Dengue Fever Management Flowchart
Initial Assessment and Diagnosis
Begin with fever plus two or more of: headache, retro-orbital pain, myalgia, arthralgia, or rash occurring 4-8 days after potential mosquito exposure. 1
Diagnostic Testing Algorithm
- Days 1-7 of symptoms: Order dengue PCR/NAAT on serum 1, 2
- After day 5-7 of symptoms: Order IgM capture ELISA if PCR unavailable or negative 1, 2
- NS1 antigen: Useful days 1-10 after symptom onset 3
- Document vaccination history for yellow fever, Japanese encephalitis, and tick-borne encephalitis to avoid cross-reactivity 1
- Pregnant women: Test by NAAT for both dengue and Zika virus regardless of outbreak patterns 1
Baseline Laboratory Monitoring
Risk Stratification: Three Categories
Group A: Dengue Without Warning Signs
Clinical features: Fever, headache, retro-orbital pain, myalgia, arthralgia, rash, no warning signs 3
Management:
- Outpatient management appropriate 1
- Acetaminophen at standard doses for fever and pain 1, 2
- Never use aspirin or NSAIDs due to bleeding risk and platelet dysfunction 1, 2
- Oral hydration with oral rehydration solutions targeting >2500ml daily 1, 2
- Daily CBC monitoring 1, 2
- Patient education on warning signs 1
Group B: Dengue With Warning Signs (Requires Hospitalization)
- Persistent vomiting
- Abdominal pain or tenderness
- Clinical fluid accumulation (pleural effusion, ascites)
- Mucosal bleeding
- Lethargy or restlessness
- Hepatomegaly >2 cm
- Rising hematocrit with concurrent rapid platelet decline
These typically appear days 3-7 during defervescence 3
Management:
- Immediate hospitalization for close monitoring 3
- Intravenous isotonic crystalloid fluids 1
- Continuous monitoring: vital signs, urine output (target >0.5 mL/kg/hour), hematocrit every 4-6 hours 1, 2
- Daily CBC 1, 2
- Acetaminophen only for fever/pain 1, 2
- Monitor for progression to Group C 1
Group C: Severe Dengue (Dengue Shock Syndrome or Severe Bleeding)
Dengue Shock Syndrome criteria: 3
- Systolic BP <90 mmHg for >30 minutes OR
- Pulse pressure <20 mmHg (more sensitive early indicator) OR
- Signs of end-organ hypoperfusion: cold/clammy extremities, capillary refill ≥3 seconds, elevated lactate >2 mmol/L
Immediate Management:
- Administer 20 mL/kg isotonic crystalloid bolus over 5-10 minutes 1, 2
- Reassess immediately after bolus completion 1, 2
- If pulse pressure remains <10 mmHg or persistent shock, consider colloid solutions 1, 2
- Repeat 20 mL/kg boluses as needed based on reassessment 1
- If persistent tissue hypoperfusion despite adequate fluid resuscitation, initiate vasopressors (dopamine or epinephrine) 1, 2
- Continuous cardiac telemetry and pulse oximetry 1, 2
- Blood transfusion for significant bleeding 1
Critical Pitfall: Narrow pulse pressure <20 mmHg is an earlier indicator than absolute hypotension—monitor closely 3
Critical Pitfall: Avoid over-resuscitation as excessive fluids worsen outcomes due to underlying plasma leakage pathophysiology 3
Monitoring During Hospitalization
Daily Requirements
- Complete blood count to track platelet counts and hematocrit 1, 2
- Vital signs with attention to pulse pressure 3
- Urine output monitoring (target >0.5 mL/kg/hour in adults) 1, 2
- Fluid balance charting 1
If Fever Persists Beyond 5 Days
- Obtain blood and urine cultures 1
- Chest radiograph 1
- Broaden management to cover potential secondary bacterial infections if hemodynamically unstable 1
- Do not change antibiotics based solely on persistent fever without clinical deterioration or new findings 1
Discharge Criteria (All Must Be Met)
Patients can be safely discharged when: 1, 2
- Afebrile for ≥48 hours without antipyretics
- Resolution or significant improvement of symptoms
- Stable hemodynamic parameters for ≥24 hours without support (normal heart rate, stable BP, normal capillary refill)
- Adequate oral intake maintained
- Adequate urine output (>0.5 mL/kg/hour in adults)
- Laboratory parameters returning to normal ranges
Post-Discharge Instructions
- Monitor and record temperature twice daily 1
- Return immediately if: Temperature ≥38°C on two consecutive readings OR any warning signs develop 1
Special Population Considerations
Pregnant Women
Children
- Acetaminophen dosing must be carefully calculated based on weight 1, 2
- Same risk stratification and management principles apply 1
Key Pitfalls to Avoid
- Never use aspirin or NSAIDs when dengue cannot be excluded 1, 2
- Do not delay fluid resuscitation in patients showing signs of shock 1
- Monitor pulse pressure closely—it is more sensitive than absolute hypotension for detecting early shock 3
- Avoid over-resuscitation in dengue shock syndrome 3
- Do not discharge patients before meeting all discharge criteria 1, 2