PENATALAKSANAAN DEMAM ( Approach to Fever )

Dr. Paul.N. Harijanto, Sp.PD-KPTI

Divisi Penyakit Tropik & Infeksi

Departemen Penyakit Dalam ,

RSU Bethesda Tomohon/ FK UNSRAT Manado

Fever is one of the most common

reason for caregivers to seek medical

attention

Up to 22% of the visits to the

emergency department by children

are for fever

DEFINITION OF FEVER

Fever is an elevation of body

temperature that exceeds the normal

daily variation, in conjunction with an

increase in hypothalamic set point

VARIATION IN TEMPERATURE

Anatomic variation

Physiologic variation: Age

Sex

Exercise

Circadian rhythm

Underlying disorders

NORMAL BODY TEMPERATURE

Maximum normal oral temperature

At 6 AM : 37.2

At 4 PM : 37.7

PHYSIOLOGY OF FEVER

Pyrogens:

Exogenous pyrogens:

Bacteria, Virus, Fungus, Allergen,

Endogenous pyrogen

Immune complex, lymphokine,

Major EPs: IL1, TNF, IL6

PHYSIOLOGY OF FEVER

Exogenous pyrogen Activated leukocytes Endogenous pyrogen(IL1,TNF,)

Acute Phase Response

Preoptic area of anterior hypothalamus (PGE2) increase of set point =>

Brain cortex

Vasoconstriction heat conservation

Muscle contraction heat production FEVER

Method of Temperature Measurement

Rectal gold standard

Oral reflect core temperature in older child able to cooperate; is altered by ingestion of hot or cold food or liquids

Axillary reflects surface temp ; low sensitivity

Tympanic accurate; commonly used

Definition of fever

Normal - 98.6 F (37 C) with a diurnal

fluctuation between 97 and 100.4

Mild Fever- 100.5 to 101.2F (38-38.5C)

Moderate Fever 101.2 to 105F (39-40.5C)

High Fever - > 105F (40.5C)

Harmful Fever - > 107F

Effects of Fever

The effects of fever in otherwise healthy

children include discomfort,dehydration

and seizures. Usually fever is non-harmful

and self-limited.

Children with underlying medical

problems are more likely to experience

complications of fever.

Normal Temperatur Tubuh

Di ukur secara ORAL

Paling rendah jam 6.00 pagi, 37,2C (98,9F)

Paling tinggi jam 18.00 sore, 37.7 C (99,9F)

Normal variasi 0,5 C 1 C

Rectal temperatur lebih Tinggi 0,4 C

Di urnal variation

Wanita lebih tingi pria

DEFINISI

Demam/ Fever : > 37,7 C

Hyperpyrexia : > 41.1 C

Malaria :

Temp > 41C Malaria Berat

PASIEN DENGAN DEMAM

Brapa lama Demam ?

DEMAM

Demam

Akut

< 14 hari

Demam

Kronik

> 14 hari

Infeksi kronik :

TBC, Endokarditis, HIV/AIDS

Lepra

Malignancy :

Leukemia, Limfoma

Imunologik :

SLE, RA,

Duration of Fever ( Lama Demam )

1 3 days 3 - 7 days 8 14days > 14 days ( 2 weeks )

Chronic Infection

TBC Endocarditis Lepra HIV

Imunological Dis : SLE RA Sarcoidosis

Malignancy : Leucaemia Lymphoma

Simple fever

Viral infec.:

Resp.

Epstein Bar Influenzae

GIT

Exercises

Dehydration

Injury/ Trauma

Allergic

Most of Infection :

Bacterial Infection :

Typhoid fever Pneumonia Pyelonephritis Sepsis Parasitic :

Malaria Viral systemic:

Dengue/ DHF J-Encephalitis Myocarditis

TIPE DEMAM

Tipe Karakter Contoh

Kontinyu Terus menerus tinggi

beda 0,5-1 C

Tifoid, DHF, drug fever

Intermiten Temp turun sampai

normal setiap hari

Infeksi piogenik,

limfoma, TBC,

Remiten Fluktuasi harian > 2C,

tapi tak pernah normal

Malaria

Berulang

(Relaps)

Suhu turun sampai

normal bbrp hari

meningkat lagi

Malaria

CONSEQUENCES OF THE GENERAL CLINICAL RESPONSES TO INFECTION AND INFLAMMATION

Sign/symptom Metabolic effect Benefit for host

Fever

Increased energy consumption is required to

cause and maintain body temperature above

normal

Beneficial effect on survival at moderate increases

(102104F (3940C)). May be detrimental with more marked increases (e.g. >107F (>42C))

Enzyme reactions are accelerated

Anorexia

Decreased nutrient intake requires

catabolism of body stores for new protein

synthesis

No apparent benefit in infection

Amino acids are converted to glucose by

way of hepatic gluconeogenesis

May permit survival during the healing process after

trauma

Lethargy

Decreased voluntary activity reduces energy

needs

Benefits of rest documented in some infections

(poliovirus, Coxsackie B4 virus) in which exercise

increases severity of clinical manifestations

Allows metabolic support to be directed to host

defense responses

Myalgia

Result of muscle activity and muscle

catabolism to breakdown muscle protein

releases amino acids into the circulation

Generates heat to elevate body temperature

Provides source of amino acids for increased protein

synthesis of host defense molecules and cells

PENYEBAB DEMAM

INFEKSI : BAKTERI

VIRUS

PARASIT

JAMUR

MALIGNANCY

IMMUNOLOGIK

DIMANA INFEKSINYA ?

ORGAN/SYSTEM TERLIBAT

-Respiratory

-Gastro-intestinal

-Uro-genital

-Upper respiratory

-Ear-nose-throat

-Eyes

-CNS

NO

YES

MALARIA

DENGUE

TETES

TEBAL/

RDT

Hb, Leuko ,

Trombo, Ht

PENYEBAB ?

LEUKO GRAM +

GRAM ve; VIRUS, PARASIT

Differential Leukosit

Eos : parasit

Neutro : bakteri

Limfo : gram -; virus

Mono : virus

Tatalaksana pada Pasien

1. Anamnesa : Lama & keluhan lainnya Obat, tindakan bedah/dental

Prostetic material/ implanted device

Riwayat pekerjaan : kontak dgn binatang, bahan toxic, antigen/ agent infectious

Tempat tinggal/ riwayat perjalanan

Riwayat imunisasi/ obat prophylaktis

Hobby, kebiasaan, perilaku tertentu

Riwayat keluarga/ lingkungan

Ethic tertentu

Clinical History

HISTORY

Travel history - Bioterrorism & fever

Occupational

PHYSICAL EXAMINATION :

Temperature - Spleen

Mouth - Lymph nodes

Eyes

Making a decission : - Is the patient ill ?

Laboratory Investigation

MANAGEMENT : Isolation & Treatment

Fever in Returning Travellers

COMMON

Malaria

No Diagnosis made

Respiratory Infection

Diarrheal Disease

Urinary Tract Infection

Viral Hepatitis

UNCOMMON

Dengue Thyphoid Tuberculosis Acute HIV Infection Acute Schistosomiasis Rickettial infec. Amoebiasis

Pemeriksaan Fisik :

Tanda vital

Pengukuran temperatur aksiler tidak akurat

Skin ( rash)

Kelenjar limfe

Mata

Kardiovaskuler & respiratory

Abdomen : Hepar & Lien, ascites,

Muskuloskeletal( Artritis), saraf

Rectal Examination

Penis, prostate, scrotum, testes

Wanita : pem.gynaecologik

LABORATORIUM : Leukosit & Differential Hb, Trombosit, PCV,LED Malaria smear Urinalisis Bacterial smear Tes Antigen Tes Serologik Microskopic tinja

Kimia Darah : Elektrolit, gula darah, ureum, kreatinin,

LFT

Mikrobiologik : Radiologik

DANGER POINT IN ACUTE FEVER

Petechial/ purpuric rash

Travel (risk of malaria)

Chills/ rigors

Extreme of age

Neurologic sign

Asplenia

Hypogammaglobinaemia

Post bone marrow transplant

TREATMENT OF FEVER

Most fevers are associated with

self-limited infections, most

commonly of viral origin.

TREATMENT OF FEVER

Reasons not to treat fever:

The growth and virulance of some organisms

Host defense-related response

Fever is an indicator of disease

Adverse effect of antipyretic drugs

Iatrogenic stress

Social benefits

DISCOMFORT DUE TO FEVER

For each 1 C elevation of body temperature:

Metabolic rate increase 10-15%

Insensible water loss increase 300-500ml/m2/day

O2 consumption increase 13%

Heart rate increase 10-15/min

TREATMENT OF FEVER

Reasons to treat fever: The elderly individual with pulmonary or cardiovascular

disease

The patient at additional risk from the hypercatabolic state

(Poor nutrition, Dehydration)

The young child with a history of febrile convulsions

Toxic encephalopathy or delirium

Pregnant women (contraversy)

For the patient comfort

Hyperpyrexia

Treatment Fever

Oral Aspirin ( Anak # ReyeS Syndr)

Acetaminophen

NSAID ( ibuprofen, diclofenac )

Non-drugs : Cooling : blangket, Fan, AC, Teppid sponge, ice bath.

IV Fluid

Internal cooling : gastric/ peritoneal lavage with ice, hemodyalisis

IV dantrolene sodium 1 2,5 mg/kg BB/ 6 jam

Procainamide

Treatment Strategies

Acetaminophen is generally a first-line

antipyretic due to being well tolerated

with minimal side effects.

Pediatric dose: 10-15mg/kg q4-6h (2400mg/day);

adult: 650mg q 4 h(4000mg)

Can be hepatotoxic in high doses; can upset stomach

FEVER & RASH

Centrally distributed Maculopapular Eruptions : Measles, German measles, Primary HIV, Infec.

Mononuc.,leptospirosis, Typhoid, Rheumatic fever, SLE, Lyme

Peripherial Eruptions : Secondary Syphylis, Hand Foot Dis, Endocarditis

Confluent Desquamtive Erythemas Scarlet fever, TSS, Toxic epidermal necrolysis, Kawasaki dis.

Vesiculobullous Eruptions : Hand foot Dis, Varicella, Diss. Herpes infec.,

Urticarial Eruptions Urticarial vasculitis

Nodular Eruptions Diss. Eruption

Purpuric Eruptions : Viral Haemorhagic fever ( DHF), acute meningococaemia,

Eruptions with Ulcers & Eschars Tularemia, Anthrax

ACUTELY ILL FEBRILE PATIENT

History:nonspecific, onset, progression, host factor ( immune status), source of infection

Physical Examination :

Specific Presentations ; SEPSIS

NEUROLOGIC INFECTIONS ( Bacterial meningitis, Brain abcess, Cerebral Malaria, )

FOCAL SYNDROME WITH FULMINANT COURSES

DETEKSI DINI KASUS MALARIA

DEMAM TIFOID

Limpa, Hati, Kel. Limfe,

Ikterik, Petekien, Urin, Gangguan kesadaran

DEMAM DENGUE MALARIA Mikrosk/ QBC / Rapid test

Demam/Riwayat Demam,

Sakit kepala

Pengobatan Malaria

Anamnesa

Pemeriksaan Fisik

Trias Malaria

Riwayat Perjalanan

Berkemah/Berburu/

Riwayat Pakai Obat Malaria

Pendatang/Pelancong

Keadaan non-imun

Keluhan Abdomen

Bradikardi relatif

Rose spot

Nyeri Otot

Rash petekien

Tes Rumpel Leede

Perdarahan

LEPTOSPIROSIS

Nyeri Otot

Nyeri Betis

Trias Malaria

Pucat/ anemis

Splenomegali

PAKATUAN WO PAKALAWIREN

Dr. Paul Harijanto, Sp.PD-KPTI

Div. Penyakit Tropik & Infeksi

SMF/ Bag. Penyakit Dalam

FK UNSRAT Manado

RSU Bethesda -Tomohon

Telp.:

0431-356829 ( RSU Bethesda)

0812-430-2869 ( HP)

0431-351187 (Res)

E-mail : paulharijanto@gmail.com

Sampai Baku Dapa !