What is the management plan for a patient with dengue fever?

Management of Dengue Fever

For dengue patients, provide symptomatic management with careful fluid management tailored to their clinical status: oral rehydration (2,500-3,000 mL daily) for stable patients without shock, and immediate 20 mL/kg crystalloid boluses for those with dengue shock syndrome, while strictly avoiding aspirin and NSAIDs. 1, 2

Initial Assessment and Risk Stratification

Monitor for warning signs that indicate progression to severe disease:

• Rising hematocrit with rapidly falling platelet count 1, 3
• Severe abdominal pain, persistent vomiting 1, 2
• Lethargy, restlessness, or altered mental status 1, 2
• Mucosal bleeding 1, 3
• Signs of shock: tachycardia, hypotension, poor capillary refill, cold extremities, narrow pulse pressure 2

Obtain daily complete blood counts to track platelet counts and hematocrit levels, particularly during the critical phase (days 3-7 of illness). 1, 3

Fluid Management for Stable Patients (No Shock)

Encourage oral hydration targeting 2,500-3,000 mL daily, which evidence shows 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
• Practical approach: encourage 5 or more glasses of fluid throughout the day 1

Do NOT administer 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. 4, 1

Fluid Management for Dengue Shock Syndrome

Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes. 4, 1, 2

Reassess immediately after each bolus for signs of improvement:

• Improvement in tachycardia and tachypnea 1
• Normal capillary refill time, warm and dry extremities 1, 2
• Well-felt peripheral pulses, return to baseline mental status 1, 2
• Adequate urine output 1, 2

If shock persists after initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy. 1, 2

For severe dengue shock with pulse pressure <10 mmHg or refractory shock, consider colloid solutions (gelafundin or albumin), which provide faster resolution of shock compared to crystalloids alone (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (mean 31.7 mL/kg versus 40.63 mL/kg). 1, 3

Management of Refractory Shock

Stop fluid resuscitation immediately if signs of fluid overload develop (hepatomegaly, pulmonary rales, respiratory distress) and switch to inotropic support. 1, 2

For persistent hypotension despite adequate fluid resuscitation:

• Cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 2
• 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 are associated with major increases in mortality 1

Pain and Fever Management

Use acetaminophen (paracetamol) at standard doses for pain and fever relief. 1, 3, 2

Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk and worsening of bleeding tendencies. 1, 3, 5

Management of Bleeding Complications

For significant bleeding, blood transfusion may be necessary, maintaining hemoglobin at a minimum of 10 g/dL as oxygen delivery depends on hemoglobin concentration. 1, 2

Monitoring During Treatment

Track these clinical indicators of adequate tissue perfusion:

• Normal capillary refill time, absence of skin mottling 1, 2
• Warm and dry extremities, well-felt peripheral pulses 1, 2
• Return to baseline mental status 1, 2
• Adequate urine output (>0.5 mL/kg/hour in adults) 3, 2

Monitor hematocrit closely, as rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation. 2

Critical Pitfalls to Avoid

Do not delay fluid resuscitation in established dengue shock syndrome, as once hypotension occurs, cardiovascular collapse may rapidly follow. 1 Blood pressure alone is not a reliable endpoint in children 1

Do not continue aggressive fluid resuscitation once signs of fluid overload appear (hepatomegaly, rales, respiratory distress). 1, 2 Evidence shows that aggressive shock management combined with judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1

Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock. 1

Do not use restrictive fluid strategies in established dengue shock syndrome, as moderate-quality evidence shows no survival benefit from colloid restriction, and three RCTs demonstrated near 100% survival with aggressive fluid management. 1

Discharge Criteria

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

• Afebrile for at least 48 hours without antipyretics 3
• Resolution or significant improvement of symptoms 3
• Stable hemodynamic parameters for at least 24 hours without support 3
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults) 3
• Laboratory parameters returning to normal ranges 3

Instruct patients to monitor temperature twice daily after discharge and return if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop. 3

Supportive Care

Resume age-appropriate diet as soon as appetite returns. 1

For persistent fever beyond 5 days with hemodynamic instability, broaden management to include coverage for potential secondary infections and obtain blood/urine cultures and chest radiograph. 3