What is the management for dengue fever in the critical phase without shock?

Management of Dengue Fever in Critical Phase Without Shock

The cornerstone of managing dengue fever in the critical phase without shock is careful fluid management with oral rehydration, aiming for more than 2500ml daily intake, while avoiding excessive fluid administration that could lead to fluid overload. 1

Monitoring Parameters

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels, which are crucial indicators of disease progression 1, 2
• Monitor for warning signs of progression to severe disease, including:
  • Persistent vomiting
  • Severe abdominal pain
  • Lethargy or restlessness
  • Mucosal bleeding
  • Rising hematocrit with falling platelet count 1, 2
• Ultrasound assessment for gallbladder wall thickening can help detect early plasma leakage with a positive likelihood ratio of 2.14 (95% CI 1.12-4.12) 3
• Watch for clinical indicators of adequate tissue perfusion:
  • Normal capillary refill time
  • Absence of skin mottling
  • Warm and dry extremities
  • Well-felt peripheral pulses
  • Normal mental status
  • Adequate urine output 2

Fluid Management

• Ensure adequate oral hydration with oral rehydration solutions for moderate dehydration 1
• Target more than 2500ml daily fluid intake 1
• Avoid routine use of bolus intravenous fluids in patients who are not in shock, as this can lead to fluid overload and respiratory complications 2, 4
• If oral intake is insufficient, consider maintenance IV fluids without boluses 2
• Monitor for signs of fluid overload, particularly during the recovery phase 2

Pain and Symptom Management

• Use acetaminophen at standard doses for pain and fever relief 1
• Strictly avoid aspirin and NSAIDs due to increased bleeding risk 1, 2, 4
• For persistent symptoms despite adequate management, consider evaluating for secondary infections 1

Management of Complications

• For clinical fluid accumulation (ascites, pleural effusion):
  • Avoid drainage procedures when possible as they can lead to severe hemorrhages and sudden circulatory collapse 5
  • Monitor closely for signs of respiratory compromise 4
• For significant bleeding:
  • Blood transfusion may be necessary 1, 2
  • Consider fresh frozen plasma and platelet transfusions if disseminated intravascular coagulation (DIC) develops 5

Critical Phase Management Algorithm

1. Assess for warning signs and plasma leakage (clinical fluid accumulation, hemoconcentration) 1
2. Ensure adequate oral hydration (>2500ml daily) 1
3. Monitor vital signs, hematocrit, and platelet count at least daily 1, 2
4. Administer acetaminophen for symptom relief 1
5. If unable to maintain adequate oral intake, initiate maintenance IV fluids 2
6. If signs of shock develop (hypotension, tachycardia, poor capillary refill), immediately administer 20 mL/kg crystalloid bolus 1, 2

Common Pitfalls to Avoid

• Administering excessive fluid boluses in patients without shock can lead to fluid overload and respiratory complications 2, 4
• Using NSAIDs or aspirin which can worsen bleeding tendencies 1, 2, 4
• Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 2
• Delaying fluid resuscitation if signs of shock develop 2, 4
• Attempting drainage of pleural effusion or ascites, which can lead to severe hemorrhage 5

Discharge Criteria

• Afebrile for at least 48 hours without antipyretics 1
• Improved general condition and return to baseline mental status 1
• Stable hemodynamic parameters for at least 24 hours 1
• Laboratory parameters returning to normal ranges 1
• Adequate urine output (>0.5 mL/kg/hour in adults) 1