What are the clinical and practical aspects of managing dengue?

Clinical and Practical Management of Dengue Fever

Dengue fever requires prompt recognition, careful monitoring, and appropriate fluid management to prevent progression to severe disease and reduce mortality.

Clinical Presentation 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
• Common symptoms include fever, headache, retro-orbital pain, myalgia, arthralgia, and rash 2
• Diagnosis is confirmed by positive PCR (early in disease) or IgM capture ELISA (after 5-7 days of symptoms) 1, 2

Classification and Risk Stratification

• Dengue hemorrhagic fever is defined by bleeding phenomena, thrombocytopenia, and evidence of plasma leakage 2
• Dengue shock syndrome includes all criteria for DHF plus hypotension or narrow pulse pressure 2
• Monitor for warning signs of severe dengue, including:
  • Persistent vomiting
  • Severe abdominal pain
  • Lethargy or restlessness
  • Mucosal bleeding
  • Rising hematocrit with falling platelet count 1, 2

Monitoring Recommendations

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1, 2
• A rise in hematocrit of 20% along with a continuing drop in platelet count is an important indicator for the onset of shock 3
• Frequent recording of vital signs and determinations of hematocrit are important in evaluating treatment response 3

Fluid Management

For Non-Shock Patients

• Ensure adequate oral hydration with more than 2500ml daily for adults 1, 2
• Use oral rehydration solutions for moderate dehydration 2

For Dengue Shock Syndrome

• Administer an initial fluid bolus of 20 mL/kg crystalloid with careful reassessment afterward 1, 2
• Crystalloids are given as boluses as rapidly as possible, and as many as 2 to 3 boluses may be needed in profound shock 3
• Consider colloid solutions for severe shock when available, particularly in patients with massive plasma leakage and in whom a large volume of crystalloids has been given 2, 3
• Careful titration of fluid therapy is necessary with frequent reassessment for signs of worsening shock or fluid overload 4

Pain and Symptom Management

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

Management of Complications

Bleeding

• For significant bleeding, blood transfusion may be necessary 1, 2
• Prophylactic platelet transfusion is not recommended 6

Shock

• For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required 1, 2

Respiratory Support

• For patients with respiratory distress and/or persistent hypoxemia despite oxygen therapy, consider non-invasive ventilation if available 1
• If intubation is necessary, ketamine with atropine premedication is suggested for sedation to maintain cardiovascular stability 1

Organ Impairment

• Organ involvement in severe dengue should be carefully looked for and managed 6
• Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication that may require specific management with steroids or intravenous immunoglobulin 6

Special Populations

Pregnant Women

• Acetaminophen remains the safest analgesic option 1, 2

Children

• Acetaminophen dosing should be carefully calculated based on weight 1, 2
• Careful fluid management is particularly important in children with dengue shock syndrome 1

Discharge Criteria

• Afebrile for at least 48 hours without antipyretics 2
• Resolution or significant improvement of symptoms 2
• Improved general condition and return to baseline mental status 2
• Laboratory tests previously abnormal returning to normal ranges 2
• Stable hemodynamic parameters for at least 24 hours without support 2
• Adequate urine output (>0.5 mL/kg/hour in adults) 2

Post-Discharge Instructions

• Monitor and record temperature twice daily 2
• Return to healthcare facility if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 2

Common Pitfalls to Avoid

• Delaying fluid resuscitation in patients showing signs of shock 2
• Using aspirin or NSAIDs 1, 2
• Changing antibiotics based solely on persistent fever pattern without clinical deterioration 2
• Drainage of pleural effusion or ascites should be avoided when possible as it can lead to severe hemorrhages and sudden circulatory collapse 3