What is the management protocol for dengue?

Dengue Management Protocol

Immediate Assessment and Diagnosis

Dengue management centers on aggressive fluid resuscitation for shock, strict avoidance of NSAIDs/aspirin, and close monitoring during the critical phase (days 3-7) when plasma leakage can rapidly progress to cardiovascular collapse. 1, 2, 3

Clinical Recognition

• Suspect dengue in patients presenting with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash occurring 4-8 days after mosquito exposure 2
• Confirm diagnosis with PCR/NAAT on serum for patients with symptoms for 1-7 days 2
• Use IgM capture ELISA if PCR is unavailable or for patients with symptoms >5-7 days 1, 2

Warning Signs Requiring Immediate Action

• Monitor for high hematocrit with rapidly falling platelet count, severe abdominal pain, persistent vomiting, lethargy or restlessness, and mucosal bleeding 3
• A rise in hematocrit of 20% along with continuing platelet drop signals impending shock 4

Monitoring Protocol

Daily Laboratory Surveillance

• Obtain complete blood count daily to track platelet counts and hematocrit levels 1, 2, 3
• Watch for thrombocytopenia with concurrent hemoconcentration, which differentiates dengue hemorrhagic fever from classical dengue fever 4

Clinical Parameters

• Assess capillary refill time, skin mottling, extremity warmth, peripheral pulses, mental status, and urine output (target >0.5 mL/kg/hour in adults) 3
• Monitor vital signs frequently during the critical phase 4

Fluid Management Strategy

For Patients WITHOUT Shock

• Ensure adequate oral hydration with >2500 mL daily using water, oral rehydration solutions, cereal-based gruels, soup, or rice water 1, 3
• Avoid routine bolus IV 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 3

For Dengue Shock Syndrome (DSS)

• Administer 20 mL/kg isotonic crystalloid bolus over 5-10 minutes with immediate reassessment 1, 2, 3
• Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists 3
• Switch to colloid solutions (dextran, gelafundin, or albumin) for severe shock with pulse pressure <10 mmHg or after large crystalloid volumes 2, 3
• Moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reduce total bolus volume needed (31.7 mL/kg versus 40.63 mL/kg for crystalloids) 3

Critical Fluid Management Pitfalls

• Stop fluid resuscitation immediately if hepatomegaly, pulmonary rales, or respiratory distress develop 3
• Do not continue aggressive fluids once signs of overload appear; switch to inotropic support instead 3
• Avoid drainage of pleural effusion or ascites as it can lead to severe hemorrhage and sudden circulatory collapse 4

Vasopressor Support for Refractory Shock

• For persistent tissue hypoperfusion despite adequate fluid resuscitation, initiate vasopressors 1, 3
• For cold shock with hypotension: titrate epinephrine as first-line 3
• For warm shock with hypotension: titrate norepinephrine as first-line 3
• Begin peripheral inotropic support immediately if central access is not readily available, as delays in vasopressor therapy increase mortality 3

Pain and Fever Management

Safe Analgesics

• Use acetaminophen at standard doses for pain and fever relief 1, 2, 3
• Calculate acetaminophen dosing carefully based on weight in children 1, 2
• Acetaminophen remains the safest option for pregnant women 1, 2

Absolute Contraindications

• Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk 1, 2, 3
• This prohibition applies even when dengue cannot be definitively excluded 2

Management of Bleeding Complications

• Blood transfusion may be necessary for significant bleeding 1, 2, 3
• Some patients develop DIC requiring supportive therapy with blood products (blood, FFP, platelet transfusions) 4
• Prophylactic platelet transfusion is not recommended 5

Respiratory Support

• Provide oxygen to all patients in shock 4
• For respiratory distress and/or persistent hypoxemia despite oxygen therapy, consider non-invasive ventilation if available and staff adequately trained 1
• If intubation necessary, use ketamine with atropine premedication to maintain cardiovascular stability 1

Special Populations

Pregnant Women

• Test by NAAT for both dengue and Zika virus regardless of outbreak patterns due to risk of adverse outcomes 2
• Acetaminophen remains the safest analgesic option 1, 2

Children

• Use weight-based acetaminophen dosing 1, 2
• Fluid management is particularly critical in pediatric DSS 1
• Blood pressure alone is not a reliable endpoint in children; monitor other perfusion parameters 3

Discharge Criteria

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

• Afebrile for ≥48 hours without antipyretics 2
• Resolution or significant improvement of symptoms 2
• Stable hemodynamic parameters for ≥24 hours without support 2
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults) 2
• Laboratory parameters returning to normal ranges 2

Post-Discharge Instructions

• Monitor and record temperature twice daily 2
• Return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 2

Common Clinical Pitfalls to Avoid

• Do not delay fluid resuscitation in patients showing signs of shock—cardiovascular collapse may rapidly follow 2, 3
• Do not fail to recognize the critical phase (typically days 3-7) when plasma leakage can rapidly progress 3
• Do not administer excessive fluid boluses in patients without shock, which leads to fluid overload and respiratory complications 3
• Do not change management based solely on persistent fever pattern without clinical deterioration or new findings 2
• Obtain blood and urine cultures and chest radiograph if fever persists to diagnose secondary bacterial infections 2