THE DENGUE GUIDELINES1997. 2009. 2011

How They Different

Pembimbing : Prof. W.H.Sibuea, Sp.PD

Dengue Guidelines

199720092011Guideline for treatment of DF and DHF in small hospitalsGuidelines for diagnosis, treatment, prevention, and control Comprehensive guideline for prevention and control of Dengue and DHF Pages : 33160212Clinical Manifestation, Diagnosis, Case ManagementChapter : 6Epidemiology and burden of disease, clinical management, vector management, lab diagnostic tests, surveillance and emergency response, new avenues Chapter : 15Epidemiology, disease burden, clinical manifestation and diagnosis, lab diagnosis, management, surveillance, vector, vector management, IVM, COMBI, PHC approach, case investigation, monitoring, strategic plan for prevention and control dengue in Asia Pasific

Secondary Heterologous Infection

Antibody dependent enhancement

PATOGENESIS

Proposed model for the pathogenesis of DF, DHF, and DSS, based on an integrated view of the data presented (see section The Integrated View in the text). Martina B E E et al. Clin. Microbiol. Rev. 2009;22:564-581

Proposed model for the pathogenesis of DF, DHF, and DSS, based on an integrated view of the data presented (see section The Integrated View in the text). Black arrows, processes leading to the indicated event; colored boxes with white centers, pathological events. Each event will ultimately affect the EC or the hemostatic system (purple arrows).

PATOGENESIS

Association of Leukocyte and Thrombocyte Counts as aPredictor of Bleeding Outcomes among Dengue Patients Gener D. Rubio Jr., M.D. and Larissa Lara Torno, M.D. San Pedro Hospital, Davao CityLeukopenia in dengue patients may be caused by virus-induced destruction or inhibition of myeloid progenitor cells. While thrombocytopenia may result from destruction of peripheral platelet or bone marrow megakaryocytes by viruses which consequently reduce the platelet production.With the severity of thrombocytopenia and acut off value of < 4,000 mm3 leukocyte count as a predictor of bleeding, physicians can wisely utilize these values and be a guide on when to order serial leukocyte and platelet count monitoring especially to unfortunate patients who are financially incapable.

Philippine Journal of Microbiology and Infectious DiseasesVol. 36 Nos. 1 & 2, January-June 2007

Diagnosis Classification

199720092011Dengue feverDengue without warning signsDengue fever

DHF grade IDengue with warning signsDHF grade I

DHF grade IIDHF grade II

DHF grade IIISevere dengue (for management it is divided into two : severe dengue with compensated shock and severe dengue with hypotensive shock)DHF grade III

DHF grade IVDHF grade IV

* Expanded dengue syndrome

1997 CLASSIFICATION

Probable an acute febrile illness with two or more of the following manifestation :HeadacheRetro orbital painMyalgiaAthralgiaRashHaemorrhagic manifestationsHepatomegaliLeukopeni

andSupportive serology (Ig G and Ig M antibody)

WHO Dengue Classification

DFDHF1. Fever 2-7 days++2. Bleeding TendencyPositive tourniquet test orSpontaneous bleeding+/-+3. Thrombocytopenia 100.000/mm3+/-+4. Plasma leakage Pleural effusion/ ascites/ hypoproteinaemia 20% increase in Hematocrit -+

GradeDFWithout plasma leakageDHFIFever with non specific constitutional symptoms; the only hemorrhagic manifestation is a positive tourniquet testThrombocytopenia ( platelet count

2009 CLASSIFICATION

Dengue case classification by severityDengue +/- warning signSevere dengue

Criteria for dengue warning signs Criteria for severe denguewithout1.Severe plasma leakage2.Severe haemorrhage3.Severe organ impairmentWith warning signs

Probable dengueLive in/travel to dengueendemic area. Fever and 2 ofthe following criteria: Nausea, vomiting Rash Aches and pains Tourniquet test positive Leucopenia Any warning signLaboratory confirmeddengue(important when no sign ofplasma leakage)Warning signs* Abdominal pain ortenderness Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy; restlessness Liver enlargement >2cm Laboratory: Increase in HCTconcurrent with rapiddecrease in platelet count* Requiring strict observationand medical intervention1. Severe plasma leakage leading to: Shock (DSS) Fluid accumulation withrespiratory distress2. Severe bleedingas evaluated by clinician3. Severe organ involvement Liver: AST or ALT>=1000 CNS: Impaired consciousness Heart and other organs

2011 CLASSIFICATION

Manifestations of dengue virus infectionDengue virus infection

Asymptomatik Symptomatik

Undifferentiated Dengue Fever Dengue Haemorrheagic Expanded Dengue syndrome fever fever (DHF)Isolated Organopathy (viral syndrome) (with plasma leakage)(Unsual manifestation)

Without with unsual DHFDHF with shockHaemorrhage Haemorrhage Non shockDengue ShockSyndrome (DSS)

WHO classification of dengue infections and grading of severity of DHF

DF/ DHFGradeSigns and SymptomsLaboratoryDFFever with two of the following: Headache. Retro-orbital pain. Myalgia. Arthtralgia/bone pain. Rash. Haemorrhagic manifestations. No evidence of plasmaleakage. Leucopenia (wbc 5000cells/mm3). Thrombocytopenia (PlateletCount

Laboratory Diagnosis

Laboratory Diagnosis

Fluid Management

199720092011DHF Grade I-IIDengue with warning signsDHF grade I-II6-7ml/kg/hour 5ml/kg/hour 3ml/kg/hour Monitor/6 hourStop after 24-48 hourIsotonic solution such as 0,9% saline, Ringers Lactate, or Hartman solution. Start with 5-7ml/kg/hour for 1-2 hours, then reduce to 3-5ml/kg/hour for 2-4 hours, and then reduce to 2-3ml/kg/hour or less according to the clinical response.Maintenance (for one day) + 5% deficit (oral and IV fluid together), to be administered over 48 hours

197720092011DSSSevere Dengue Compensated ShockDHF grade III10-20 ml/kgBB bolus, repeat if necessaryIsotonic crystalloid solutions at 5-10 ml/kg/hour 0ver one hour. reassess10ml/kg in children or 300-500 ml in adults over one hour by bolus, if necessary further, fluid administration should follow the graph

20092011Severe dengue hypotensive shockDHF grade IVInitiate intravenous fluid resuscitation with crystalloid or coloid solution ( if available) at 20ml/kg as a bolus given over 15 minutes to bring the patient out of shock as quickly as possible.10ml/kg of bolus fluid should be given as fast as possible, ideally within 10 to 15 minutes. When the blood pressure is restored, further intravenous fluid may be given as in grade 3. if shock is not reversible after the first 10ml/kg, a repeat bolus of 10ml/kg and laboratory results should be persued and corrected as soon as possible.

Tranfusion in Severe Bleeding

20092011Give 5-10 ml/kg of fresh PRC or 10-20 ml/kg of fresh Whole blood at an appropriate rate and observe the clinical response10ml/kg of fresh whole blood or 5ml/kg of freshly PRC reassess, repeat if necessary

Discharge criteria

Criteria199720092011Absence of fever24 hours without the use of anti fever therapy48 hours24 hours without the use of anti fever therapyClinical improvement++ (general well-being, appetite, hemodynamic status, urine output, no respiratory distress) +Return of appetite+-+Good urine output+-+Stable Hematocrit++ (without Intravenous fluid)+Elapse from shock recoveryAt least 2 days-At least 2-3 days

No respiratory distress+-+Platelet count> 50.000/lIncreasing trend> 50.000/l

High-Risk Patients (2011)Infants and the elderlyObesityPregnant womenPeptic ulcer diseaseWomen who have abnormal vaginal bleeding or menstruationHaemolytic disease such as (G6PD) deficiencyThalassemia and other HaemoglobinopathiesCongenital heart diseaseChronic diseases such as DM, hypertension, asthma, ischaemic heart diseaseChronic renal failure, liver cirrhosisPatients on steroid or NSAID treatment

Proposed model for the pathogenesis of DF, DHF, and DSS, based on an integrated view of the data presented (see section The Integrated View in the text). Black arrows, processes leading to the indicated event; colored boxes with white centers, pathological events. Each event will ultimately affect the EC or the hemostatic system (purple arrows).