What are the management guidelines for dengue hemorrhagic fever?

Management Guidelines for Dengue Hemorrhagic Fever

The management of dengue hemorrhagic fever (DHF) requires careful fluid resuscitation with crystalloids at 5-10 ml/kg/hour, adjusted according to clinical response, with close monitoring of vital signs every 15-30 minutes during rapid fluid administration. 1

Diagnosis

• Diagnosis can be made using:
  • RT-PCR for dengue virus RNA in serum or NS1 antigen detection during acute phase
  • IgM antibody detection or demonstration of fourfold rise/fall in IgG or IgM antibody titers in paired samples during convalescent phase 1
• Key diagnostic criteria for DHF:
  • Thrombocytopenia with concurrent hemoconcentration (rise in hematocrit ≥20%) differentiates DHF from classical dengue fever 2
  • Monitor for warning signs: abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement, and increasing hematocrit with decreasing platelets

Fluid Management Protocol

Initial Resuscitation

• For shock (DSS - Grade III and IV):
  • Administer crystalloid fluid bolus of 20 ml/kg as rapidly as possible
  • May need to repeat 2-3 times in profound shock 1
  • If not responsive despite adequate crystalloid resuscitation, switch to colloids 3

Maintenance Fluid Therapy

• Fluid administration rate: 5-10 ml/kg/hour, adjusted according to clinical response
• Once hemodynamic stability is achieved and hematocrit begins to decrease:
  • Reduce rate to 3-5 ml/kg/hour
  • Consider switching to 0.45% NaCl if corrected serum sodium is normal or elevated 1

Special Population Considerations

• Chronic Kidney Disease: Administer normal saline at reduced rate of 5-7 ml/kg/hour 1
• Children: Initial fluid bolus of 20 ml/kg for shock, with closer monitoring due to higher susceptibility to fluid overload 1
• Pregnant women: Require more intensive surveillance due to higher risk of complications 1
• Older adults: May require more aggressive management due to comorbidities 1

Monitoring Parameters

• Vital signs every 15-30 minutes during rapid fluid administration
• Hematocrit levels: Monitor trends (rising indicates ongoing plasma leakage)
• Platelet count: Monitor for progressive decline
• Urine output: Ensure adequate renal perfusion
• Signs of fluid overload:
  • Dyspnea, enlarging liver, gallop rhythm, pulmonary edema
  • Increasing respiratory rate and peripheral edema 1

Management of Complications

Shock Management

• If unresponsive to fluid resuscitation:
  • Search for other causes of hemodynamic instability
  • Consider vasopressors (norepinephrine) if fluid restriction is necessary due to pulmonary edema 3

Hemorrhagic Complications

• For significant bleeding or DIC:
  • Provide supportive therapy with blood products (blood, FFP, and platelet transfusions) 2
  • For intracranial hemorrhage: Maintain high index of suspicion in patients with altered sensorium
  • Timely neurosurgical intervention may be lifesaving in cases of intracranial hemorrhage 4

Polyserositis

• Pleural effusion and ascites are common in dengue shock syndrome
• Avoid drainage if possible as it can lead to severe hemorrhages and sudden circulatory collapse 2

Electrolyte Management

• Once renal function is assured, add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) to maintenance fluids 1
• Monitor and correct electrolyte imbalances promptly

Discharge Criteria

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

Follow-up

• Evaluation after 2-4 weeks of treatment to assess response
• Consider further evaluation if symptoms persist despite optimal treatment 1

Pitfalls and Caveats

1. Fluid Management Pitfalls:

   • Avoid excessive fluid administration leading to fluid overload
   • Don't reduce fluids too early during critical phase
   • Remember to reduce fluid rates once stabilized to prevent overload

2. Monitoring Pitfalls:

   • Don't rely solely on platelet count; hematocrit trend is crucial
   • Altered sensorium should not be dismissed as fever delirium but investigated for intracranial complications 4

3. Treatment Pitfalls:

   • Avoid unnecessary drainage of pleural effusion/ascites
   • Don't delay fluid resuscitation in shock
   • Remember there is no specific antiviral therapy; management is supportive 5