What are the guidelines for managing dengue fever?

Guidelines for Managing Dengue Fever

The management of dengue fever requires careful fluid administration, close monitoring for warning signs, and supportive care, with crystalloid fluids as the initial treatment of choice for patients with dengue shock syndrome, administered at 10-20 mL/kg boluses up to 40-60 mL/kg in the first hour while titrating to response and discontinuing if signs of fluid overload develop. 1

Diagnosis and Classification

Dengue fever should be classified according to severity:

• Probable dengue: Fever plus two of the following: nausea/vomiting, rash, headache, retro-orbital pain, myalgia/arthralgia, positive tourniquet test, or leukopenia 1
• Dengue with warning signs: Abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement, increasing hematocrit with decreasing platelets
• Severe dengue: Severe plasma leakage leading to shock, severe bleeding, or severe organ impairment 2

Laboratory Diagnosis

• Acute phase (0-5 days): RT-PCR for dengue virus RNA or NS1 antigen detection
• Convalescent phase (>5 days): IgM antibody detection or demonstration of fourfold rise/fall in IgG/IgM titers in paired samples 1
• Supporting findings: Thrombocytopenia, leukopenia, elevated hematocrit, and elevated liver enzymes 1

Management Approach

1. Fluid Management (Critical Component)

For Non-Shock Patients:

• Encourage oral fluids if tolerated
• If oral intake is inadequate or patient has warning signs, initiate IV fluid therapy:
  • Use isotonic crystalloids (0.9% saline or Ringer's lactate) 1, 2
  • Maintenance fluid rate plus deficit replacement

For Dengue Shock Syndrome (DSS):

• Initial resuscitation: Crystalloid fluid bolus of 20 mL/kg as rapidly as possible 1
  • May need to repeat 2-3 times in profound shock 3
• After initial resuscitation:
  • Adjust rate to 5-10 mL/kg/hour based on clinical response 1
  • Gradually reduce as clinical condition improves

For Refractory Shock:

• Consider colloid solutions (including albumin) if patient remains in shock despite crystalloid boluses 3, 4
• Medium-molecular-weight colloids provide good initial plasma volume support with acceptable side effects 5

2. Monitoring

• Vital signs: Monitor every 15-30 minutes during rapid fluid administration 1
• Warning signs: Persistent vomiting, increasing abdominal pain, lethargy, bleeding
• Laboratory parameters:
  • Hematocrit: A rise of 20% along with dropping platelet count indicates onset of shock 3
  • Platelet count: Monitor for severe thrombocytopenia
  • Liver function tests and other organ function tests as indicated

3. Supportive Care

• Pain and fever management: Acetaminophen 650-1000 mg every 4-6 hours (maximum 4g/day) 1
• Avoid aspirin and NSAIDs due to bleeding risk 1
• Oxygen therapy: Mandatory for all patients in shock 3
• Blood products: For patients with severe bleeding or DIC:
  • Whole blood or packed RBCs for significant bleeding
  • Fresh frozen plasma for coagulopathy
  • Note: Prophylactic platelet transfusion is not recommended 2

4. Management of Complications

• Polyserositis (pleural effusion, ascites): Avoid drainage if possible as it can lead to severe hemorrhages and circulatory collapse 3
• Organ dysfunction: Monitor and provide organ-specific support
• Secondary hemophagocytic lymphohistiocytosis: Consider steroids or intravenous immunoglobulin in confirmed cases 2

Special Populations

Children

• More susceptible to fluid overload; require closer monitoring
• Initial fluid bolus of 20 mL/kg for children with DSS, with regular reassessment 1

Pregnant Women

• Higher risk of complications; require more intensive surveillance 1

Older Adults

• Higher risk of severe dengue due to comorbidities; may require more aggressive management 1

Discharge Criteria

Patients can be discharged when they have:

• No fever for 48 hours without antipyretics
• Improving clinical status
• Increasing platelet count
• Stable hematocrit
• No respiratory distress
• Good urine output 1

Common Pitfalls to Avoid

1. Overhydration: Can lead to pulmonary edema, especially during recovery phase
2. Underhydration: Insufficient fluid resuscitation can lead to prolonged shock
3. Delayed recognition of warning signs: Failure to identify progression to severe disease
4. Inappropriate use of NSAIDs: Increases bleeding risk
5. Failure to adjust fluid therapy: Not reducing fluids during recovery phase can lead to fluid overload 4

Early recognition and prompt management of dengue, particularly careful fluid administration, are crucial for reducing mortality to below 1% in children with dengue hemorrhagic fever 6.