/jam
Stop dalam 24-48jam
Monitor tanda vital Hb,Ht,trombo tiap 6-12jam Perbaikan
Gelisah Distres nafas Frek nadi naik Ht tinggi
Tek nadi <20mmHg Diuresis kurang
Evaluasi 12-24jam
Tidak ada perbaikan
Tetesan dinaikkan 10 ml/kgBB/jam
Tanda vital tidak stabil Tatalaksana DSS Tidak gelisah Nadi kuat Tek drh stabil Ht turun Diuresis 2ml/kgBB/jam
Jumlah Cairan :
Rumatan : Halliday & Segar
BB (Kg) Jumlah cairan / 24 jam
< 10 100cc/kg BB
10 – 20 1000 + 50cc/kg BB untuk tiap kelebihan > 10 kg >20 1500 + 20cc/kg BB untuk tiap kelebihan > 20 kg
Kehilangan cairan : DHF dianggap dehidrasi sedang = 5-8%, setiap 1% = 10cc/kg BB
Contoh : berat badan 18 kg
Rumatan = (10 x 100) + (8x50) = 1400 cc Kehilangan cairan = 18 x 5 x 10 cc = 900 cc
Jumlah : 2300 cc/24 jam
Order untuk kebutuhan tiap jam ( + 100cc /jam)
selanjutnya cairan disesuaikan bergantung pada hasil monitoring Hematokrit dan klinis
