Proceedings of The 1st Syiah Kuala International Conference on Medical and Health Sciences May 11-12, 2017, Banda Aceh, Indonesia
The Relationships of Clinical Features and Laboratory as Risk Factors of Shock in Dengue Hemorage Fever 1
Mulyati Sri Rahayu*
1
Faculty of Medicine, Universitas Malikussaleh *Corresponding Author:
[email protected] Abstract Dengue Hemorrhagic Fever (DHF) is a disease caused by dengue virus that transmitted to human through Aedes sp. DHF which continues into shock is a serious problem. Prompt diagnosis and as an accurate assessment of the shock cases is a very important factor for determining patient prognosis. This research aims to determine the relationship of clinical features and laboratory as risk factors of shock event in dengue hemoragic fever at General Hospital (RSUD Cut Meutia), North Aceh District 2015-2016. This research with retrospective design in 84 samples were taken from medical record in General Hospital (RSUD Cut Meutia), North Aceh by purposive sampling technique. The statistical analysis used descriptive analysis and hypothesis test by using chi-square, fischer's exact, with (α = 0.05). The result show that, there were 2 patients (2.46%) experienced shock. The most ages 18-40 years (70.2%) and male patients (59.5%) more than women (40.5%). Based on the results of the bivariate analysis there were significant relationship between manifestation of bleeding, hepatomegaly and platelet count with shock event in DHF with p value respectively p = 0.039, p = 0.047 and p = 0.04. There were no significant relationship between body temperature, hemoglobin level, hematocrit number, leukocyte with shock in DHF (p> 0.005). Clinical features of spontaneous bleeding, hepatomegaly, and platelet counts are the most correlated as risk factors of shock event in DHF. Key words: Dengue Haemorrhagic Fever, hepatomegaly, haematocrit value, platelet count, haemoglobin level Preface Dengue Haemorrhagic Fever (DHF) is one of the emerging diseases globally and growing in some areas with high morbidity.1 All areas in Indonesia have a risk of contracting dengue fever because of Dengue virus and Aedes aegypti as a vector. Indonesia Ministry of Health recorded the number of DHF patients in Indonesia in January-February 2016 as many as 8487 people with the number of deaths 108 people. The highest number of dengue fever in Indonesia is at the age range of 5-14 years (43.44%) and the age range of 15-44 years (33.25%).2 The number of DHF patients in 2014 was reported as many as 2211 cases with the number of deaths was 8 people. Incidence Rate is 45 per 100000 population and Case Fatality Rate (CFR) of 0.4% with 1 region with high CFR (>2%) is North Aceh District.3 Dengue shock syndrome (DSS) is a major problem in almost all DHF patients. This occurs because of plasma leakage. The proper and early treatment of DHF and DSS patients is an important factor for successful treatment of patients.4,5 209
Proceedings of The 1st Syiah Kuala International Conference on Medical and Health Sciences May 11-12, 2017, Banda Aceh, Indonesia
Dengue Hemorrhagic Fever which continues into shock is a serious problem. Hadinegoro6 reported that the prevalence of shock in DHF in all Indonesia hospitals reached 16%-40% with mortality rate of 5.7%. Most deaths occur from shock and recurrence shock. The pathophysiology of dengue infection disease is difficult to predict. Until now often found DHF patients who initially did not appear heavy clinically and laboratory, but sudden shock and cause death.7 The proper diagnosis and accurate assessment of the staging and condition of the patient is a very important factor for determining the patient prognosis. The more severe the disease, the worse the prognosis. Therefore, an accurate assessment of the risk of shock, is essential for adequate management, prevention of shock. In North Aceh, particularly General Hospital (RSUD Cut Meutia), no research has been done about risk factors that contribute to shock in DHF. This research aims to determine the relationship of clinical features and laboratory as risk factors of shock event in dengue hemoragic fever at General Hospital (RSUD Cut Meutia), North Aceh. Methods Research was observational analytic with cohort retrospective approach. Samples were taken from medical record of DHF patient at General Hospital (RSUD Cut Meutia), North Aceh from January 2015 to December 2016 with total 84 people by purposive sampling technique based oninclusion and exclusion criteria. The inclusion criteria were all DHF patients who suitable with WHO's diagnostic criteria in 1997. Data recorded were age, sex, clinical symptoms at hospital admission including body temperature (axillary measurements), manifestations of hemorrhage, hepatomegaly, laboratory data during hospital admission include hemoglobin level, leukocyte count, hematocrit level, platelet count and diagnosis of dengue clinical degree. DHF degrees I and II are classified as DHF without shock and DHF degrees III and IV as DSS. Patients with incomplete medical record data were excluded from this research. Data were recorded, grouped and analyzed by SPSS 17.0 using chi-square test, fisher's exact analysis. Results and Discussion Cases of DHF at General Hospital (RSUD Cut Meutia), North Aceh had 127 cases in the range of January 2015 to December 2016 with the highest incidence in September 2015 of 11. There were 84 DHF patients who suitable with the research criteria, 82 dengue patients without shock (97.6%) and 2 patients DSS (2.4%).
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Proceedings of The 1st Syiah Kuala International Conference on Medical and Health Sciences May 11-12, 2017, Banda Aceh, Indonesia
Table 1. DHF patients characteristics
Characteri stics Age(years ) 18-40 41-60 > 60
Sex Female Male
Clinical Symptoms
Shock (-) n %
DHF Shock (+) n %
Total n
%
5 8 1 7 7
69 .0 20 .2 8. 3
1 1 0
1.2 1.2 0
5 9 1 8 7
70 .2 21 .4 8. 3
3 3 4 9 8 2
39 .3 58 .3 97 .6
1 1
1.2 1.2
2
2.4
3 4 5 0 8 4
40 .5 59 .5 10 0
Table 1 showed the number of DHF patients who experienced shock 2.4%. Most ages 18-40 years (70.2%), age> 60 years 7 patients (8.3%) and no shock in this group. Male patients (59.5%) more than women (40.5%). Table 2. The relationship between clinical symptoms with shock
Clinical Symptoms Temperatures at hospital admissions (oC) ≤37.5 >37.5 Spontaneous haemorrhage No Yes Hepatomegaly No Yes
Shock (-) n %
DHF Shock (+) n %
Total n
p value
0.62 31 51
96.8 98.7
1 1
3.3 1.3
32 52
67 15
100 88.2
0 2
0 11.8
67 17
81 1
98.8 50
1 1
1.2 50
82 2
0.039*
0.047*
Table 2 showed there were significant relationships between spontaneous bleeding and hepatomegaly with shock event in DHF patients (p 0.05).
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Proceedings of The 1st Syiah Kuala International Conference on Medical and Health Sciences May 11-12, 2017, Banda Aceh, Indonesia
Table 3. The relationship between laboratory parameters with shock DHF Laboratory Hemoglobin (gr/dl) >14 ≤14 leukocyte (cell/µL) >5000 ≤5000 hematocrit (vol%) >42 ≤42 platelet (sel/µL) ≤50.000 >50.000
Shock (-) n %
Shock (+) n %
Total n
p
21 61
100 96.8
0 2
0 3.2
21 63
0,560
50 32
98.0 97.0
1 1
2.0 3.0
51 33
0,634
34 48
100 96
0 2
0 4
34 50
0.512
16 66
88.9 100
2 0
11.1 0
18 66
0.044*
Table 3 showed that shock may occur in patients with leukocyte count ≤5000 mm3 or >5000 mm3 of 3% and 2% respectively. Levels of hemoglobin ≤14g/dL (3.2%), hematocrit ≤42vol% (4%) and low platelet count ≤50000/μL (11.1%). Based on statistics only platelets that showed significant relationship with the occurrence of shock in DHF patients (p 5000/mm3 and also seen a tendency increase in shock when the number of leukocytes is increasing. This difference may occur because the number of samples in this study is not comparable with previous studies. Based on the results of research, shock patients occurred on hematocrit value ≤42%, although not a risk factor for shock occurred in DHF. Pathophysiology of DHF shows DHF patients have plasma leakage so that the percentage of hematocrit should be increased. However, if the patient is bleeding or anemic, the amount of erythrocytes is low, affecting the hematocrit value and may be low or even normal.10 The size of erythrocytes can also affect the blood viscosity. If the size of erythrocite is small then blood viscosity be low so it can affect hematocrit. Adequate rehydration in patients before hospitalization also affects hematocrit values.17 Decreasing hematocrit values> 20% after receiving fluid therapy may also help in the diagnosis of DHF after other criteria are suitable.1 The research by Nurhayati5 found that studies of hematocrit levels showed significantly associated with DSS in peak hematocrit measurements or hematocrit levels at the peak of diseasea. The findings of that researcher also confirm the results obtained by this study, that baseline hematocrit levels and shock event in DHF patients were not significantly associated. The initial hematocrit level is not related to the shock event in DHF, while the peak hematocrit level is correlated. The elevated hematocrit level is probably not the predominant factor in the pathogenesis of DHF, but simply an advanced variable in the course of the disease.
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Proceedings of The 1st Syiah Kuala International Conference on Medical and Health Sciences May 11-12, 2017, Banda Aceh, Indonesia
Platelet value is a related parameter and is a risk factor for shock in DHF (p