What is the management approach for dengue?

Management of Dengue Fever

The management of dengue fever requires careful fluid resuscitation with crystalloids as first-line therapy, close monitoring for warning signs of progression to severe dengue, and supportive care without prophylactic platelet transfusions. 1, 2

Clinical Classification and Assessment

Dengue is classified into three categories that guide management:

1. Probable dengue
2. Dengue with warning signs
3. Severe dengue (characterized by plasma leakage, severe bleeding, or organ impairment)

Warning Signs to Monitor

• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation
• Mucosal bleeding
• Lethargy or restlessness
• Liver enlargement >2 cm
• Laboratory: Increasing hematocrit with rapid decrease in platelet count

Fluid Management Protocol

Non-Severe Dengue Without Warning Signs

• Encourage oral fluids
• If unable to tolerate oral intake, initiate IV fluid therapy with isotonic crystalloids

Dengue With Warning Signs or Severe Dengue

1. Initial resuscitation:

   • Crystalloid fluid bolus of 20 ml/kg as rapidly as possible
   • May need to be repeated 2-3 times in profound shock 1

2. Maintenance fluid therapy:

   • Administer at 5-10 ml/kg/hour, adjusted according to clinical response
   • Monitor vital signs every 15-30 minutes during rapid fluid administration 1
   • Normal saline is preferred over lactated Ringer's solution 1

3. For patients not responding to crystalloids:

   • Switch to colloid solutions for refractory shock 3
   • Consider adding vasopressors (e.g., norepinephrine) if fluid restriction is necessary due to pulmonary edema 3

Monitoring During Fluid Administration

• Vital signs (pulse, blood pressure, respiratory rate)
• Urine output (target >0.5 ml/kg/hr)
• Hematocrit trends
• Signs of fluid overload:
  • Dyspnea
  • Enlarging liver
  • Gallop rhythm
  • Pulmonary edema 1

Special Considerations

Pediatric Patients

• Children require closer monitoring and are more susceptible to fluid overload
• Initial fluid bolus of 20 mL/kg for children with dengue shock syndrome
• Regular reassessment is critical to detect deterioration or fluid overload early 1

Pregnant Women

• Higher risk of complications
• Require more intensive surveillance 1

Older Adults

• Higher risk of developing severe dengue due to comorbidities
• May require more aggressive management 1

Patients with Chronic Kidney Disease

• Should receive lower volumes of fluid than those with normal renal function
• Adjust fluid administration rate based on clinical response 1

Laboratory Monitoring

• Complete blood count with platelet count
• Hematocrit (for monitoring hemoconcentration)
• Liver function tests
• Renal function tests
• Coagulation profile if bleeding manifestations are present

Management of Complications

Bleeding

• Avoid prophylactic platelet transfusions 2
• Transfuse platelets only for significant bleeding
• Avoid aspirin and NSAIDs 4

Organ Involvement

• Carefully assess and manage organ dysfunction in severe dengue 2
• Consider secondary hemophagocytic lymphohistiocytosis (HLH) in cases with persistent fever and cytopenias
  • May benefit from steroids or IVIG 2

Discharge Criteria

Patients can be discharged when:

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

Prevention and Control

• Implement early warning systems for outbreaks
• Enhanced vector surveillance
• Follow standardized clinical management protocols 1
• Community empowerment approaches for vector control 5

Important Pitfalls to Avoid

1. Overhydration - can lead to pulmonary edema and respiratory distress
2. Underhydration - can lead to prolonged shock and organ failure
3. Inappropriate use of blood products - prophylactic platelet transfusions are not recommended
4. Failure to recognize warning signs - delays appropriate escalation of care
5. Use of NSAIDs - can worsen bleeding risk

Remember that while no specific antiviral treatment is currently available for dengue, proper supportive care can reduce mortality to less than 1% in dengue hemorrhagic fever 6, 2.