What is the treatment approach for dengue?

Treatment Approach for Dengue

The treatment of dengue primarily involves supportive care with careful fluid management, where crystalloid solutions are recommended as first-line therapy for dengue shock syndrome, while avoiding routine use of bolus intravenous fluids in patients with severe febrile illness who are not in shock. 1, 2

Initial Assessment and Classification

• Assessment for warning signs of severe dengue is crucial, including high hematocrit with rapidly falling platelet count, severe abdominal pain, persistent vomiting, lethargy or restlessness, and mucosal bleeding 1
• Monitoring for signs of shock (tachycardia, hypotension, poor capillary refill, altered mental status) is essential in the initial evaluation 1, 2
• Dengue typically presents with fever, headache, retro-orbital pain, muscle/joint pain, and rash, with warning signs typically appearing around days 3-7 of illness 3, 4

Fluid Management

• For patients without shock, oral rehydration with fluids containing electrolytes is the first-line treatment 1, 2
• For dengue shock syndrome, an initial fluid bolus of 20 mL/kg of isotonic crystalloid solution is recommended, with careful reassessment afterward 5, 2
• Evidence from multiple pediatric RCTs (682 patients) shows no mortality benefit for noncrystalloid fluids compared to crystalloid fluids in dengue shock syndrome (RR, 0.98; 95% CI, 0.96–1.00) 5
• For severe dengue shock syndrome that is unresponsive to initial crystalloid therapy, colloid solutions may be considered when available 2
• Avoid routine use of bolus intravenous fluids in patients with severe febrile illness who are not in shock, as this can lead to fluid overload and respiratory complications 5, 2

Monitoring Parameters

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

Medication Management

• Acetaminophen/paracetamol is recommended for fever and pain management 3, 4
• NSAIDs and aspirin must be strictly avoided due to increased bleeding risk 2, 3, 4
• There is currently no specific antiviral therapy approved for dengue treatment 2, 6
• Corticosteroids have shown no benefit in preventing progression to severe illness or reducing mortality in children with dengue hemorrhagic fever (very low quality evidence) 7

Management of Complications

• For patients with persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required 1, 2
• Blood transfusion may be necessary in cases of significant bleeding 1, 2
• For severe thrombocytopenia with bleeding, platelet transfusions may be considered 6, 8

Common Pitfalls to Avoid

• Administering excessive fluid boluses in patients without shock can lead to fluid overload and respiratory complications 2
• Failing to recognize the critical phase (days 3-7 of illness) when plasma leakage can rapidly progress to shock 2, 3
• Using aspirin or NSAIDs, which can worsen bleeding tendencies 2, 3, 4
• Delaying fluid resuscitation in patients with dengue shock syndrome 2
• Inadequate monitoring of patients during the critical phase of illness 2, 3

Hospitalization Criteria

• Hospitalization is recommended for patients with moderate to severe dengue, especially those with warning signs 1
• Admission to ICU is indicated for children requiring ventilatory support, having impending respiratory failure, sustained tachycardia, inadequate blood pressure, or altered mental status 1
• Patients with persistent vomiting may require hospitalization for intravenous fluid therapy 3