What is the treatment approach for dengue?

Dengue Treatment Approach

The cornerstone of dengue treatment is symptomatic management with appropriate fluid therapy, as there is currently no specific antiviral therapy approved for dengue. 1

Classification and Assessment

• Dengue presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash, with a spectrum ranging from mild febrile illness to dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS) 2
• Monitor 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 1
• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels, particularly during the critical phase (days 3-7 of illness) 1, 2

Fluid Management Algorithm

For patients without shock:

• Ensure adequate oral hydration as first-line treatment 1
• Use oral rehydration solutions for moderate dehydration, aiming for more than 2500ml daily 2
• Avoid routine use of bolus intravenous fluids in patients with severe febrile illness who are not in shock 1, 3

For patients with dengue shock syndrome:

• Administer an initial fluid bolus of 20 mL/kg of isotonic crystalloid solution with careful patient reassessment afterward 4, 1
• For severe dengue shock syndrome, colloid solutions may be beneficial when crystalloids are ineffective 1
• For moderate dengue shock syndrome, crystalloid solutions remain first-line therapy 1

Pain and Symptom Management

• Use acetaminophen at standard doses for pain and fever relief 2
• Strictly avoid aspirin and other non-steroidal anti-inflammatory drugs due to increased bleeding risk 1, 2, 5

Management of Complications

• For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required 1, 3
• Blood transfusion may be necessary in cases of significant bleeding 1, 2
• Monitor for and manage fluid overload, which can lead to pulmonary edema, particularly during the recovery phase 1

Hospitalization Criteria

• Hospitalize patients with moderate to severe dengue, especially those with:
  • Warning signs (persistent vomiting, abdominal pain, lethargy, mucosal bleeding)
  • Rising hematocrit with falling platelet count
  • Respiratory distress or hypoxemia 3
• ICU admission is indicated for patients requiring ventilatory support, having impending respiratory failure, sustained tachycardia, inadequate blood pressure, or altered mental status 3

Monitoring Parameters

• Watch for clinical indicators of adequate tissue perfusion:
  • Normal capillary refill time
  • Absence of skin mottling
  • Warm and dry extremities
  • Well-felt peripheral pulses
  • Return to baseline mental status
  • Adequate urine output 1, 3

Common Pitfalls to Avoid

• Administering excessive fluid boluses in patients without shock, which can lead to fluid overload and respiratory complications 1
• Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 2
• Using aspirin or NSAIDs, which can worsen bleeding tendencies 1, 5
• Delaying fluid resuscitation in patients with dengue shock syndrome 1
• Inadequate monitoring during the critical phase of illness 1, 6

Special Considerations

• For pregnant women with dengue fever, acetaminophen remains the safest analgesic option 2
• In children, acetaminophen dosing should be carefully calculated based on weight 2
• The mortality rate for severe dengue with appropriate treatment is 1-5%, highlighting the importance of proper management 6