MEDICAL THERAPY for DHF

Two days ago, a medical student came to Mbah Dukun. She asked about DHF. How to treat DHF?

there's no specific therapy for DHF, just support therapy.

DEFINITION

DHF or DENGUE HEMORRHAGIC FEVER is acute infection which caused by dengue virus with clinical manifestasions are fever, myalgia, athralgia  be accompanied by leukopenia, rash, lymphodenopathy, thrombocytopenia and diatesis haemorrhagic, also haemoconcentration (increasing hematocryt). in Indonesia it called "DEMAM BERDARAH"

ETIOLOGY

What is cause of DHF?

DHF is caused by virus included in Genus Flavivirus, family Flaviviridae. There are 4 serotypes virus, DEN-1, DEN-2, DEN-3, and DEN-4, which all of them can cause Dengue Fever and DHF. In Indonesia, DEN-3 is more commonly found. 

THERAPY

 I. FIRST STEP

when your patient come. you have to diagnostic this patient by anamnestic. You can use heteroanamnestic or autoanamnestic.

Dengue Fever is acute fever between 2-7 days and be accompanied with two or more clinical manifestations:

* Headache

* Retro-orbital pain

* Myalgia/athralgia

* Rash

* bleeding manifestations (petechie or positif tourniquet test)

* Leukopenia

Dengue Haemorrhagic Fever by WHO criteria 1997

* acute Fever between 2-7 days, biphasic

* minimal there is one of bleeding manifestations, following:

   1. Positive tourniquet test

   2. Petechie, echimosis, or purpura

   3. Mucous Bleeding (epistaxis, gumm bleeding or another site)

   4. Hematemesis and melena

* Thrombocytopenia < 100.000/

* There is minimal one of sign of plasma leakage, following:

   1. Increasing hematocryt >20%, compared by age and sex

   2. Decreasing Hematocryt >20%, after get rehydration and compared by hematocryt before rehydration

   3. Pleura Effusion, ascites or hypoproteinemia.

DSS (Dengue Shock Syndrome) : 

all criteria WHO be accompanied failed of circulation with manifestations are: pulse weak and rapidly, tension drop (<20 mmHg), hypotension by age standard, cold, and anxious.

II SECOND STEP

Classified this patient

a. Dengue Fever    : fever 2-7 days with 2 or more signs : headache, retro-orbital pain, myalgia, athralgia,  Leukopenia, thrombocytopenia but no plasma leakage.

b. DHF grade I     :   fever 2-7 days with 2 or more signs : headache, retro-orbital pain, myalgia, athralgia,  Leukopenia, thrombocytopenia < 100.000, positive tourniquet test and plasma leakage.

c. DHF grade II    :  fever 2-7 days with 2 or more signs : headache, retro-orbital pain, myalgia, athralgia,  Leukopenia, thrombocytopenia < 100.000, positive tourniquet test, plasma leakage, spontaneous bleeding.

d. DHF grade III  :    Fever 2-7 days with 2 or more signs : headache, retro-orbital pain, myalgia, athralgia,  Leukopenia, thrombocytopenia < 100.000, positive tourniquet test, plasma leakage, spontaneous bleeding.failed circulation, cold and anxiety

e. DHF grade IV :     Fever 2-7 days with 2 or more signs : headache, retro-orbital pain, myalgia, athralgia, Leukopenia, thrombocytopenia < 100.000, positive tourniquet test, plasma leakage, spontaneous bleeding.failed circulation, cold and anxiety, tension and pulse can't measured.

III THIRD STEP

1. Protocol 1

Treatment suspect DHF without shock for adult

someone who is suffering from DHF suspected in the emergency room, examination of Hb, HCT and platelets, if:
a. Hb, HCT, and platelets, normal or decreased between 100.000-150.000, patients can be discharged with the recommendation or outpatient controls within the next 24 hours (examination of Hb, HCT, and platelets) or when the patient's condition deteriorated quickly returned to the emergency room.
b. Hb, HCT normal but platelets <100,000 recommended for hospitalized
c. Hb, HCT and platelets increased to normal or down is also recommended for hospitalized

Rehydration

give crystaloid (ringer lactat or NaCL 0.9%) use formula 

1500 + (20 x (weight kg - 20))

example: patient's weight 60 kg --> 1500 + (20 x (60-20)) = 2300 ml/day

if 1 flash RL contain 500 cc so need 4-5 flashes per day,

so 4-5 flashes for 24 hours, 1 flashes need 4-5 hours, ok, assumptions 4 hours, so 500 cc need 4 hours. 1 hour for 125 cc, one minute 125 cc/60 minute ---> 20 cc/minute
if use macro infus set (1cc= 20 drops/minute),so for this case 40 drops/minute
if use micro infus set (1cc=60 drops/minute), so for this casa 120 drops/minute

After rehydration check Hb, Hct and trombocyt every 24 hours

* if  Hct increases10-20% and trombocyt < 100.000, continue protocol 1 but monitor Hb, Hct and thrombocyt every 12 hours.

* if Hb, Hct increasing >20% and trombocyt < 100.000,change protocol to protocol for Hct increases > 20%.

2. Protocol 2

For Hct increases > 20%

Increased HCT> 20% indicates that the body fluid deficit of 5%. in these circumstances, early therapy is to give intravenous crystalloid 6-7 cc / kg / hour. then patients are monitored after 3-4 hours of initial rehydration. if there is a marked improvement with a decrease in HCT. pulse frequency decreased, stable blood pressure, urine production increases the amount of fluid infusion reduced be 5 cc / kg / hour. 2 hours later be back and when the condition monitoring equipment showed improvement infusion reduced the number of an advanced 3 cc / kg / hour. if still better then the fluid can be stopped 24-48 hours later.
If after the initial rehydration 6-7/kg/jam earlier, the condition still does not improve, which is marked with HCT and the pulse increased, decreased blood pressure <20 mmHg, urine production declines, then the amount of fluid infusion was increased to 10 cc / kg / hour. 2 hours later, the monitor again and if conditions indicate improvementt then the amount of liquid is reduced to 5 cc / kg / h but if things do not show improvement, the amount of fluid infusion was increased to 15 cc / kg / hour and if the development of the patient's condition worsened and obtained marks shock the patient treated according to protocol treatment of dengue shock syndrome.

4. Protocol 4.

Treatment for DHF with spontaneous Bleeding

spontaneous and massive bleeding in patients with DHF are: uncontrolled epistaxis despite being given a tampon nose, gastrointestinal bleeding (hematemesis and melena or hematochezia), hematuria, brain hemorrhage or bleeding hidden by the amount of bleeding as much as 4-5 ml / kg / hour. in conditions just as this amount and speed of rehydration remain as DHF without shock. Monitor blood pressure, pulse, hb, HCT, urine production, and platelet counts should be repeated every 4-6 hours.
Giving heparin if the clinical and laboratory signs of DIC obtained. transfusion of blood components is given as indicated. FFP given if found deficient clotting factor (prolonged PT and aPTT), PRC is given if the value of Hb <10 g / dl. Platelet transfusions are given only in DHF patients with spontaneous bleeding and massive with amount platelet <100,000 with or without DIC

5. Protocol 5

For DSS 

first give oxygen 2-4 l / min, and then treat shock with rehydration using crystalloid fluids. Do not forget to complete peripheral blood examination, hemostasis, blood gas analyse, electrolytes (Na, K, Cl), Also urea and creatinine.
in the initial phase, give rapidly with crystalloid fluids as much as 10-20 ml / kg and evaluated after 15-30 minutes. if the shock has been resolved which marked with systolic blood pressure 100 mm Hg and pulse pressure over 20 mmHg, pulse frequency of less than 100 x / min with enough volume, warm extremities, and skin is not pale and diuresis from 0.5 to 1 cc / kg / hours. If within 60-120 minutes, the condition remains stable, then the liquid was reduced to 3 ml / kg / hour. if within 24-48 hours after the shock is resolved, and HCT stable vital signs, diuresis enough, then rehydration should stop.
if after the initial phase of rehydration was shock is not resolved, then rehydration crystalloids can be increased to be 20-30 ml / kg, then evaluated after 20-30 minutes. If the situation remains unsolved, then note the value of HCT. if HCT increased mean plasma leakage is still ongoing, so giving a colloidal fluid of choice, but if the HCT value declines, it means there is internal bleeding, then Whole Blood transfusion given 10 ml / kg and can be repeated as needed.
Before the liquid colloid is given, should have known the properties of these fluids. Providing early, rapid drop of 10-20 ml / kg and evaluated after 10-30 minutes. if the condition is still not resolved, then to monitor the adequacy of fluid made central vein catheter installation (PVC), and the provision of colloid can be added up to a maximum of 30 ml / kg with a target of 15-18 cmH2O PVC. If the situation remains unsolved, must be considered and made corrections to the acid-base disorders, electrolyte, hypoglycemia, anemia, DIC, secondary infection. If PVC is on target but the shock is not resolved then it can be given inotropic drugs / vasopressin