What are the management strategies for dengue (Dengue Virus)?

Management Strategies for Dengue Fever

The cornerstone of dengue management is supportive care with careful fluid management, monitoring for warning signs, and avoiding NSAIDs, as there is no specific antiviral therapy currently approved for dengue virus infection. 1, 2

Clinical Classification and Diagnosis

• Dengue presents with a spectrum ranging from mild febrile illness to dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS), with an incubation period of 4-8 days 1
• Diagnosis is confirmed by positive PCR (early in disease) or IgM capture ELISA (after 5-7 days of symptoms) 1
• Patients should be classified into risk groups based on clinical findings and presence of warning signs 3

Monitoring Recommendations

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1, 2
• Monitor for warning signs of severe dengue, including:
  • Persistent vomiting and severe abdominal pain 1, 2
  • Lethargy or restlessness 2
  • Mucosal bleeding 1
  • Rising hematocrit with falling platelet count (≥20% increase in hematocrit is a critical indicator for impending shock) 1, 4

Fluid Management

• For patients without shock:

  • Ensure adequate oral hydration with more than 2500ml daily 1
  • Use oral rehydration solutions for moderate dehydration 1, 2
  • Avoid routine use of bolus intravenous fluids in patients without shock 2

• For dengue shock syndrome:

  • Administer an initial fluid bolus of 20 mL/kg crystalloid with careful reassessment afterward 1, 2
  • For severe shock, consider colloid solutions when available 2
  • Crystalloids are recommended as first-line therapy for moderate shock 2
  • Early and effective replacement of plasma losses is critical for favorable outcomes 4

Pain and Symptom Management

• Acetaminophen (paracetamol) at standard doses is recommended for pain and fever relief 1, 2, 5
• Avoid aspirin and NSAIDs under any circumstances due to increased bleeding risk 1, 2, 5

Management of Complications

• For significant bleeding, blood transfusion may be necessary 2
• For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required 1, 2
• Polyserositis (pleural effusion, ascites) is common in dengue shock syndrome; drainage should be avoided when possible as it can lead to severe hemorrhages 4
• Oxygen therapy is mandatory for all patients with shock 4
• For patients developing DIC, supportive therapy with blood products (blood, FFP, and platelet transfusions) may be needed 4

Respiratory Support

• For patients with respiratory distress and/or persistent hypoxemia despite oxygen therapy, consider non-invasive ventilation if available and staff is adequately trained 6
• If intubation is necessary, ketamine with atropine premedication is suggested for sedation to maintain cardiovascular stability 6
• Place patients in semi-recumbent position (head of bed raised 30-45°) unless hemodynamically unstable 6
• Unconscious patients should be placed in lateral position with airway kept clear 6

Common Pitfalls to Avoid

• Delaying fluid resuscitation in patients showing signs of shock 1, 2
• Administering excessive fluid boluses in patients without shock, which can lead to fluid overload and respiratory complications 2, 7
• Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 2
• Using aspirin or NSAIDs which can worsen bleeding tendencies 1, 2
• Inadequate monitoring during the critical phase of illness 2

Special Populations

• For pregnant women with dengue fever, acetaminophen remains the safest analgesic option 1
• In children, acetaminophen dosing should be carefully calculated based on weight 1
• Careful fluid management is particularly important in children with dengue shock syndrome 6