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Senin, 30 Mei 2011


Dengue Haemorrhagic Fever (DHF)

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".
Dengue hemorrhagic fever (DHF) is a specific syndrome that tends to affect children under 10 years of age. It causes abdominal pain, hemorrhage (bleeding), and circulatory collapse (shock). DHF is also called Philippine, Thai, or Southeast Asian hemorrhagic fever and dengue shock syndrome.
DHF starts abruptly with high continuous fever and headache. There are respiratory and intestinal symptoms with sore throat, cough, nausea, vomiting, and abdominal pain. Shock occurs two to six days after the start of symptoms with sudden collapse, cool, clammy extremities (the trunk is often warm), weak pulse, and blueness around the mouth (circumoral cyanosis).
In DHF, there is bleeding with easy bruising, blood spots in the skin (petechiae), spitting up blood (hematemesis), blood in the stool (melena), bleeding gums, and nosebleeds (epistaxis). Pneumonia is common, and inflammation of the heart (myocarditis) may be present.
Patients with DHF must be monitored closely for the first few days since shock may occur or recur precipitously (dengue shock syndrome). Cyanotic (bluish) patients are given oxygen. Vascular collapse (shock) requires immediate fluid replacement. Blood transfusions may be needed to control bleeding.
The mortality (death) rate with DHF is significant. It ranges from 6%-30%. Most deaths occur in children. Infants under a year of age are especially at risk of dying from DHF.

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.
There are four Dengue viruses (DENV) that cause Dengue fever, all of which are spread by a species of mosquito known as the Aedes aegypti mosquito, and more rarely by the Aedes albopictus mosquito. Aedes aegypti originated in Africa, but nowadays is found in all the tropical areas around the world and prospers in and close to areas of human population.
The high risk regions for catching dengue fever are Central America, South America, the Caribbean and tropical Asia; more specifically - northern Argentina, northern Australia, the entirety of Bangladesh, Barbados, Bolivia, Brazil, Cambodia, Costa Rica, Dominican Republic, Guatemala, Guyana, Honduras, India, Indonesia, Jamaica, Laos, Malaysia, Mexico, Micronesia, Pakistan, Panama, Paraguay, Philippines, Puerto Rico, Samoa, Singapore, Sri Lanka, Suriname, Taiwan, Thailand, Trinidad, Venezuela and Vietnam, and increasingly in southern China.
The virus is transmitted from an infected mosquito to human. The process begins when a person who is infected with the Dengue virus is bitten by a mosquito, the virus is then passed on when someone else is then bitten by the infected mosquito.
If you have suffered from dengue fever previously it is still possible to contract it again, because of the number of different types of viruses that cause the fever. If you were infected again and became ill, there is a greater risk of developing a harsher form of the disease, such as dengue hemorrhagic fever (particularly in children). This is unusual because, normally, previous exposure to a virus causes the body to carry antibodies that allow the body to fight off the virus more easily the second time.
A symptom is something the patient feels or reports, while a sign is something that other people, including the doctor detects. A headache may be an example of a symptom, while a rash may be an example of a sign.
As there are different severities of dengue fever, the symptoms can vary.
Mild Dengue Fever - symptoms can appear up to seven days after the mosquito carrying the virus bites, and usually disappear after a week. This form of the disease hardly ever results in serious or fatal complications. The symptoms of mild dengue fever are:
• Aching muscles and joints
• Body rash that can disappear and then reappear
• High fever
• Intense headache
• Pain behind the eyes
• Vomiting and feeling nauseous
Dengue hemorrhagic fever (DHF) - symptoms during onset may be mild, but gradually worsen after a number of days. DHF can result in death if not treated in time. Mild dengue fever symptoms may occur in DHF, as well as the ones listed below:
• Bleeding from your mouth/gums
• Nosebleeds
• Clammy skin
• Considerably damaged lymph and blood vessels
• Internal bleeding, which can result in black vomit and feces (stools)
• Lower number of platelets in blood - these are the cells that help clot your blood
• Sensitive stomach
• Small blood spots under your skin
• Weak pulse
Dengue shock syndrome - This is the worst form of dengue which can also result in death, again mild dengue fever symptoms may appear, but others likely to appear are:
• Intense stomach pain
• Disorientation
• Sudden hypotension (fast drop in blood pressure)
• Heavy bleeding
• Regular vomiting
• Blood vessels leaking fluid
• Death
In moderate DHF cases, all signs and symptoms abate after the fever subsides. In severe cases, the patient's condition may suddenly deteriorate after a few days of fever; the temperature drops, followed by signs of circulatory failure, and the patient may rapidly go into a critical state of shock. The Dengue Shock Syndrome (DSS) is characterized by bleeding that may appear as tiny spots of blood on the skin (petechiae) and larger patches of blood under the skin (ecchymoses). Minor injuries may cause bleeding (see figure 4). Shock may cause death within 12 to 24 hours. Patients can recover following appropriate medical treatment.
• The progress towards DHF or DSS occur after 3-5 days of fever (see figure 3). At this time, fever has often come down. This may mislead many of us to believe that the patient is heading towards recovery. In fact, this is the most dangerous period that requires high vigilance from care-givers.

Figure 3. Generalized time course of the events associated with DF,DHF and DSS.The incubation period before the development of signs of infection generally ranges from 4 to 7 days.
Recognition of Dengue Haemorrhagic Fever (DHF)
-Symptoms similar to dengue fever plus,any one of the following
-severe and continuous pain in abdomen
-Bleeding from the nose, mouth and gums or skin bruising
-Frequent vomiting with or without blood
-black stools,like coal tar
-Excessive thirst (dry mouth)
-Pale,cold skin
-Restlessness,or sleepiness
Dengue shock syndrome is defined as dengue hemorrhagic fever plus:
-Weak rapid pulse
-Narrow pulse pressure (less than 20 mm Hg)
-Cold, clammy skin and restlessness.
The management of DF is symptomatic and supportive.
Bed rest is advisable during the acute febrile phase.
Antipyretics or sponging are required to keep the body temperature below 40oC. Aspirin should be avoided since it may cause gastritis, bleeding and acidosis; paracetamol is preferable.
Analgesics or mild sedatives may be required for patients with severe pain.
Oral fluids and electrolyte therapy are recommended for patients with excessive sweating or vomiting.
In DHF-endemic areas, patients should be monitored until after they become afebrile and after platelet counts and haematocrit determinations are normal.

Dengue viruses are transmitted to humans through the bites of infective female Aedes mosquitoes. Mosquitoes generally acquire the virus while feeding on the blood of an infected person. After virus incubation for eight to 10 days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus for the rest of its life. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining transmission of the virus to humans has not yet been defined.
Infected humans are the main carriers and multipliers of the virus, serving as a source of the virus for uninfected mosquitoes. The virus circulates in the blood of infected humans for two to seven days, at approximately the same time that they have a fever; Aedes mosquitoes may acquire the virus when they feed on an individual during this period. Some studies have shown that monkeys in some parts of the world play a similar role in transmission.
Dengue fever is a severe, flu-like illness that affects infants, young children and adults, but seldom causes death.
The clinical features of dengue fever vary according to the age of the patient. Infants and young children may have a fever with rash. Older children and adults may have either a mild fever or the classical incapacitating disease with abrupt onset and high fever, severe headache, pain behind the eyes, muscle and joint pains, and rash.
Dengue haemorrhagic fever (DHF) is a potentially deadly complication that is characterized by high fever, often with enlargement of the liver, and in severe cases circulatory failure. The illness often begins with a sudden rise in temperature accompanied by facial flush and other flu-like symptoms. The fever usually continues for two to seven days and can be as high as 41°C, possibly with convulsions and other complications.
In moderate DHF cases, all signs and symptoms abate after the fever subsides. In severe cases, the patient's condition may suddenly deteriorate after a few days of fever; the temperature drops, followed by signs of circulatory failure, and the patient may rapidly go into a critical state of shock and die within 12 to 24 hours, or quickly recover following appropriate medical treatment (see below).
• Increased Vascular Permeability
Dengue virus causes an acute condition of increased vascular permeability and plasma leakage. Supporting the patient through this vascular crisis by proper hydration management leads to resolution.
Because dengue is a virus there is no specific treatment or cure, however there are things the patient or the doctor can do to help, depending on the severity of the disease.

For milder forms of dengue the treatment methods are:
• Prevent dehydration - high fever and vomiting can dehydrate the body. Make sure you drink clean (ideally bottled) water rather than tap water. Rehydration salts can also help replace fluids and minerals.
• Painkillers - this can help lower fever and ease pain. As some NSAIDs (non-steroidal anti-inflammatory drugs), such as aspirin or ibuprofen can increase the risk of internal bleeding, patients are advised to use Tylenol (paracetamol) instead.
The following treatment options are designed for the more severe forms of dengue fever:
• Intravenous fluid supplementation (IV drip) - in some harsher cases of dengue the patient is unable to take fluids orally (via the mouth) and will need to receive an IV drip.
• Bloood transfusion - a blood transfusion may be recommended for patients with severe dehydration.
• Hospital care - it is important that you be treated by medical professionals, this way you can be properly monitored (e.g. fluid levels, blood pressure) in case your symptoms worsen. If the patient is cared for by physicians and nurses experienced with the effects and complications of hemorrhagic fever, lives can be saved.
At present there is no dengue vaccine; one is currently in development. Even so, developing a vaccine to protect against four closely related viruses that can cause the disease will not be easy.

The best method of prevention is to avoid being bitten by mosquitoes. If you live or travel to an area where dengue exists, there a number of ways to avoid being bitten:
• Clothing - your chances of being bitten are significantly reduced if you expose as little skin as possible. When in an area with mosquitoes, be sure to wear long trousers/pants, long sleeved shirts, and socks. For further protection, tuck your pant legs into your shoes or socks. Wear a hat.
• Mosquito repellants - be sure to use one with at least 10% concentration of DEET, you will need a higher concentration the longer you need the protection, avoid using DEET on young children.
• Use mosquito traps and nets - studies have shown that the risk of being bitten by mosquitoes is considerably reduced if you use a mosquito net when you go to sleep. Untreated nets are significantly less effective because the mosquito can bite the host through the net if the person is standing next to it. Also, even tiny holes in the netting are usually enough for the mosquito to find a way in. Nets that have been treated with insecticide are much more protective. Not only does the insecticide kill the mosquito and other insects, it is also a repellent - fewer mosquitoes are likely to enter the room(s).
• Smell - Avoid wearing heavily scented soaps and perfumes.
• Windows - use structural barriers, such as window screens or netting.
• Camping - if you are camping, treat clothes, shoes and camping gear with permethrin. There are clothes which have been treated with permethrin.
• Certain times of day - try to avoid being outside at dawn, dusk and early evening.
• Stagnant water - the Aedes mosquito prefers to breed in clean, stagnant water. It is important to frequently check and remove stagnant water in your home/premises.
o Turn pails (buckets) and watering cans over; store them under shelter so water cannot accumulate in them.
o Remove the water from plant pot plates. To remove mosquito eggs, clean and scrub them thoroughly. Ideally, do not use plant pot plates.
o Loosen soil from potted plants. This will prevent puddles from developing on the surface of hard soil.
o Make sure scupper drains are not blocked; do not place potted plants and other objects over the scupper drains.
o Gully traps that are rarely used should be covered; replace gully traps with non-perforated ones, and install anti-mosquito valves.
o Do not place receptacles under or on top of any air-conditioning unit.
o Flower vases - change the water every other day. When you do so, scrub the inside of the vase thoroughly and rinse it out.
o Leaves - make sure leaves are not blocking anything which may result in the accumulation of puddles or stagnant water.

1. http://www.searo.who.int/en/Section10/Section332/Section366_1212.htm.
2. http://www.ehow.com/about_4618289_dengue-fever-nursing-management.html
3. Harnack, Gordon (1999). Mastering and Managing the FDA Maze: Medical Device Overview. American Society for Qualit. ISBN 9780873894555.
4. Device Inspections Guide. Washington Business Information. p. 52657. ISBN 9781932074109.
5. http://www.ehow.com/about_4618289_dengue-fever-nursing-management.html#ixzz1JGGxGwVd

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