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DEMAM BERDARAH DENGUE Diagnosa dan Penatalaksanaan
 

DEMAM BERDARAH DENGUE Diagnosa dan Penatalaksanaan

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DEMAM BERDARAH DENGUE Diagnosa dan Penatalaksanaan DEMAM BERDARAH DENGUE Diagnosa dan Penatalaksanaan Presentation Transcript

  • Curriculum Vitae
    • Nama : KURNIA F. JAMIL
    • Tempat/Tanggal Lahir : Medan, 8 Februari 1965
    • Istri : Cut Fazia Rosanti, SE
    • Anak : - Fania Putri Alifa
    • - Fasya Rizky Aliya
    • Pendidikan : - Lulus Dokter Umum : FK-UI (1992)
    • - Lulus Spesialis Penyakit Dalam : FK-UNPAD (2003)
    • - Lulus Magister Kesehatan : FK-UNPAD (2004)
    • - Lulus Konsultan Tropik Infeksi(KPTI) : KOLEGIUM PAPDI 2008
    • Jabatan :
    • - Staf Bagian Ilmu Penyakit Dalam FK-Unsyiah/RSUZA
    • - Kepala Sub-Bagian Penyakit Tropik & Infeksi, Bagian IPD FK-Unsyiah/RSUZA
    • - Koordinator Skills Lab FK-Unsyiah
    • - Ketua POKJA HIV/AIDS RSU. Dr. Zainoel Abidin, Banda Aceh
    • Pendidikan Tambahan:
    • - ACLS : RS. Jantung Nasional Harapan Kita, Jakarta (1994)
    • - TOT HIV/AIDS : Tingkat Dasar DEPKES-RI (2002), Lanjutan (2003 dan 2006)
    • - Pelatihan Khusus Penyakit Dalam : Herz und diabetezcentrum, Jerman (2004)
    • - Biology Molecular : Gottingen University,Jerman (2009), Eijkman Insitute, Jakarta (2011)
  • DEMAM BERDARAH DENGUE Diagnosa dan Penatalaksanaan KURNIA F. JAMIL Sub-Bagian Penyakit Tropik & Infeksi Bagian Ilmu Penyakit Dalam FK-UNSYIAH/RSUZA BANDA ACEH 2012
  • Demam Berdarah Dengue Masih merupakan masalah penyakit infeksi yang serius di Indonesia DEPKES-RI tahun 2005 Jumlah kasus 80.837 dengan 1.099 kematian Ledakan kasus 5 tahunan Sejak tahun 1968 dan seterusnya Self Limiting Diseases
  • Pendahuluan
    • Virus dengue termasuk genus Flavivirus dari family Flaviviridae
    • Ada 4 serotipe: Den 1- 4
    • Patogenesis masih kontroversi
    • Penelitian masih diperlukan
  • Overview of the Major Viral Hemorrhagic Fever Family Genus Mortality Transmission Cook GC, Zumla A. Manson’s Tropical Diseases, 2003 Arenaviridae Lassa West Africa 16% Rodents Junin’58* Argentina 30% Rodents Machupo’63 Bolivia 25% Rodents Sabia’90 Brazil 30% Rodents Guanarito’90 Venezuela 25% Rodents Flaviviridae Dengue 1-4 0.2-2% Mosquitos Yellow fever virus * 10-85% Mosquitos Kyasanur * India 5% Ticks Omsk Rusia 2% Ticks Bunyaviridae Phlebovirus- Rift Valley HF 1% Mosquitos Hantavirus - HF Renal Synd * 5-15% Rodents Nairovirus- Crimean Congo HF 20-50% Ticks Puumala 1% Rodents Filoviridae Marburg ** 20-25% Monkey Ebola ** 70-90% Monkey Alphaviridae Chikungunya # 0% Mosquitos Reoviridae Coltvirus <1% Ticks * Cardiac complication ** Nosocomial # Mild HF
  • Replication and Transmission of Dengue Virus (Part 1) 1. Virus transmitted to human in mosquito saliva 2. Virus replicates in target organs 3. Virus infects white blood cells and lymphatic tissues 4. Virus released and circulates in blood 3 4 1 2
  • Patogenesis DBD
    • Teori virulensi virus
    • Teori infection enhancing antibody
  • Viral Risk Factors for DHF Pathogenesis
    • Virus strain (genotype)
      • Epidemic potential: viremia level, infectivity
    • Virus serotype
      • DHF risk is greatest for DEN-3, followed by DEN-2, DEN-1 and DEN-4
  • Hypothesis on Pathogenesis of DHF (Part 1)
    • Persons who have experienced a dengue infection develop serum antibodies that can neutralize the dengue virus of that same ( homologous ) serotype
  • Neutralizing antibody to Dengue 1 virus Dengue 1 virus Homologous Antibodies Form Non-infectious Complexes Non-neutralizing antibody Complex formed by neutralizing antibody and virus 1 1 1 1 1
  • Hypothesis on Pathogenesis of DHF (Part 2)
    • In a subsequent infection, the pre-existing heterologous antibodies form complexes with the new infecting virus serotype, but do not neutralize the new virus
  • Non-neutralizing antibody to Dengue 1 virus Dengue 2 virus Heterologous Antibodies Form Infectious Complexes Complex formed by non-neutralizing antibody and virus 2 2 2 2 2 2
  • Hypothesis on Pathogenesis of DHF (Part 3)
    • Antibody-dependent enhancement is the process in which certain strains of dengue virus, complexed with non-neutralizing antibodies, can enter a greater proportion of cells of the mononuclear lineage, thus increasing virus production
  • Heterologous Complexes Enter More Monocytes, Where Virus Replicates Non-neutralizing antibody Dengue 2 virus Complex formed by non-neutralizing antibody and Dengue 2 virus 2 2 2 2 2 2 2 2 2 2 2 2
  • Hypothesis on Pathogenesis of DHF (Part 4)
    • Infected monocytes release vasoactive mediators, resulting in increased vascular permeability and hemorrhagic manifestations that characterize DHF and DSS
  • Kompleks Imun
  •  
  • Manifestations of dengue infection Dengue virus infection Asymptomatic Symptomatic Undifferentiated fever Dengue fever syndrome Without haemorrhage With unusual haemorrhage Dengue haemorrhagic fever No shock Dengue shock syndrome Dengue fever Dengue haemorrhagic fever
    • Non-specific constitutional symptoms observed
    • in haemorrhagic fever patients with dengue
    • Criteria DHF(%)
    • Injected pharynx 96.8
    • Vomiting 57.9
    • Constipation 53.5
    • Abdominal pain 50.0
    • Headache 44.6
    • Generalized lymphadenopathy 40.5
    • Conjunctival injection 32.8
    • Cough 21.5
    • Rhinitis 12.8
    • Maculopapular rash 12.1
    • Myalgia/arthralgia 12.0
    • Enanthema 8.3
    • Abnormal reflex 6.7
    • Diarrhea 6.4
    • Palpable spleen 6.3
    • Coma 3.0
  • The following classifications are proposed : • Probable- an acute febrile illness with two or more of the following manifestations : – headache – retro-orbital pain – myalgia – arthralgia – rash – haemorrhagic manifestations – leukopenia – serology (+) or DF occurrence at the same location / time
  • Kriteria Diagnosis DBD (WHO 1997)
    • Demam, atau riwayat demam akut, antara 2-7 hari biasanya bifasik,
    • Trombositopenia (< 100.000/mm3)
    • Terdapat minimal satu dari manifestasi perdarahan berikut ini:
    • Uji tourniquet positif
    • Petekie, ekimosis, atau purpura
    • Perdarahan mukosa, saluran cerna, bekas suntikan atau di tempat lain
    • Hematemesis atau melena
    • Terdapat minimal satu dari tanda-tanda plasma leakage oleh karena peningkatan permeabilitas kapiler berikut:
    ۵ ۵ ۵ ۵ Hematokrit meningkat > 20% dibandingkan hematokrit rata-rata pada usia, jenis kelamin, dan populasi yang sama Hematokrit turun hingga > 20% dari hematokrit awal, setelah pemberian cairan Terdapat efusi pleura, asites , hiponatremia, hipoalbuminemia
  • Diagnosa Banding
    • I nfeksi bakteri
    • Infeksi virus
    • D emam tiroid
    • C ampak
    • I nfluenza
    • H epatitis
    • D emam chikungunya
    • L eptospirosis
    • M alaria.
    • S epsis
    • M eningitis meningokokus spinal.
    • Idiopathic Thrombocytopenic Purpura (ITP)  mirip DHF derajat II
  • Pola panas Demam Dengue Ruam primer Ruam sekunder I VI V VII VIII III II IV 36 o C 39 o C 40 o C 38 o C 37 o C
  •  
  •  
  • Warning Signs for Dengue Shock
    • When Patients Develop DSS:
    • 3 to 6 days after onset of symptoms
    • Initial Warning Signals:
    • Disappearance of fever
    • Drop in platelets
    • Increase in hematocrit
    • Alarm Signals:
    • Severe abdominal pain
    • Prolonged vomiting
    • Abrupt change from fever
    • to hypothermia
    • Change in level of
    • consciousness (irritability
    • or somnolence)
    • Four Criteria for DHF:
    • Fever
    • Hemorrhagic manifestations
    • Excessive capillary
    • permeability
    •  100,000/mm 3 platelets
  • Four Grades of DHF
    • Grade 1
      • Fever and nonspecific constitutional symptoms
      • Positive tourniquet test is only hemorrhagic manifestation
    • Grade 2
      • Grade 1 manifestations + spontaneous bleeding
    • Grade 3
      • Signs of circulatory failure (rapid/weak pulse, narrow pulse pressure, hypotension, cold/clammy skin)
    • Grade 4
      • Profound shock (undetectable pulse and BP)
  • Problem in Dengue Fever/Dengue Hemorrhagic Fever in Indonesia
    • High viral transmission
    • Economical impact :
    • Cost of treatment
    • Lost of productivity
    • Mortality especially in children about 2 %
    • Not effective prevention:
    • vector eradication
    • no effective vaccine
  • Incidence of Dengue Hemorrhagic Fever in Indonesia 1968-1996 Ministry of Health, Rep of Indonesia
  • Mortality of Dengue Hemorrhagic Fever in Indonesia 1968-1997 Ministry of Health, Rep of Indonesia
  • Pemeriksaan Penunjang
    • 1. Konfirmasi infeksi virus dengue diperoleh melalui isolasi virus dari darah atau ser um :
    • - IgM antibodi spesifik dengue dalam serum
    • - P eningkatan titer antigen spesifik dengue 4 x
    • - R everse transcriptase polymerase chain reaction
    • 2. Hemaglutinasi Inhibisi : G old S tandard p x. serologi.
    • 3. Mac Elisa
  • Treatment of Dengue Haemorrhagic Fever
    • Fluids
    • Rest
    • Antipyretics (avoid aspirin and non-steroidal anti-inflammatory drugs)
    • Monitor blood pressure, hematocrit, platelet count, level of consciousness
  • Suspek DBD (kriteria WHO 1997 ) Hb, Ht, Trombo N Hb, Ht normal Trombo < 100.00 0 Hb, Ht normal Trombo > 100.000 < 150.000 Hb, Ht meningkat Trombo normal atau turun Observasi Rawat jalan Periksa Hb, Ht Leko Tr/24 jam Rawat Rawat Observasi dan pemberian cairan suspek DBD dewasa tanpa renjatan di IGD Observasi Rawat jalan Periksa Hb Ht Leko Tr /24 jam
  • Suspek DBD Perdarahan Spontan dan Masif (-) Syok (-) - Hb,Ht (n) - Tromb. <100.000 - Infus Kristaloid * - Hb,Ht,Tromb. tiap 24 jam Hb,Ht meningkat > 20% Tromb.<100.000 Pemberian cairan pada suspek DBD dewasa di ruang rawat - Hb,Ht meningkat 10-20% - Tromb. <100.000 - Infus Kristaloid* - Hb,Ht,Tromb. tiap 12 jam ** Protokol pemberian Cairan DBD dengan Ht Meningkat > 20% * Volume cairan kristaloid per hari yang diperlukan: Sesuai rumus berikut 1500 + 20 x (berat badan dalam kg - 20) Contoh volume rumatan untuk berat badan 55 kg : 1500 + 20 x (55-20) = 2200 ml (Pan American Health Organization: Dengue and DengueHemorrhagic Fever: Guidelines for Prevention and Control . PAHO: Washington, D.C., 1994: 67). ** Pemantauan disesuaikan dengan fase/hari perjalanan penyakit dan kondisi klinis
  • Penatalaksanaan DBD dengan peningkatan Ht > 20% (1) 5% defisit cairan Terapi awal cairan intravena Kristaloid 6-7 ml/kg/jam PERBAIKAN Hematokrit dan frekuensi nadi turun, tekanan darah stabil, produksi urin meningkat TIDAK MEMBAIK Hematokrit, nadi meningkat Tekanan nadi menurun < 20 mm Hg Produksi urin menurun Kurangi infus kristaloid 5 ml/kg/jam TANDA VITAL DAN HEMATOKRIT MEMBURUK Infus kristaloid 10 ml/kg/jam PERBAIKAN PERBAIKAN TIDAK MEMBAIK Kurangi infus kristaloid 3 ml/kg/jam Infus kristaloid 15 ml/kg/jam PERBAIKAN KONDISI TIDAK STABIL Tanda renjatan Terapi cairan dihentikan 24 – 48 jam Tatalaksana sesuai Protokol Renjatan dan perdarahan PERBAIKAN Evaluasi 3-4 jam
  • Terapi cairan DBD dengan peningkatan Ht > 20% (2) Volume cairan per hari : Defisit cairan + kebutuhan cairan harian Defisit 5% berat badan = 5% x berat badan Kebutuhan cairan harian = 1500 + 20x (berat badan-20) Evaluasi tanda vital tiap jam Hematokrit tiap 4 jam Jumlah cairan disesuaikan dengan perbaikan klinis lihat protokol Contoh untuk berat badan 60 kg: Defisit 5% berat badan = 5%x60x1000ml = 3000 ml Kebutuhan harian = 1500+ 20 x 40 = 2300 ml Jumlah cairan = 5300/24 jam
  • KASUS DBD Perdarahan Spontan Masif (-) Syok (-) Hb,Ht (n)/ meningkat Tromb.>100-150.000 -RL 4 jam/kolf -Hb,Ht,Tromb. tiap 24 jam Hb,Ht (n)/ meningkat Tromb.<100.000 -RL 4 jam/kolf -Hb,Ht,Tromb. tiap 12 jam Hb,Ht,Tromb. (n) 24 jam stabil Hb,Ht meningkat Tromb.>100-150.000 -RL 4 jam/kolf -H,Ht,Tromb. 1 x 24 jam Klinis memburuk : TD turun , Nadi meningkat , Diuresis berkurang P rotokol DBD dengan syok Hb,Ht (n)/ meningkat Tromb.<100.000 -RL 4 jam/kolf - Hb,Ht,Tromb. 1x12 jam Pulang 24 jam Hb,Ht, Tromb.(n) Hemodinamik baik 24 jam stabil Pulang Catatan pulang : - Pasien tidak demam, hemodinamik baik - Bila keadaan pasien memburuk segera ke IGD - Kontrol poliklinik 2 x 24 jam kemudian (DPL) Penatalaksanaan Suspek DBD dewasa (tanpa syok dan perdarahan) di ruang rawat
  • Penatalaksanaan Perdarahan pada DBD dewasa KASUS DBD : Perdarahan S PONTAN dan MASIF : -Epistaksis tidak terkendali -Hematemesis melena/hematoskezia -Perdarahan otak Syok (-) -DPL,hemostase KID (+) -Transfusi komponen darah : * PRC (Hb<10g * FFP * T C (Tromb.<100.000 - Heparinisasi *Hb,Ht,Tromb. tiap 4-6 jam *Ulang hemostase 24 jam kemudian KID (-) -Transfusi komponen darah : *PRC (Hb<10g% ) *FFP *T C (Tromb.<100.000) *Hb,Ht, Tromb. tiap 4-6 jam *Ulang hemostase 24 jam kemudian
  • Penatalaksanaan Sindrom Renjatan Dengue
  • Kriteria Pemulangan pasien DBD
    • Tidak demam selama 24 jam tanpa antipiretik
    • Nafsu makan membaik
    • Klinis tampak perbaikan
    • Hematokrit stabil
    • Tiga hari setelah renjatan teratasi
    • Jumlah trombosit > 50.000
    • Tidak dijumpai distres pernafasan
  • KESIMPULAN
    • Indonesia merupakan negara tropis dengan risiko kemungkinan terjadinya DBD cukup tinggi
    • Menegakkan diagnosis serta penatalaksanaan Dengue tidaklah mudah
    • Penanganan pasien DBD melalui pedoman tatalaksana yang ada, di sarana pelayanan kesehatan
    • Pedoman ini perlu disosialisasikan ke semua petugas kesehatan, pemantauan, evaluasi implementasinya agar penanganan DBD dapat maksimal