What are the treatment guidelines for patients with suspected or confirmed dengue fever?

Treatment Guidelines for Suspected or Confirmed Dengue Fever

Crystalloid solutions are recommended as first-line fluid therapy for patients with dengue shock syndrome, while oral rehydration is appropriate for patients without shock. 1

Classification and Initial Assessment

• Assess for warning signs of severe dengue, including high hematocrit with rapidly falling platelet count, severe abdominal pain, persistent vomiting, lethargy or restlessness, and mucosal bleeding 2, 1
• Monitor for signs of shock, including tachycardia, hypotension, poor capillary refill, and altered mental status 2
• Classify patients into risk groups based on clinical findings and comorbidities to determine appropriate treatment setting (outpatient vs. hospital) 3

Fluid Management

Non-Shock Patients

• Oral rehydration is the first line of treatment for patients without shock 2, 1
• Avoid routine use of bolus intravenous fluids in patients with severe febrile illness who are not in shock 2, 1
• Consider using a fluid chart to improve oral fluid intake (target approximately 3,000 ml daily for adults) 4

Dengue Shock Syndrome

• For patients with dengue shock syndrome, administer an initial fluid bolus of 20 mL/kg of isotonic crystalloid solution with careful reassessment afterward 2, 1
• For severe dengue shock syndrome not responding to initial crystalloid therapy, colloid solutions may be beneficial 1, 5
• Be cautious with fluid administration to avoid overhydration, which can lead to pulmonary edema, particularly during the recovery phase 1

Monitoring Parameters

• Perform daily complete blood count monitoring, particularly to track platelet counts and hematocrit levels 1, 3
• Watch for clinical indicators of adequate tissue perfusion, including normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output 2, 1
• Be vigilant during the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 2, 1

Symptomatic Management

• Use acetaminophen (paracetamol) at standard doses (10-15 mg/kg every 4-6 hours, not exceeding 4 g/day in adults) for pain relief 6
• Avoid aspirin and other non-steroidal anti-inflammatory drugs due to increased bleeding risk 1, 6
• Monitor liver function tests when using acetaminophen, particularly in patients with pre-existing liver disease or signs of hepatic involvement 6

Management of Complications

• For patients with persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required 2, 1
• Blood transfusion may be necessary in cases of significant bleeding 2, 1
• If leakage leads to restriction of fluid use (pulmonary edema), consider adding vasopressors like norepinephrine 7

Common Pitfalls to Avoid

• Avoid administering excessive fluid boluses in patients without shock, which can lead to fluid overload and respiratory complications 1
• Do not use aspirin or NSAIDs under any circumstances due to high bleeding risk 1, 6
• Avoid delaying fluid resuscitation in patients with dengue shock syndrome 1
• Do not fail to recognize the critical phase when plasma leakage can rapidly progress to shock 1
• After stabilizing hemodynamics and clinical improvement, remember to reduce and discontinue fluids appropriately to avoid congestion 7