What is the management approach for patients with dengue, including asymptomatic, symptomatic, and severe cases, in the Indian clinical context, including treatment and prescription for both outpatient (OPD) and inpatient (IPD) settings?

Management of Dengue Fever in Indian Clinical Practice

Classification of Dengue

Dengue presents in three distinct clinical categories that determine management approach: dengue without warning signs (outpatient management), dengue with warning signs (hospitalization required), and severe dengue (ICU admission mandatory). 1

Dengue Without Warning Signs

• Presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash occurring 4-8 days after mosquito exposure 1
• Platelet count may be low but patient remains hemodynamically stable with no signs of plasma leakage 2
• These patients can be safely managed as outpatients with daily monitoring 1

Dengue With Warning Signs

• Warning signs include: severe abdominal pain, persistent vomiting, lethargy or restlessness, mucosal bleeding, high hematocrit with rapidly falling platelet count (rise in hematocrit of 20% along with continuing drop in platelets) 1, 3, 4
• These patients are at risk of progression to shock and require hospitalization for close monitoring 1
• The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock 3

Severe Dengue

• Includes dengue shock syndrome (hypotension or narrow pulse pressure <20 mmHg), severe bleeding, or organ impairment 5, 2
• Mortality can reach 1-5% without appropriate management but can be reduced to <0.5% with proper clinical care 5
• Requires immediate ICU admission and aggressive fluid resuscitation 3

OPD Prescription for Dengue Without Warning Signs

Rx for Dengue Fever (Outpatient Management)

Diagnosis: Dengue Fever without warning signs

Investigations:

• Complete Blood Count (CBC) - Daily monitoring mandatory 1, 3
• Dengue NS1 Antigen/PCR (if symptoms <7 days) 1
• Dengue IgM ELISA (if symptoms >5-7 days) 1

Treatment:

1. Tab. Paracetamol 500-650 mg PO q6h PRN for fever/pain 1, 3

   • Maximum dose: 4g/day
   • NEVER use Aspirin or NSAIDs (Ibuprofen, Diclofenac) - increases bleeding risk 1, 3

2. Oral Rehydration:

   • Target fluid intake: >2500-3000 mL daily (minimum 5 glasses throughout the day) 1, 3
   • Use ORS, water, cereal-based gruels, soup, rice water 3
   • Avoid soft drinks due to high osmolality 3

Instructions to Patient:

• Return immediately if any warning signs develop: severe abdominal pain, persistent vomiting (>3 episodes), bleeding from nose/gums, black stools, lethargy, restlessness, cold extremities 1, 3
• Monitor temperature twice daily - return if fever >38°C on two consecutive readings 1
• Daily CBC monitoring essential - bring reports for review 1
• Maintain fluid intake chart
• Adequate rest, avoid strenuous activity
• Resume normal diet as appetite returns 3

Follow-up: Daily until afebrile for 48 hours and platelet count improving 1

IPD Prescription for Dengue With Warning Signs

Rx for Dengue With Warning Signs (Inpatient Management)

Diagnosis: Dengue Fever with warning signs

Admission Orders:

Monitoring:

• Vital signs q2-4h (BP, HR, temperature, respiratory rate) 3
• CBC with hematocrit q6-12h - watch for rising hematocrit with falling platelets 1, 3
• Strict intake-output charting 3
• Watch for signs of plasma leakage: hepatomegaly, pleural effusion, ascites 4

Investigations:

• CBC with hematocrit - q6-12h 1
• Dengue NS1/PCR or IgM ELISA (as per timing) 1
• Liver function tests, Renal function tests 2
• Coagulation profile if bleeding present 4
• Blood grouping and cross-matching (keep ready) 3

IV Fluids:

• Start with 0.9% Normal Saline or Ringer's Lactate 3
• Maintenance rate initially, increase if signs of plasma leakage 3
• Avoid excessive fluids in non-shock patients - risk of pulmonary edema 3

Medications:

1. Tab/Syp Paracetamol 500-650 mg PO/IV q6h PRN 1
   • Absolute contraindication: Aspirin, NSAIDs 1, 3

Transfusion Triggers:

• Platelet transfusion: Only if active bleeding with platelet count <20,000/μL or <50,000/μL with ongoing hemorrhage 3, 4
• Fresh Frozen Plasma: If DIC develops with deranged coagulation 4
• Packed Red Blood Cells: If significant bleeding with falling hemoglobin 3

Discharge Criteria:

• Afebrile for ≥48 hours without antipyretics 1
• Resolution or significant improvement of symptoms 1
• Stable hemodynamic parameters for ≥24 hours 1
• Adequate oral intake 1
• Urine output >0.5 mL/kg/hour 1
• Laboratory parameters returning to normal 1

IPD Prescription for Severe Dengue/Dengue Shock Syndrome

Rx for Dengue Shock Syndrome (ICU Management)

Diagnosis: Severe Dengue with Shock

ICU Admission - Immediate Resuscitation Protocol:

Initial Assessment:

• Signs of shock: hypotension, narrow pulse pressure (<20 mmHg), cold extremities, delayed capillary refill (>2 seconds), altered mental status 3, 4
• Note: Blood pressure may be maintained initially in children despite shock 3

Immediate Fluid Resuscitation:

1. First Bolus: 20 mL/kg of 0.9% Normal Saline or Ringer's Lactate over 5-10 minutes 1, 3

   • Reassess immediately after bolus completion 1, 3
   • Look for improvement: decreased tachycardia, improved capillary refill, warming of extremities, improved mental status 3

2. If shock persists after first bolus:

   • Repeat crystalloid boluses up to total 40-60 mL/kg in first hour 3
   • After 40-60 mL/kg crystalloids, switch to colloids (Dextran 40 or 6% Hetastarch or 5% Albumin) at 10-20 mL/kg over 30-60 minutes 3, 4, 6
   • Moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09) and reduce total volume needed (31.7 vs 40.63 mL/kg) 3

Critical Monitoring:

• Stop fluid resuscitation immediately if signs of fluid overload develop: hepatomegaly, pulmonary rales, respiratory distress 3, 4
• Continuous cardiac monitoring and pulse oximetry 1
• Hourly vital signs and urine output 3
• Hematocrit q2-4h during resuscitation 3, 4
• Watch for abdominal compartment syndrome - measure intra-abdominal pressure if abdomen tense 6

Vasopressor Support (if shock persists despite adequate fluid resuscitation):

• For cold shock with hypotension: Inj. Adrenaline infusion 0.05-0.3 mcg/kg/min 3
• For warm shock with hypotension: Inj. Noradrenaline infusion 0.05-0.3 mcg/kg/min 3
• Target MAP appropriate for age 3
• Do not delay vasopressor therapy - delays associated with increased mortality 3

Medications:

1. Inj. Paracetamol 15 mg/kg IV q6h PRN (or oral if tolerating) 1
2. Oxygen supplementation - maintain SpO2 >95% 4

Blood Product Transfusion:

• Packed Red Blood Cells: If major bleeding with Hb <7 g/dL or hemodynamic instability 3, 4
• Fresh Frozen Plasma: 10-15 mL/kg if DIC with deranged PT/aPTT and active bleeding 4
• Platelet concentrate: 0.1-0.2 units/kg if platelet count <20,000/μL with active bleeding or <50,000/μL with major hemorrhage 4
• Cryoprecipitate: If fibrinogen <100 mg/dL 4

Management of Complications:

• Pleural effusion/Ascites: Avoid drainage unless causing severe respiratory compromise - drainage can cause severe hemorrhage and circulatory collapse 4
• Symptomatic Abdominal Compartment Syndrome: Consider percutaneous drainage only if causing hemodynamic or respiratory compromise 6
• Intubation (if required): Use high-risk intubation protocol with pre-oxygenation and experienced operator 6

Key Pitfalls to Avoid:

• Never continue aggressive fluid resuscitation once fluid overload signs appear - switch to inotropic support 3, 6
• Never delay fluid resuscitation in established shock - cardiovascular collapse may rapidly follow 3
• Never use restrictive fluid strategies in dengue shock syndrome - three RCTs show near 100% survival with aggressive fluid management 3
• Never drain pleural effusion/ascites routinely - high risk of hemorrhage and collapse 4

Enhanced ICU Supportive Measures (for refractory cases):

• Early albumin for crystalloid-refractory shock - shown to decrease positive fluid balance and reduce symptomatic abdominal compartment syndrome (7.7% vs 30%) 6
• Proactive monitoring and management of abdominal compartment syndrome 6
• These interventions reduced PICU mortality from 16.6% to 6.3% in severe dengue 6

Discharge Criteria (same as above):

• Afebrile ≥48 hours without antipyretics, stable hemodynamics ≥24 hours, adequate oral intake, urine output >0.5 mL/kg/hour, improving laboratory parameters 1

Common Pitfalls in Dengue Management

• Failing to recognize the critical phase (days 3-7) when plasma leakage rapidly progresses to shock 3
• Using aspirin or NSAIDs - absolute contraindication due to bleeding risk 1, 3
• Administering excessive fluid boluses in patients without shock - leads to pulmonary edema and respiratory complications 3
• Delaying fluid resuscitation in dengue shock syndrome - significantly increases mortality 3
• Routine drainage of pleural effusion/ascites - causes severe hemorrhage and sudden circulatory collapse 4
• Changing management based solely on persistent fever without clinical deterioration - fever typically resolves within 5 days 1