What are the management strategies for dengue based on its severity classification?

Dengue Severity Classification and Management

Dengue is classified into three categories—dengue without warning signs (managed with oral rehydration), dengue with warning signs (requiring close monitoring and potential IV fluids), and severe dengue including dengue shock syndrome (requiring immediate aggressive fluid resuscitation with 20 mL/kg crystalloid boluses)—with management success depending on recognizing the critical phase (days 3-7) when plasma leakage can rapidly progress to shock. 1, 2

Severity Classification

Dengue Without Warning Signs

• Patients present with fever and typical dengue symptoms but lack indicators of plasma leakage or severe disease 2
• These patients can be managed with oral rehydration targeting 2,500-3,000 mL daily fluid intake, which evidence shows reduces hospitalization rates 1, 2

Dengue With Warning Signs

• Warning signs include: persistent vomiting, severe abdominal pain, lethargy/restlessness, mucosal bleeding, rising hematocrit with rapidly falling platelet count, clinical fluid accumulation (ascites/pleural effusion), and liver enlargement 1, 2, 3
• A rise in hematocrit of 20% along with continuing platelet drop is a critical indicator for impending shock 4
• These patients require hospitalization with close monitoring but avoid routine bolus IV fluids if not in shock, as this increases fluid overload risk without improving outcomes 1, 3

Severe Dengue (Dengue Shock Syndrome)

• Shock indicators include: tachycardia, hypotension, poor capillary refill (<2 seconds), altered mental status, cold extremities, narrow pulse pressure, and skin mottling 1, 2
• This represents a medical emergency with potential death within 12-24 hours without prompt treatment 4

Management Algorithm by Severity

Non-Shock Dengue Management

• Oral rehydration is first-line: Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water; avoid soft drinks due to high osmolality 1, 2
• Encourage 5 or more glasses throughout the day, targeting approximately 2,500-3,000 mL daily 1
• Pain and fever control: Use acetaminophen (paracetamol) only; strictly avoid aspirin and NSAIDs due to increased bleeding risk 1, 2, 3
• Resume age-appropriate diet as soon as appetite returns 1
• Daily complete blood count monitoring to track platelet counts and hematocrit levels 1, 3

Dengue Shock Syndrome Management

Initial Fluid Resuscitation

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes 1, 2, 3
• Reassess immediately after each bolus for signs of improvement: improved tachycardia and tachypnea, better capillary refill, warming of extremities, improved mental status 1, 2
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 1, 2
• Crystalloids are first-line for moderate shock; colloids (dextran 70 or hydroxyethyl starch) may be considered for severe shock when available, as 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) 1, 5, 6
• If colloids are used, hydroxyethyl starch is preferable to dextran 70 due to fewer adverse reactions, though efficacy is similar 6

Critical Monitoring During Resuscitation

• Target endpoints: Normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, adequate urine output 1, 2
• Monitor hematocrit closely—rising hematocrit indicates ongoing plasma leakage requiring continued resuscitation 2
• Stop fluid resuscitation immediately if signs of fluid overload develop: hepatomegaly, pulmonary rales, or respiratory distress 1, 3

Management of Refractory Shock

• If shock persists despite adequate fluid resuscitation (40-60 mL/kg), switch to inotropic support rather than continuing aggressive fluid administration 1, 2
• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 2
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 2
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy significantly increase mortality 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1

Management of Complications

Bleeding Management

• Blood transfusion may be necessary in cases of significant bleeding 1, 3
• Maintain hemoglobin at minimum of 10 g/dL, as oxygen delivery depends on hemoglobin concentration 2
• Some patients develop disseminated intravascular coagulation requiring supportive therapy with blood products (blood, fresh frozen plasma, platelet transfusions) 4
• Prophylactic platelet transfusion is not recommended 7

Fluid Accumulation (Pleural Effusion/Ascites)

• Polyserositis is common in dengue shock syndrome 4
• Avoid drainage if possible, as it can lead to severe hemorrhages and sudden circulatory collapse 4
• Manage with judicious fluid strategy and monitor for respiratory compromise 3

Critical Pitfalls to Avoid

Fluid Management Errors

• Do not administer routine bolus IV fluids in patients with severe febrile illness who are NOT in shock—this increases fluid overload and respiratory complications without improving outcomes 1, 3
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 1
• Do not use restrictive fluid strategies in established dengue shock syndrome—moderate-quality evidence shows no survival benefit from colloid restriction, and aggressive fluid management achieves near 100% survival 1
• Do not delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow 1
• Avoid overhydration particularly during the recovery phase, which can lead to pulmonary edema 1

Medication Errors

• Never use aspirin or NSAIDs—these worsen bleeding tendencies due to antiplatelet effects and increased bleeding risk 1, 2, 3

Monitoring Failures

• Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 3
• Blood pressure alone is not a reliable endpoint in children—use multiple perfusion parameters 1
• Adequate monitoring during the critical phase is essential to prevent progression 1

Special Considerations

Secondary Hemophagocytic Lymphohistiocytosis

• This is a potentially fatal complication of dengue that needs recognition 7
• Specific management with steroids or intravenous immunoglobulin may improve outcomes 7

Organ Involvement

• Organ impairment in severe dengue should be carefully looked for and managed appropriately 7
• Correction of electrolyte and metabolic disturbances is important 4
• Oxygen is mandatory in all patients with shock 4