What is the treatment approach for dengue?

Dengue Treatment

Dengue treatment is primarily supportive with no specific antiviral therapy currently approved, focusing on careful fluid management, symptom control with acetaminophen only, and close monitoring for progression to severe disease during the critical phase (days 3-7). 1

Symptomatic Management

• Use acetaminophen (paracetamol) exclusively for fever and pain control. 1
• Strictly avoid aspirin and all NSAIDs due to increased bleeding risk from thrombocytopenia and platelet dysfunction. 1
• Encourage resumption of age-appropriate diet as soon as appetite returns. 1

Fluid Management Strategy

For Patients WITHOUT Shock

• Oral rehydration is the cornerstone of treatment for uncomplicated dengue. 1
• Target approximately 2,500-3,000 mL daily fluid intake (roughly 5 or more glasses throughout the day), which reduces hospitalization rates. 1
• 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
• Do NOT give routine bolus intravenous fluids to patients with severe febrile illness who are not in shock—this increases fluid overload and respiratory complications without improving outcomes. 1

For Dengue Shock Syndrome

Initial resuscitation:

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes. 1
• Reassess immediately after each bolus for signs of improvement: reduced tachycardia, improved capillary refill, warming of extremities, improved mental status. 1
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy. 1

Escalation for refractory shock:

• Switch to colloid solutions (dextran, gelafundin, or albumin) if shock persists despite adequate crystalloid resuscitation—moderate-quality evidence shows colloids achieve faster shock resolution (RR 1.09,95% CI 1.00-1.19) and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids). 1
• For cold shock with hypotension: titrate epinephrine as first-line vasopressor. 1
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor. 1
• Target age-appropriate mean arterial pressure and maintain ScvO2 >70%. 1

Monitoring Parameters

Daily laboratory monitoring:

• Complete blood count with particular attention to platelet counts and hematocrit levels. 1
• Rising hematocrit with falling platelets signals plasma leakage and impending shock. 1

Clinical perfusion indicators:

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

Warning signs requiring immediate escalation of care:

• Severe abdominal pain. 1
• Persistent vomiting. 1
• Lethargy or restlessness. 1
• Mucosal bleeding. 1
• Clinical fluid accumulation (ascites, pleural effusion). 1
• Hepatomegaly. 1

Management of Complications

• Blood transfusion may be necessary for significant bleeding, though this is uncommon with appropriate supportive care. 1
• Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop—these signal fluid overload requiring switch to inotropic support rather than continued fluids. 1

Critical Pitfalls to Avoid

The critical phase (days 3-7 of illness) is when plasma leakage occurs and patients can rapidly deteriorate:

• Failing to recognize this window leads to delayed intervention and increased mortality. 1
• Maintain heightened vigilance during this period even if patient appears stable. 1

Fluid management errors:

• Excessive fluid boluses in patients without shock cause pulmonary edema and respiratory failure—this is the most common iatrogenic complication. 1
• Conversely, delaying fluid resuscitation once shock develops significantly increases mortality as cardiovascular collapse rapidly follows. 1
• Do not use restrictive fluid strategies in established dengue shock syndrome—three RCTs demonstrate near 100% survival with aggressive fluid management, and restrictive approaches show no survival benefit. 1

Medication errors:

• Aspirin and NSAIDs worsen bleeding tendencies in the context of thrombocytopenia and must be strictly avoided. 1

Monitoring failures:

• Blood pressure alone is not a reliable endpoint in children—use the comprehensive perfusion indicators listed above. 1
• Begin peripheral inotropic support immediately if central access is not readily available, as delays in vasopressor therapy significantly increase mortality. 1