Demam Berdarah Dengue
•Download as PPTX, PDF•
2 likes•6,899 views
This document discusses dengue fever, its diagnosis and treatment. It begins with an overview that dengue fever remains a serious infectious disease problem in Indonesia. It then covers the virus classification, pathogenesis theories, risk factors, signs and symptoms, WHO diagnostic criteria, treatment protocols, and epidemiological data on cases and mortality in Indonesia from 1968-1996.
More Related Content
What's hot
What's hot (20)
Viewers also liked
Similar to Demam Berdarah Dengue
Similar to Demam Berdarah Dengue (20)
Recently uploaded
Recently uploaded (20)
Demam Berdarah Dengue
- 1. Demam Berdarah Dengue Diagnosa dan Penatalaksanaan KURNIA F. JAMIL Sub-Bagian Penyakit Tropik & Infeksi, Bagian Ilmu Penyakit Dalam FK-UNSYIAH/RSUZA BANDA ACEH 2007
- 2. 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
- 3. Pendahuluan Virus dengue termasuk genus Flavivirus dari family Flaviviridae Ada 4 serotipe: Den 1- 4 Patogenesis masih kontroversi Penelitian masih diperlukan
- 4. 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
- 5. 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
- 6. Patogenesis DBD Teori virulensi virus Teori infection enhancing antibody
- 7. Viral Risk Factors for DBD Pathogenesis Virus strain (genotype) – Epidemic potential: viremia level, infectivity Virus serotype – DBD risk is greatest for DEN-3, followed by DEN-2, DEN-1 and DEN-4
- 8. 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
- 9. 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
- 10. 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
- 11. Non-neutralizing antibody to Dengue 1 virus Dengue 2 virus Heterologous Antibodies Form Infectious Complexes Complex formed by non-neutralizing antibody and virus
- 12. 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
- 13. Heterologous Complexes Enter More Monocytes, Where Virus Replicates Non-neutralizing antibody Dengue 2 virus Complex formed by non-neutralizing antibody and Dengue 2 virus
- 14. 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
- 16. Replikasi 2 – 3 hari Sirkulasi & Jaringan Infeksi : Macrofag Monosit Limfosit ANTIBODI
- 20. Kompleks Imun
- 22. 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
- 23. 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
- 24. 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
- 25. 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: 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
- 26. I VIV VII VIIIIIIII IV 36 oC 39 oC 40 oC 38 oC 37 oC Pola panas Demam Dengue Ruam primer Ruam sekunder
- 29. 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/mm3 platelets
- 30. CENTERS FOR DISEASE CONTROL AND PREVENTION 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)
- 31. CENTERS FOR DISEASE CONTROL AND PREVENTION 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
- 32. CENTERS FOR DISEASE CONTROL AND PREVENTION years 1996 1994 1992 1990 1988 1986 1984 1982 1980 1978 1976 1974 1972 1970 1968 70000 60000 50000 40000 30000 20000 10000 0 Incidence of Dengue Hemorrhagic Fever in Indonesia 1968-1996 Ministry of Health, Rep of Indonesia
- 33. CENTERS FOR DISEASE CONTROL AND PREVENTION years 1996 1994 1992 1990 1988 1986 1984 1982 1980 1978 1976 1974 1972 1970 1968 50 40 30 20 10 0 Mortality of Dengue Hemorrhagic Fever in Indonesia 1968-1997 Ministry of Health, Rep of Indonesia
- 34. 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
- 35. Tatalaksana DBD pada Dewasa Protokol 1 Penanganan Tersangka ( Probable ) DD/DBD dewasa tanpa syok Protokol 2 Pemberian cairan pada tersangka DBD dewasa di ruang rawat Protokol 3 Penatalaksanaan DBD dengan peningkatan Ht > 20 % Protokol 4 Penatalaksanaan Perdarahan Spontan pada DBD dewasa Protokol 5 Tatalaksana sindroma syok Dengue pada dewasa
- 36. Keluhan DBD (Kriteria WHO 1997) Hb, Ht Normal Tromb > 100.000/mm³ Observasi Rawat jalan Periksa Hb, Ht dan leuko, tromb/ 24 jam Hb, Ht normal Trombo < 100.000 Hb, Ht meningkat Trombo N / turun Protokol 1. Penanganan Tersangka ( Probable ) DD / DBD Dewasa tanpa syok Rawat Inap ( Protokol 2 )
- 37. Protokol 2. Pemberian cairan pada tersangka DBD dewasa di ruang rawat Suspek DBD Perdarahan Spontan dan Masif (-) Syok (-) Hb,Ht (n) Tromb. <100.000 Hb,Ht 10-20% Tromb. <100.000 Hb,Ht > 20% Tromb.<100.00 0 ◘Infus Kristaloid ◘Hb,Ht,Tromb. tiap 24 jam Infus Kristaloid Hb,Ht,Tromb. tiap 12 jam Protokol 3
- 38. Volume cairan kristaloid per hari yang diperlukan : 1500 + 20 X ( BB dalam kg – 20 ) Contoh : BB 50 kg : 1500 + 20 X ( 50 – 20) = 1500 + (20 x 30) = 1500 + 600 = 2100 ml (Pan American Health Organization: Dengue and Dengue Hemorrhagic Fever: Guidelines for Prevention and Control. PAHO: Washington,D.C,1994:67). Awasi kadar elektrolit darah jika memungkinkan.
- 39. Protokol 3. Penatalaksanaan DBD dengan peningkatan Ht > 20 % 5 % defisit cairan Kristaloid 6 – 7 ml/kg/jam PERBAIKAN TIDAK MEMBAIK Kristaloid 5 ml/kg/jam Kristaloid 10 ml/kg/jam TIDAK MEMBAIK Kristaloid 15 ml/kg/jam MEMBURUK SYOK PROTOKOL 4 / 5 PERBAIKAN Kristaloid 3 ml/kg/jam PERBAIKAN STOP CAIRAN PERBAIKAN PERBAIKAN 3-4 jam 2 jam 3 jam 24-48 jam
- 40. Protokol 4. Penatalaksanaan Perdarahan Spontan pada DBD dewasa KASUS DBD : Perdarahan Spontan dan Masif : - Epistaksis tidak terkendali - Hematemesis melena - Perdarahan otakSyok (-) Hb, Ht, Trombo, Leuko, Pemeriksaan Hemostasis (KID) Golongan darah, uji cocok serasi Transfusi komponen darah : * PRC (Hb<10 g %) * FFP (APTT > 1,5 X normal ) * TC (Tromb.<100.000) * Pemantauan Hb, Ht, Tromb. Tiap 4-6 jam * Ulang pemeriksaan hemostasis 24 jam kemudian KID +: HEPARINISASI 5000 – 10.000 / 24J
- 41. Protokol 5. Tatalaksana Syok pasien Dewasa AIRWAY BRAETHING : O2 1 – 4 l/menit CIRCULATION : 10 – 20 ml/kgBB 20 – 30 MENITPERBAIKAN TETAP SYOK Kristaloid 20-30 ml/kgBB 20-30 menit TETAP SYOK Ht k Koloid 10-20 ml/kg/BB tetes cepat 10-15 menit Transfusi PRC 10 ml/kgBB Ht k TETAP SYOK Koloid hingga maksimal 30 ml/kgBB TETAP SYOK Pasang CVP Hipovolemik Normovolemik KRISTALOID TETAP SYOK Inotropik , Vasoaktif Koreksi : As/Bs, Electr,Glikemia, Anemia, KID, Infeksi Sekunder PERBURUKAN
- 42. AIRWAY BREATHING : O2 1 – 4 l/menit CIRCULATION : 10 – 20 ml/kgBB Protokol 5. Tatalaksana Syok pasien Dewasa 20 – 30 MNT PERBAIKAN Kristaloid 7 ml/kg/jam dalam 1 jam PERBAIKAN Kristaloid 5 ml/kg/jam dalam 1 jam PERBAIKAN Kristaloid 3 ml/kg/jam dalam 1 jam STABIL 24 – 48 JAM PERBURUKAN TETAP SYOK
- 43. Protokol pemberian zat inotropik / zat vasoaktif Dopamin 5 mg/kg/mnt dititrasikan sampai 10 mg/kg/mnt Sasaran : MAP > 60 mmHg. Gagal Dobutamin 5 mg/kg/mnt + Norepinefrin 0,05 – 0,1 mg/kg/mnt 10 mg/kg/mnt 1 mg/kg/mnt Epinefrin 0,1 mg/kg/mnt Dititrasikan setiap 0,1 mg/kg/mnt Max 2 mg/kg/mnt GAGAL ?
- 44. Indikasi masuk ICU : Syok yang tidak dapat teratasi maksimal 2 jam Syok berulang Syok dengan perdarahan hebat Syok dengan penyulit seperti : kegagalan pernafasan, ensefalopati, gagal jantung, dll.
- 45. Penatalaksanaan Sindrom Renjatan Dengue
- 46. Kriteria Pemulangan pasien DBD 1. Tidak demam selama 24 jam tanpa antipiretik 2. Nafsu makan membaik 3. Klinis tampak perbaikan 4. Hematokrit stabil 5. Tiga hari setelah renjatan teratasi 6. Jumlah trombosit > 50.000 7. Tidak dijumpai distres pernafasan
- 47. 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
- 48. THANK YOU