What are the management strategies for dengue?

Dengue Fever Management

The management of dengue fever requires careful monitoring of vital signs, appropriate fluid resuscitation, and supportive care with acetaminophen for fever, while avoiding NSAIDs and aspirin due to bleeding risk. 1

Clinical Assessment and Diagnosis

Initial Evaluation

• Monitor vital signs: heart rate, blood pressure, respiratory rate, pulse pressure, capillary refill time, mental status, urine output, and temperature 1
• Look for warning signs:
  • Abdominal pain or tenderness
  • Persistent vomiting
  • Clinical fluid accumulation (pleural effusion, ascites)
  • Mucosal bleeding
  • Lethargy or restlessness
  • Hepatomegaly
  • Increasing hematocrit with rapid decrease in platelet count 1

Laboratory Diagnosis

• Acute phase (0-7 days): RT-PCR for dengue virus RNA or NS1 antigen detection
• Convalescent phase: IgM antibody detection or demonstration of fourfold rise/fall in IgG or IgM antibody titers 1
• Monitor hematocrit and platelet counts regularly - a rise in hematocrit of 20% with concurrent drop in platelets indicates progression to severe disease 2

Management Algorithm

1. Non-Severe Dengue (Without Warning Signs)

• Encourage oral fluids
• Administer acetaminophen/paracetamol for fever and pain
• Avoid NSAIDs and aspirin due to increased bleeding risk 1
• Monitor for warning signs
• Follow up daily until fever resolves

2. Dengue with Warning Signs

• Admit for close observation and medical intervention
• Initiate crystalloid fluid therapy (5-10 ml/kg/hour) 1
• Monitor:
  • Vital signs every 1-2 hours
  • Urine output (target >0.5 ml/kg/hour in adults, >1 ml/kg/hour in children)
  • Hematocrit before and after fluid boluses
  • Clinical status for signs of fluid overload 1
• Adjust fluid rates based on clinical response

3. Severe Dengue/Dengue Shock Syndrome (DSS)

• Emergency management required
• Immediate fluid resuscitation:
  • Start with 20 ml/kg crystalloid bolus over 15-30 minutes 1
  • Reassess and repeat bolus if necessary (up to 2-3 boluses may be needed in profound shock) 2
  • If inadequate response to crystalloids, switch to colloids 1, 3
• Place patient in semi-recumbent position (head elevated 30-45°) 1
• Provide oxygen therapy 2
• Monitor for fluid overload (development of hepatomegaly, rales) 1
• For refractory shock despite adequate fluid resuscitation, consider:
  • Checking for occult bleeding or other complications
  • Adding vasopressors (norepinephrine) if pulmonary edema limits fluid administration 3

Special Considerations

Management of Bleeding

• For significant bleeding:
  • Fresh frozen plasma and/or platelet transfusions may be required 2
  • Avoid invasive procedures to prevent hemorrhagic complications 2

Fluid Management Pitfalls

• Avoid excessive fluid administration - can lead to pulmonary edema, pleural effusions, and respiratory distress
• Avoid inadequate fluid resuscitation - can lead to prolonged shock and organ failure
• Carefully reduce fluid rates once hemodynamic stability is achieved and signs of plasma leakage resolve 3

High-Risk Patients

• Infants require more careful fluid management due to higher susceptibility to fluid overload 1
• Patients with comorbidities (cardiac or renal disease) need more intensive monitoring 1
• Secondary dengue infections carry higher risk of progression to severe disease 1

Prevention Strategies

• Vector control through elimination of mosquito breeding sites
• Use of repellents, appropriate clothing, and mosquito nets 1
• Community-based approaches have shown success in dengue control programs 4

Treatment Outcomes

With appropriate management, mortality from dengue can be reduced to less than 0.5%, even in hospitalized patients 1. The key to successful management is frequent monitoring and timely adjustment of treatment strategies based on the patient's clinical status 2.