Curriculum Vitae

Nama : Dr. Ronald Irwanto Natadidjaja, SpPD – KPTI, FINASIM

Pendidikan :

SMP - SMA : Kolese KANISIUS, Jakarta 1994

Dokter Umum : FK TRISAKTI, 2002
Spesialis Penyakit Dalam (Internist) : FKUI, 2009
Konsultan / Subspesialis Penyakit Tropik & Infeksi : FKUI / PAPDI, 2013

Pekerjaan :
Bendahara Pengurus Besar Perhimpunan Konsultan Penyakit Tropik dan
Infeksi Indonesia (PB PETRI)

Tim Panel Ahli Pembuatan PNPK / Guidelines Sepsis Kemenkes

Kepala Bagian Ilmu Penyakit Dalam, FK TRISAKTI

Ketua Panitia Pengawas Resistensi Antibiotika (PPRA), RS PONDOK

INDAH – PURI INDAH

Internist Konsultan, RS PONDOK INDAH – PURI INDAH

 Predicting Dengue Shock Syndrome :
WHO Guidelines 1997 vs 2009

Ronald Irwanto
Infectious Disease (ID) Consultant
Division of Tropical Medicine & Infectious Disease
Department of Internal Medicine
Faculty of Medicine, Trisakti University
 How To Predict the DSS?

We Only Can Use the High Sensitivity

Diagnostic Criteria for Patient Safety
Which is the BEST Diagnostic Criteria?
WHO 2997 or WHO 2009 ?
 Global Impact of Dengue
2.5 billion people (2/5ths of world population) are at
risk for dengue

50 million to 100 million dengue cases worldwide

every year (WHO)

500,000 cases require hospitalization (90% are

pediatric cases)

25,000 fatalities annually

Ron Rosenberg, CDC Forth Collin, 2008

ID-CONSULTANT
Dengue Receptors and Cells Apoptosis
Dendritic Langerhans Cells

Lymphocytes and Monocytes Leucopenia

Hepatocytes Transaminase
elevation
MAIN
Endothelium BATTLEFIELD : NAÏVE RECEPTORS :
Plasma Leakge DC SIGN
VasculopathyDIC
POST INFECTION
Bone Marrow?? Trombocytopenia
RECEPTORS :
Leukopenia
FcR

ID-CONSULTANT
 Macromolecules Can Cross The Endothelial
Barrier in Three Ways:
1.Between the cells, through cell junctions
(paracellular)
2.Through the EC, via pores (diaphragms or
fused vesicles)
3.Transcellularly, via shuttling vesicles
(transcytosis) and specific receptors
ID-CONSULTANT
(transcellular).
 Pathogenesis in DENGUE

Decreasing of
LEUCOPENIA BLEEDING
Platelets
Endothelium
Apoptosis
Adhesion and
Aggregation
Vasculopathy
Platelets adhesion and
aggregation
Primary hemostasis
APOPTOSIS
Secondary hemostasis
Antibody
AntiPlatelets
Coagulopathy
ID-CONSULTANT
 Dengue
Guidelines

WHO, 1997 WHO, 2009 WHO, 2011

ID-CONSULTANT
Criteria of DHF Clinical Diagnosis (WHO 1997)

Fever: acute onset, high and continuous, lasting 2 to 7 days.

Any of the following hemorrhagic manifestations (including at
least a positive tourniquet test: petechiae, purpura, echymosis,
epistaxis, gum bleeding, and hematemesis and/or melena).
Thrombocytopenia (100,000/mm3 or less)
Any of the following signs of plasma leakage:
– Increment of > 20% hematocrit compared to standard
age and sex
– Decrement of > 20% hematocrit after fluid therapy,
compared to previous hematocrit level
– Pleural effusion, ascites, Pericardial effusion or
hypoprotreinemia
ID-CONSULTANT
 KONAS PETRI-ACEH.2012

Diagnostic Criteria 2009

2009

Dengue guidelines for diagnosis, treatment, prevention, and control. World Health Organization,
ID-CONSULTANT UNICEF, UNDP. New Edition 2009.
 Diagnosis Classification
1997 2009 2011
Dengue fever Dengue without warning Dengue fever
signs
DHF grade I Dengue with warning signs DHF grade I

DHF grade II DHF grade II

DHF grade III Severe dengue DHF grade III
( severe plasma leakage,
severe hemorrhage, severe
organ involvement)

DHF grade IV DHF grade IV

High Specificity Low Specificity nExpanded dengue
Low Sensitivity High Sensitivity syndrome
Adult management Adult management
ID-CONSULTANT High Specificity
Low Sensitivity
 Dengue Diagnostic :
Accuracy vs Awareness
WHO 2009
Low Mortality
High Cost
ACCURACY AWARENESS
High
Mortality
Low Cost ???
WHO 1997/2011 Pressed by Hospitalization
Criteria :
Group A, B and C
ID-CONSULTANT WHO Guidelines,2009
 Days of Dengue
2009

Dengue guidelines for diagnosis, treatment, prevention, and control. World Health Organization, UNICEF,
ID-CONSULTANT UNDP. New Edition 2009.
 KONAS PETRI-ACEH.2012

Group A
Patients who may be sent home
Able to tolerate adequate volumes of oral
fluids
Pass urine at least once every six hours
Do not have any of the warning signs,
particularly when fever subsides.

Dengue guidelines for diagnosis, treatment, prevention, and control. World Health Organization,
UNICEF, UNDP. New Edition 2009.
ID-CONSULTANT
 Group B
Should be referred for in-hospital
management
– patients with warning signs
– co-existing conditions that may make dengue or
its management more complicated (such as
pregnancy, infancy, old age, obesity, diabetes
mellitus, renal failure, chronic haemolytic
diseases)
– certain social circumstances (living alone, or living
far from a health facility without reliable means of
Dengue guidelines for diagnosis, treatment, prevention,
transport) and control. World Health Organization, UNICEF, UNDP.
New Edition 2009.
ID-CONSULTANT
 KONAS PETRI-ACEH.2012

Group C
Require emergency treatment and urgent
referral when they have severe dengue
– severe plasma leakage leading to dengue
shock and/or fluid accumulation with
respiratory distress;
– severe haemorrhages;
– severe organ impairment (hepatic damage,
renal impairment, cardiomyopathy,
encephalopathy or encephalitis).
Dengue guidelines for diagnosis, treatment, prevention, and control. World Health Organization,
UNICEF, UNDP. New Edition 2009.
ID-CONSULTANT
 Immunity Response
Onset of
symptoms
NS1 Ag Antibody
Bite
DA
-7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12
Y
ACUTE PHASE
CONVALESENCE PHASE
Ag/Ab level

IgG
IgM
NS1 Ag

ID-CONSULTANT
 Immunity Response Against DHF
Concentration

Early symptoms IgG Early symptoms IgG cut off

HAI 1:2500

Virus IgM Virus IgM IgM cut off

Infection 1 Infection 2 ID-CONSULTANT

Days
 WHO Guidelines 2009
ID-CONSULTANT
 Arterial Catheter
As soon as
practical

ID-CONSULTANT WHO Guidelines 2009

 Treatment Recommendation in DSS
Therapy Recommendation
Not studied in trials. Intravenous bolus of 10–20 ml/kg
Ideal dose of fluids
recommended by WHO guidelines[1]
No difference between colloids and crystalloids.[49–51] No evidence
Type of fluid
from adult studies.
No clear evidence from trials. Required in the presence of
Platelet transfusion
hemorrhage. Effect of plt transfusion short-lived in shock.[52]
No clear evidence of benefit.[56–63] Most trials underpowered, poor
Corticosteroids
methodological quality; not studied in adults.
IV immunoglobulins No evidence of benefit in published literature.
No evidence from clinical trials. Empiric use of vasopressors
Inotropes and
(dopamine, noradrenaline) in shock, with addition of inotropic
vasopressors
agents (dobutamine) if myocardial depression present.

Carbazochrome sodium
No evidence of benefit. Single trial, underpowered.[78]
sulfonate (AC-17)

1. World Health Organization; 1997. Dengue haemorrhagic fever: diagnosis, treatment, prevention and control.
49. Dung NM, et al. A randomized, double-blind comparison of four intravenous-fluid regimens. Clin Infect Dis. 1999;29:787–94.
50. Ngo NT, et al. A randomized double-blind comparison of 4 i.v. fluid regimens in the first hour. Clin Infect Dis. 2001;32:204–13.
51. Wills BA, et al. Comparison of three fluid solutions for resuscitation in dengue shock syndrome. N Engl J Med. 2005;353:877–89. .
 Conclusions
Endothelium is the main “battle field” in dengue
WHO 2009 criteria has higher awareness than
others
Clinical impression is the major point in
diagnostic criteria
Laboratory diagnostic done for confirming
diagnostic in dengue, according to days of
illness
Coloid is recommended for DSS
DSS has a Bad Prognosis
ID-CONSULTANT
THANK YOU