What are the clinical practice guidelines for managing dengue?

Dengue Clinical Practice Guidelines Summary

General Management Principles

Dengue management centers on symptomatic care and meticulous fluid management, as no specific antiviral therapy exists. 1, 2

• Acetaminophen (paracetamol) is the only acceptable analgesic and antipyretic at 10-15 mg/kg every 4-6 hours (maximum 4 g/day in adults) for fever and severe body pain. 1, 3
• Absolutely avoid aspirin and NSAIDs under all circumstances due to significantly increased bleeding risk and potential for hemorrhagic complications. 1, 3
• Ensure adequate oral hydration with oral rehydration solutions for patients without shock, targeting >2500 mL daily. 1, 4
• Diagnosis is confirmed by PCR or IgM capture ELISA (for symptoms >5-7 days). 4

Monitoring Requirements

Daily complete blood count monitoring is mandatory to track platelet counts and hematocrit levels, particularly during the critical phase (days 3-7 of illness). 1, 4

Watch for warning signs of progression to severe dengue: 1, 4

• High hematocrit with rapidly falling platelet count (rise in hematocrit of 20% is critical indicator) 5
• Severe or persistent abdominal pain
• Persistent vomiting
• Lethargy, restlessness, or altered mental status
• Mucosal bleeding
• Hepatomegaly

Monitor clinical indicators of adequate perfusion: normal capillary refill time, absence of skin mottling, warm/dry extremities, well-felt peripheral pulses, baseline mental status, and adequate urine output (>0.5 mL/kg/hour). 1

Fluid Management for Dengue Shock Syndrome

For patients in dengue shock syndrome, immediately administer 20 mL/kg isotonic crystalloid bolus over 5-10 minutes with rapid reassessment. 1, 4

Initial Resuscitation Algorithm:

1. First bolus: 20 mL/kg crystalloid over 5-10 minutes 1
2. If shock persists: Repeat crystalloid boluses up to total 40-60 mL/kg in first hour 1
3. If still refractory: Switch to colloid solutions (dextran, gelafundin, or albumin) - moderate-quality evidence shows colloids achieve faster shock resolution (RR 1.09,95% CI 1.00-1.19) and require less total volume (31.7 mL/kg vs 40.63 mL/kg for crystalloids). 1, 4
4. If persistent shock despite adequate fluids: Add vasopressors 1, 4
   • Cold shock with hypotension: Epinephrine as first-line 1
   • Warm shock with hypotension: Norepinephrine as first-line 1, 6

Critical Fluid Management Pitfalls:

Do not use restrictive fluid strategies in established dengue shock syndrome - moderate-quality evidence shows no survival benefit, and restrictive fluids in similar conditions (severe malaria) showed harm with increased need for rescue fluid (17.6% vs 0.0%; P<0.005). 1

Conversely, avoid routine bolus IV fluids in patients with severe febrile illness who are NOT in shock - this increases risk of fluid overload and respiratory complications without improving outcomes. 1

Stop aggressive fluid resuscitation immediately when signs of fluid overload appear: hepatomegaly, pulmonary rales, respiratory distress, or symptomatic abdominal compartment syndrome. Switch to inotropic support instead. 1, 7

Management of Complications

For persistent tissue hypoperfusion despite adequate fluid resuscitation: Initiate vasopressors (dopamine or epinephrine), target age-appropriate mean arterial pressure and maintain ScvO2 >70%. 1, 4

For significant bleeding: Blood transfusion may be necessary; consider fresh frozen plasma and platelet transfusions if DIC develops. 4, 5

For symptomatic abdominal compartment syndrome: Early albumin for crystalloid-refractory shock and proactive monitoring can reduce need for invasive percutaneous drainage (7.7% vs 30% with standard therapy alone, P=0.025). 7

Avoid drainage of pleural effusion and ascites unless absolutely necessary, as this can lead to severe hemorrhage and sudden circulatory collapse. 5

Oxygen is mandatory in all patients with shock. 5

Discharge Criteria

Patients can be discharged when ALL of the following are met: 4

• Afebrile for ≥48 hours without antipyretics
• Stable hemodynamic parameters for ≥24 hours without support
• Resolution or significant improvement of symptoms
• Return to baseline mental status
• Adequate oral intake
• Adequate urine output (>0.5 mL/kg/hour in adults)
• Laboratory values returning to normal ranges

Post-discharge instructions: Monitor temperature twice daily; return immediately if temperature ≥38°C on two consecutive readings or any warning signs develop. 4

Special Populations

Pregnant women: Acetaminophen remains the safest analgesic option. 4, 3

Children: Calculate acetaminophen dosing carefully based on weight (10-15 mg/kg per dose). 4, 3

Key Clinical Pitfalls to Avoid

• Do not delay fluid resuscitation in patients showing signs of shock - this is a medical emergency requiring immediate intervention. 1, 3
• Do not fail to recognize the critical phase (typically days 3-7) when plasma leakage can rapidly progress to shock. 1, 3
• Do not continue aggressive fluids once fluid overload appears - this leads to pulmonary edema and ARDS, which worsens cerebral edema. 1
• Do not change antibiotics based solely on persistent fever without clinical deterioration or new findings - fever typically resolves within 5 days and is common in dengue. 4
• Do not use aspirin or NSAIDs under any circumstances. 1, 3