What are the key recommendations for managing dengue according to the Department of Health (DOH) Philippine Society of Microbiology and Infectious Diseases (PSMID) guideline?

Management of Dengue According to DOH-PSMID Guidelines

I cannot provide specific recommendations from the DOH-PSMID (Department of Health - Philippine Society of Microbiology and Infectious Diseases) guideline as this document was not included in the evidence provided. However, I can provide comprehensive dengue management recommendations based on the highest quality available guidelines.

Core Management Principles

Symptomatic management is the cornerstone of dengue treatment, as no specific antiviral therapy is currently approved, with daily complete blood count monitoring essential to track platelet counts and hematocrit levels. 1, 2

Fluid Management Strategy

For patients without shock:

• Ensure adequate oral hydration with oral rehydration solutions for moderate dehydration, targeting more than 2500ml daily 1
• Avoid routine bolus intravenous fluids in patients with severe febrile illness who are NOT in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes 2

For dengue shock syndrome (DSS):

• Administer an initial fluid bolus of 20 mL/kg isotonic crystalloid over 5-10 minutes with careful reassessment afterward 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
• Consider colloid solutions (gelafundin, dextran, or albumin) for severe shock when crystalloids prove inadequate, as colloids provide faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (mean 31.7 mL/kg versus 40.63 mL/kg) 2, 3, 4

Critical Phase Monitoring (Days 3-7)

Watch for warning signs of progression to severe disease: 1, 2

• High hematocrit with rapidly falling platelet count
• Severe abdominal pain
• Persistent vomiting
• Lethargy or restlessness
• Mucosal bleeding
• Rising hematocrit (20% increase) with falling platelets indicates impending shock 5

Monitor clinical indicators of adequate tissue perfusion: 2

• Normal capillary refill time
• Absence of skin mottling
• Warm and dry extremities
• Well-felt peripheral pulses
• Return to baseline mental status
• Adequate urine output (>0.5 mL/kg/hour in adults)

Pain and Fever Management

Use acetaminophen at standard doses for pain and fever relief. 1

Critical pitfall: Never use aspirin or NSAIDs under any circumstances due to high bleeding risk. 1, 2

Management of Refractory Shock

For persistent tissue hypoperfusion despite adequate fluid resuscitation: 2

• Cold shock with hypotension: titrate epinephrine as first-line vasopressor
• Warm shock with hypotension: titrate norepinephrine as first-line vasopressor
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%

Watch for signs of fluid overload and switch to inotropic support instead of continuing aggressive fluid resuscitation: 2

• Hepatomegaly
• Rales on lung examination
• Respiratory distress

Bleeding Management

Blood transfusion may be necessary in cases of significant bleeding. 1, 2

Prophylactic platelet transfusion is not recommended. 6

Discharge Criteria

Patients can be discharged when: 1

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

Post-discharge instructions: 1

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

Diagnostic Confirmation

For patients with symptoms present for more than 5-7 days, diagnosis is confirmed by positive PCR or IgM capture ELISA. 7, 1

For patients with possible exposure to both dengue and Zika virus, perform nucleic acid amplification tests (NAATs) on serum collected ≤7 days after symptom onset. 7, 1

Key Pitfalls to Avoid

• Do not delay fluid resuscitation in patients showing signs of shock 1, 2
• Do not administer excessive fluid boluses in patients without shock, which can lead to fluid overload and respiratory complications 2
• Do not fail to recognize the critical phase (typically days 3-7) when plasma leakage can rapidly progress to shock 2
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear 2
• Do not avoid drainage of pleural effusion or ascites unnecessarily, as this can lead to severe hemorrhages and sudden circulatory collapse 5