What is the management of dengue (Dengue Fever) with and without warning signs?

Management of Dengue Fever

Dengue Without Warning Signs (Outpatient Management)

For patients with dengue fever without warning signs, focus on aggressive oral hydration (>2500ml daily), acetaminophen for symptom control, and daily monitoring for progression to severe disease. 1

Fluid Management

• Ensure adequate oral hydration with oral rehydration solutions for moderate dehydration, targeting more than 2500ml daily. 1
• Patients without signs of shock should be managed with oral rehydration rather than intravenous fluids. 2

Symptomatic Treatment

• Administer acetaminophen (paracetamol) at standard doses for pain and fever relief. 1, 2
• Absolutely avoid aspirin and NSAIDs under any circumstances due to increased bleeding risk and potential thrombocytopenia. 1, 2, 3

Monitoring Requirements

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels. 1, 2
• Monitor for warning signs of progression to severe disease including: 1, 2
  • Persistent vomiting
  • Severe abdominal pain
  • Lethargy or restlessness
  • Mucosal bleeding
  • Rising hematocrit with rapidly falling platelet count

Discharge Criteria

• Patients can be discharged when afebrile for at least 48 hours without antipyretics. 1
• Resolution or significant improvement of symptoms is required. 1
• Laboratory parameters should be returning to normal ranges. 1
• Patients must maintain adequate oral intake and urine output (>0.5 mL/kg/hour in adults). 1

Post-Discharge Instructions

• Patients should monitor temperature twice daily and return immediately if fever rises to ≥38°C on two consecutive readings or if any warning signs develop. 1

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Dengue With Warning Signs or Severe Dengue (Inpatient Management)

For dengue with warning signs or dengue shock syndrome, immediate hospitalization with aggressive fluid resuscitation using 20 mL/kg crystalloid boluses is critical, with readiness to escalate to colloids and vasopressors if shock persists. 4, 1, 2

Initial Fluid Resuscitation for Dengue Shock Syndrome

• Administer 20 mL/kg of isotonic crystalloid as the initial bolus over 5-10 minutes with immediate reassessment. 4, 1, 2
• If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour may be necessary. 2
• For severe dengue shock syndrome, colloid solutions (dextran, gelafundin, or albumin) may be beneficial when available, with moderate-quality evidence showing benefit for time to resolution of shock (RR 1.09; 95% CI 1.00-1.19). 4, 2

This recommendation is based on moderate-quality evidence from a pediatric RCT of 222 patients specifically examining dengue shock syndrome. 4 The evidence for colloids in dengue shock is stronger than for other shock states, where colloids showed no benefit. 4

Critical Monitoring During Resuscitation

• 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, and adequate urine output. 2
• Monitor closely for signs of fluid overload: hepatomegaly, rales on lung examination, or respiratory distress. 2
• A rise in hematocrit of 20% along with continuing drop in platelet count is an important indicator for onset of shock. 5

Management of Refractory Shock

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor. 2
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor. 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%. 2

Management of Complications

• Blood transfusion may be necessary in cases of significant bleeding. 1, 2
• For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required. 2
• Oxygen is mandatory in all patients with shock. 5

Critical Phase Recognition (Days 3-7)

The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock—this is when most severe complications occur. 2, 6 Failure to recognize this phase and provide adequate monitoring is a common pitfall. 2

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Key Clinical Pitfalls to Avoid

• Do not administer excessive fluid boluses in patients without shock, as this can lead to fluid overload and respiratory complications. 2, 3
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear; switch to inotropic support instead. 2
• Do not use restrictive fluid strategies in established dengue shock syndrome—aggressive fluid management improves outcomes. 2
• Do not delay fluid resuscitation in patients showing signs of shock. 1, 3
• Avoid invasive procedures when possible during the acute phase, especially if coagulopathy is present. 3
• Avoid drainage of pleural effusion or ascites as it can lead to severe hemorrhages and sudden circulatory collapse. 5