What is the recommended management for dengue fever?

Dengue Fever Management

Dengue management centers on aggressive oral rehydration for non-shock cases (targeting 2,500-3,000 mL daily) and immediate crystalloid boluses (20 mL/kg over 5-10 minutes) for dengue shock syndrome, with acetaminophen as the only acceptable analgesic. 1, 2

Risk Stratification and Monitoring

Critical Phase Recognition (Days 3-7):

• Monitor for shock indicators: tachycardia, hypotension (though unreliable in children), poor capillary refill (<2 seconds), altered mental status, cold extremities, and narrow pulse pressure 1, 2
• Track warning signs: persistent vomiting, severe abdominal pain, lethargy/restlessness, mucosal bleeding, rising hematocrit with rapidly falling platelet count 1, 2
• Perform daily complete blood counts to track hematocrit and platelet trends—a 20% rise in hematocrit signals impending shock 2, 3

Non-Shock Dengue Management

Oral Rehydration Protocol:

• Target 2,500-3,000 mL daily oral intake, which evidence demonstrates reduces hospitalization rates 1, 2
• Use any locally available fluids: water, oral rehydration solutions, cereal-based gruels, soup, rice water 1, 2
• Avoid soft drinks due to high osmolality 1, 2
• Encourage 5 or more glasses throughout the day 2

Symptomatic Management:

• Use acetaminophen (paracetamol) ONLY for fever and pain 1, 2
• Absolutely avoid aspirin and NSAIDs—these increase bleeding risk 2, 4
• Resume age-appropriate diet as appetite returns 2

Critical Pitfall: Do NOT give routine bolus IV fluids to patients with severe febrile illness who are NOT in shock—this increases fluid overload and respiratory complications without improving outcomes 2

Dengue Shock Syndrome Management

Immediate Resuscitation (First Hour):

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes 1, 2
• Reassess immediately after each bolus for improvement in tachycardia, tachypnea, capillary refill, and mental status 1, 2
• Repeat crystalloid boluses up to 40-60 mL/kg total in the first hour if shock persists 1, 2
• Evidence shows near 100% survival with aggressive fluid management 2

Escalation to Colloids:

• If shock persists despite adequate crystalloid resuscitation, switch to colloid solutions (gelafundin, albumin, or dextran) 2, 5
• Moderate-quality evidence shows colloids achieve faster shock resolution (RR 1.09,95% CI 1.00-1.19) and reduce total bolus volume needed (31.7 mL/kg vs 40.63 mL/kg for crystalloids) 2

Resuscitation Endpoints:

• Normal capillary refill time 1, 2
• Absence of skin mottling 1, 2
• Warm and dry extremities 1, 2
• Well-felt peripheral pulses 1, 2
• Return to baseline mental status 1, 2
• Adequate urine output 1, 2

Refractory Shock Management

When to Stop Fluids:

• Immediately halt fluid resuscitation if hepatomegaly, pulmonary rales, or respiratory distress develop—these signal fluid overload 1, 2
• Switch from fluids to inotropic support rather than continuing aggressive fluid administration 1, 2

Vasopressor Selection:

• Cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1, 2
• Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 1, 2, 5
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 2
• Begin peripheral inotropic support immediately if central access unavailable—delays in vasopressor therapy significantly increase mortality 2

Management of Complications

Bleeding:

• Maintain hemoglobin at minimum 10 g/dL, as oxygen delivery depends on hemoglobin concentration 1
• Blood transfusion may be necessary for significant bleeding 2, 4
• Fresh frozen plasma and platelet transfusions for DIC 3
• Prophylactic platelet transfusion is NOT recommended 6

Pleural Effusion/Ascites:

• Avoid drainage if possible—this can lead to severe hemorrhage and sudden circulatory collapse 4, 3
• Manage with judicious fluid strategy and monitor for respiratory compromise 4

Recovery Phase:

• Avoid overhydration during recovery phase, which can lead to pulmonary edema 2
• Evidence shows aggressive shock management combined with judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 2

Critical Pitfalls to Avoid

• Never delay fluid resuscitation in established dengue shock syndrome—cardiovascular collapse may rapidly follow once hypotension occurs 2
• Never use restrictive fluid strategies in dengue shock syndrome—three RCTs demonstrate near 100% survival with aggressive fluid management, and restrictive fluids in severe malaria showed harm with increased need for rescue fluid (17.6% vs 0.0%; P<0.005) 2
• Never fail to recognize the critical phase (days 3-7)—plasma leakage can rapidly progress to shock during this window 2, 4
• Never continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 1, 2