What is the recommended treatment for dengue?

Dengue Fever Treatment

The recommended treatment for dengue fever primarily consists of supportive care with appropriate fluid management, with crystalloid solutions (normal saline) being the preferred initial fluid for resuscitation in patients with dengue shock syndrome. 1

Diagnostic Considerations

Before initiating treatment, it's important to establish the diagnosis and severity:

• Dengue fever typically presents with high fever (39-40°C), headache, retroorbital pain, myalgias, arthralgias, and skin rash
• Complications like encephalitis, hepatitis, and myoarthritis generally occur during the critical phase (days 3-7 after fever onset)
• Diagnostic methods include PCR testing, IgM capture ELISA, and convalescent IgG at 3 weeks 1

Treatment Algorithm

1. Non-severe Dengue (Outpatient Management)

• Oral fluid intake: Encourage intake of at least five glasses of fluid daily for adults 1, 2
  • Using a fluid chart to track intake may help reduce hospitalization and IV fluid requirements 2
  • Target approximately 3,000 ml of oral fluids daily 2
• Antipyretics: Acetaminophen for fever control
• Avoid NSAIDs and aspirin due to risk of bleeding complications 3
• Monitor for warning signs: Abdominal pain, persistent vomiting, mucosal bleeding, lethargy, liver enlargement, increasing hematocrit with decreasing platelets

2. Severe Dengue/Dengue Shock Syndrome (Inpatient Management)

Initial Fluid Resuscitation

• Crystalloid fluid bolus: 20 ml/kg as rapidly as possible 1
  • May need to be repeated 2-3 times in profound shock
  • Normal saline is preferred over lactated Ringer's solution 1
• Monitoring: Vital signs every 15-30 minutes during rapid fluid administration 1

Ongoing Fluid Management

• Maintenance rate: 5-10 ml/kg/hour, adjusted according to clinical response 1
• Switch to colloids if no response to crystalloids after adequate resuscitation 4
  • Medium-molecular-weight preparations are optimal if colloids are needed 5
  • 6% hydroxyethyl starch may be preferable to dextran 70 due to fewer adverse reactions 6

Electrolyte Management

• Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) to maintenance fluids once renal function is assured 1
• Monitor for signs of fluid overload: dyspnea, enlarging liver, gallop rhythm, pulmonary edema 1

Hemodynamic Support

• If fluid restriction is necessary due to pulmonary edema, consider adding vasopressors like norepinephrine 4

Special Populations

Children

• More susceptible to fluid overload; require closer monitoring
• Initial fluid bolus remains 20 ml/kg for dengue shock syndrome 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

Chronic Kidney Disease

• Should receive lower volumes of fluid than those with normal renal function
• Adjust fluid administration rate based on clinical response, urine output, hematocrit trends 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 and Caveats

1. Fluid overload: Careful monitoring is essential during fluid resuscitation to prevent pulmonary edema, especially in children and those with comorbidities 1

2. Inadequate fluid resuscitation: Can lead to prolonged shock and organ failure; early and appropriate fluid therapy is crucial 4

3. Inappropriate use of colloids: Reserve colloids for patients who fail to respond to crystalloids; unnecessary use increases costs and potential adverse effects 5, 6

4. Failure to reduce fluids after stabilization: After hemodynamic stabilization and clinical improvement, fluids must be reduced to avoid congestion 4

5. Use of NSAIDs/aspirin: These medications increase bleeding risk and should be strictly avoided 3