What is the management of dengue?

Management of Dengue Fever

Core Management Principle

Dengue management is primarily supportive with no specific antiviral therapy available; the cornerstone is careful fluid management tailored to disease severity, with acetaminophen for symptom control and strict avoidance of aspirin and NSAIDs. 1, 2, 3

---

Initial Assessment and Monitoring

Essential Monitoring Parameters

• Daily complete blood count to track platelet counts and hematocrit levels, which are critical indicators of disease progression 1, 2, 4
• Monitor for warning signs of severe dengue: persistent vomiting, severe abdominal pain, lethargy or restlessness, mucosal bleeding, and high hematocrit with rapidly falling platelet count 1, 2, 4
• A rise in hematocrit of 20% along with continuing drop in platelet count is an important indicator for onset of shock 5

Diagnostic Confirmation

• PCR testing is positive early in disease (≤7 days after symptom onset) 1, 4
• IgM capture ELISA becomes positive after 5-7 days of symptoms 1, 4

---

Fluid Management Algorithm

For Patients WITHOUT Shock

• Ensure adequate oral hydration with more than 2500-3000 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1, 2, 4
• Encourage 5 or more glasses of fluid throughout the day 2
• 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)

Initial resuscitation protocol:

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes 1, 2, 4
• Reassess immediately after each bolus for signs of improvement: tachycardia and tachypnea improvement, better capillary refill, warming of extremities, improved mental status 2
• Repeat crystalloid boluses up to total of 40-60 mL/kg in the first hour if shock persists 2

Escalation to colloids:

• Consider colloid solutions (gelafundin, albumin, or dextran) for severe shock when crystalloids alone are insufficient, as moderate-quality evidence shows colloids achieve 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 for crystalloids) 2, 6

Vasopressor therapy for 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, 7
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy are associated with major increases in mortality 2

---

Symptom Management

Pain and Fever Control

• Acetaminophen at standard doses is the ONLY recommended analgesic for pain and fever relief 1, 2, 4
• Avoid aspirin and NSAIDs under any circumstances due to increased bleeding risk and potential for worsening hemorrhagic complications 1, 2, 4, 8

---

Management of Complications

Bleeding

• Blood transfusion may be necessary for significant bleeding 1, 2, 4
• Some patients develop DIC and need supportive therapy with blood products (blood, FFP, and platelet transfusions) 5

Respiratory Support

• Oxygen is mandatory in all patients with shock 5
• For respiratory distress and/or persistent hypoxemia despite oxygen therapy, consider non-invasive ventilation if available and staff is adequately trained 1
• If intubation is necessary, ketamine with atropine premedication is suggested for sedation to maintain cardiovascular stability 1

Fluid Overload

• Stop fluid resuscitation immediately if hepatomegaly, pulmonary rales, or respiratory distress develop and switch to inotropic support 2
• Evidence shows that aggressive shock management combined with judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 2

---

Critical Pitfalls to Avoid

Fluid Management Errors

• Do NOT continue aggressive fluid resuscitation once signs of fluid overload appear 2
• Do NOT use restrictive fluid strategies in established dengue shock syndrome, as moderate-quality evidence shows no survival benefit from colloid restriction, and restrictive fluids showed harm with increased need for rescue fluid 2
• Do NOT delay fluid resuscitation in patients showing signs of shock, as cardiovascular collapse may rapidly follow once hypotension occurs 2

Medication Errors

• Never use aspirin or NSAIDs, which worsen bleeding tendencies 2, 8

Monitoring Failures

• Do NOT fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 2
• Blood pressure alone is not a reliable endpoint in children 2

---

Special Populations

Pregnant Women

• Acetaminophen remains the safest analgesic option for pregnant women with dengue fever 1, 4

Children

• Acetaminophen dosing should be carefully calculated based on weight 1, 4
• Careful fluid management is particularly important in children with dengue shock syndrome 1
• Crystalloid solutions are first-line for resuscitation, with colloids reserved for severe cases 2

---

Discharge Criteria

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

• Afebrile for at least 48 hours without antipyretics 4
• Stable hemodynamic parameters for at least 24 hours without support (normal heart rate, stable blood pressure, normal capillary refill) 4
• Adequate urine output (>0.5 mL/kg/hour in adults) 4
• Resolution or significant improvement of symptoms and return to baseline mental status 4
• Laboratory tests returning to normal ranges 4

Post-discharge instructions:

• Monitor and record temperature twice daily 4
• Return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 4