What is the recommended management for Dengue Hemorrhagic Fever (DHF)?

Management of Dengue Hemorrhagic Fever (DHF)

The cornerstone of DHF management is aggressive fluid resuscitation with crystalloids and colloids, close monitoring of hematocrit and platelet counts, and avoidance of aspirin/NSAIDs, with acetaminophen as the sole analgesic option. 1

Immediate Assessment and Monitoring

• Daily complete blood count monitoring is mandatory to track platelet counts and hematocrit levels, as a 20% rise in hematocrit with continuing platelet drop signals impending shock 1, 2
• Monitor continuously for warning signs including persistent vomiting, abdominal pain, lethargy, restlessness, mucosal bleeding, and rising hematocrit with falling platelet count 1, 3
• Frequent vital sign recording (every 15-30 minutes during shock) and serial hematocrit determinations are critical for evaluating treatment response 2, 4
• Use continuous cardiac telemetry and pulse oximetry for patients with dengue shock syndrome 1

Fluid Management Strategy

For DHF Without Shock (Grades I-II)

• Ensure adequate oral hydration targeting more than 2500ml daily with oral rehydration solutions 1, 3
• Close observation for progression to shock is essential, as these patients can deteriorate rapidly 2

For Dengue Shock Syndrome (Grades III-IV)

• Administer initial crystalloid bolus of 20-30 mL/kg (Lactated Ringer's) as rapidly as possible - 2 to 3 boluses may be needed in profound shock 1, 2, 5
• Follow with colloid solutions (synthetic plasma expanders or albumin) at 20 mL/kg for patients with massive plasma leakage or those requiring large crystalloid volumes 2, 5
• After initial resuscitation, continue alternating Lactated Ringer's and 5% dextrose in half-saline at twice the body weight per minute for the remaining first 24 hours 5
• The key pitfall is inadequate initial fluid resuscitation - do not delay fluid boluses in patients showing signs of shock 1, 6

Pain and Fever Management

• Acetaminophen at standard doses is the only acceptable analgesic for pain and fever relief 1, 3
• Aspirin and NSAIDs are absolutely contraindicated due to increased bleeding risk and platelet dysfunction 1, 6, 3
• For severe pain unresponsive to acetaminophen, consider opioid analgesics with careful monitoring 6

Management of Complications

Bleeding

• Blood transfusion is indicated for significant bleeding with hemodynamic compromise 1, 2
• Monitor hemoglobin and hematocrit closely during bleeding episodes 6
• Fresh frozen plasma and platelet concentrates should be given for correction of coagulopathy and thrombocytopenia 2, 7
• Do not transfuse platelets prophylactically based on count alone - reserve for active bleeding or procedures 4

Fluid Overload

• Pleural effusion and ascites are common and should not be drained unless causing severe respiratory compromise, as drainage can precipitate severe hemorrhage and circulatory collapse 2
• If fluid overload develops during the recovery phase, reduce infusion rate and consider diuretics cautiously 2
• In patients with renal impairment, use a restrictive fluid approach during the ascending limb with close monitoring for hemodynamic instability 8

Persistent Hypoperfusion

• For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors (dopamine or epinephrine) may be required 1, 3
• Oxygen is mandatory in all patients with shock 2

Critical Phase Management (Days 3-7)

• This is the most dangerous period when plasma leakage occurs - intensify monitoring during this window 4
• Do not discontinue fluids prematurely based on small improvements, as patients can deteriorate rapidly 2
• During the descending limb, if hematocrit rises, transiently increase hourly fluid input but monitor closely for pulmonary edema 8

Special Considerations

Renal Impairment

• Small increases in creatinine (0.3 mg/dL) should not prompt discontinuation of fluids if shock persists 2, 8
• In patients with acute kidney injury, balance fluid needs against risk of overload - may require continuous renal replacement therapy if pulmonary edema develops 8

Pregnant Women and Children

• Acetaminophen remains the safest analgesic option for pregnant women 1, 3
• In children, calculate acetaminophen dosing carefully based on weight 1, 3

Discharge Criteria

Patients can be discharged when ALL of the following are met: 1, 3

• Afebrile for at least 48 hours without antipyretics
• Resolution or significant improvement of symptoms
• Stable hemodynamic parameters for at least 24 hours without support
• Adequate urine output (>0.5 mL/kg/hour in adults)
• Laboratory parameters returning to normal ranges
• Rising platelet count with stable hematocrit

Post-Discharge Instructions

• Monitor temperature twice daily and return if fever ≥38°C on two consecutive readings 1
• Return immediately for warning signs including severe abdominal pain, persistent vomiting, bleeding, lethargy, or restlessness 1

Common Pitfalls to Avoid

• Failing to recognize abdominal pain as a warning sign of severe dengue 6
• Delaying fluid resuscitation while waiting for laboratory confirmation 1, 6
• Inadequate monitoring during the critical phase (days 3-7) 6
• Draining pleural effusions or ascites unnecessarily 2
• Using NSAIDs or aspirin under any circumstances 1, 3