What is the management approach for patients with dengue fever, including asymptomatic, symptomatic, and severe cases, in the Indian clinical context, and how to prepare inpatient (IPD) and outpatient (OPD) prescriptions?

Management of Dengue Fever in Indian Clinical Practice

Classification and Risk Stratification

Dengue is classified into three distinct categories that determine management: dengue without warning signs (outpatient), dengue with warning signs (hospitalization required), and severe dengue (ICU admission mandatory). 1, 2

Dengue Without Warning Signs

• Presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash occurring 4-8 days after mosquito exposure 1
• No evidence of plasma leakage, shock, or organ dysfunction 3
• Managed as outpatient with aggressive oral hydration and daily monitoring 1

Dengue With Warning Signs

• Warning signs include: severe abdominal pain or persistent vomiting, mucosal bleeding, lethargy/restlessness/altered mental status, rising hematocrit with rapidly falling platelet count, hepatomegaly, and clinical fluid accumulation 2
• These signs indicate patients at high risk for progression to severe dengue, particularly during the critical phase (days 3-7 of illness) 3, 2
• Requires hospitalization for close monitoring to prevent progression to dengue shock syndrome 2

Severe Dengue

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

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Diagnostic Approach

Laboratory Testing

• Order dengue PCR/NAAT on serum for patients with symptoms for 1-7 days 1
• Order IgM capture ELISA if PCR unavailable or negative for patients with symptoms >5-7 days 1
• Obtain complete blood count with hematocrit and platelet count at admission and daily thereafter 1, 2
• Obtain liver function tests, coagulation profile if bleeding present 2
• Obtain blood and urine cultures if fever persists beyond expected course 1, 2

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OPD Prescription for Dengue Without Warning Signs

Medications

• Tablet Paracetamol 500-1000 mg PO every 6 hours PRN for fever/pain (avoid aspirin and NSAIDs completely due to bleeding risk) 1, 3, 2

Hydration Instructions

• Oral rehydration solutions: Target >2500-3000 mL daily 1, 3
• Encourage 5 or more glasses of fluid throughout the day using water, ORS, cereal-based gruels, soup, rice water 3
• Avoid soft drinks due to high osmolality 3

Monitoring Instructions

• Daily CBC monitoring to track platelet counts and hematocrit levels 1, 3
• Monitor temperature twice daily 1
• Return immediately if: temperature ≥38°C on two consecutive readings, severe abdominal pain, persistent vomiting, mucosal bleeding, lethargy, restlessness, decreased urine output 1, 2

Follow-up

• Daily review until afebrile for 48 hours and platelet count stabilizing 1

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IPD Prescription for Dengue With Warning Signs

Admission Orders

• Admit to medical ward with continuous monitoring 2
• NBM initially, then resume age-appropriate diet as appetite returns 3
• Strict input-output charting 3

Investigations

• CBC with hematocrit and platelet count at admission, then every 6-12 hours 1, 2
• LFT, RFT, serum electrolytes 2
• Coagulation profile (PT/INR, aPTT) if bleeding present 2
• Blood and urine cultures if fever persists 1, 2
• Dengue serology (IgM/IgG) if not already done 1

Fluid Management

• For stable patients: Oral rehydration solutions >2500 mL daily 2
• If unable to tolerate oral fluids: IV Normal Saline or Ringer's Lactate at maintenance rate 3
• Monitor for signs of fluid overload: hepatomegaly, pulmonary rales, respiratory distress 3

Medications

• Injection Paracetamol 1 gm IV every 6 hours PRN (if unable to take oral) OR Tablet Paracetamol 500-1000 mg PO every 6 hours PRN 1, 3, 2
• Avoid aspirin and NSAIDs under all circumstances 1, 3, 2

Monitoring

• Vital signs every 4 hours (temperature, pulse, BP, respiratory rate) 3
• Urine output monitoring (target >0.5 mL/kg/hour in adults) 1, 3
• Watch for signs of shock: tachycardia, narrow pulse pressure, cold extremities, altered mental status 3
• Monitor for warning signs of progression: severe abdominal pain, persistent vomiting, mucosal bleeding, rising hematocrit with falling platelets 3, 2

Discharge Criteria

• Afebrile for ≥48 hours without antipyretics 1, 2
• Resolution or significant improvement of symptoms 1, 2
• Stable hemodynamic parameters for ≥24 hours without support 1, 2
• Adequate oral intake and urine output (>0.5 mL/kg/hour) 1, 2
• Laboratory parameters returning to normal ranges 1, 2

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IPD Prescription for Severe Dengue (ICU Admission)

Immediate Resuscitation Protocol

• Administer 20 mL/kg isotonic crystalloid (0.9% Normal Saline or Ringer's Lactate) as rapid bolus over 5-10 minutes 1, 3, 2
• Reassess immediately after bolus completion for signs of improvement: improved tachycardia, tachypnea, capillary refill, mental status 3
• If shock persists: Repeat crystalloid boluses up to total 40-60 mL/kg in first hour 3
• For severe shock with pulse pressure <10 mmHg: Consider colloid solutions (dextran, gelafundin, or albumin) - moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09) and reduce total volume needed (mean 31.7 mL/kg vs 40.63 mL/kg for crystalloids) 1, 3

Critical Monitoring

• Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop - switch to inotropic support 3
• Continuous cardiac telemetry and pulse oximetry 1
• Monitor for signs of adequate tissue perfusion: normal capillary refill, absence of skin mottling, warm/dry extremities, well-felt peripheral pulses, baseline mental status, adequate urine output 3

Vasopressor Management (if shock persists despite adequate fluid resuscitation)

• For cold shock with hypotension: Titrate Injection Epinephrine as first-line vasopressor 3, 2
• For warm shock with hypotension: Titrate Injection Norepinephrine as first-line vasopressor 3, 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 3
• Begin peripheral inotropic support immediately if central venous access not readily available - delays in vasopressor therapy associated with major increases in mortality 3

Blood Product Transfusion

• For significant bleeding: Blood transfusion may be necessary with close monitoring of hemoglobin and hematocrit 1, 3, 2
• Platelet transfusion generally not indicated unless active bleeding with severe thrombocytopenia 3

Medications

• Injection Paracetamol 1 gm IV every 6 hours PRN for fever/pain 1, 3, 2
• Never use aspirin or NSAIDs 1, 3, 2

Investigations

• CBC with hematocrit and platelet count every 4-6 hours 1, 3
• ABG for metabolic acidosis monitoring 4
• Serum lactate 3
• LFT, RFT, serum electrolytes every 12-24 hours 2, 4
• Coagulation profile 2, 4
• Serum ferritin if available (levels >40,000 ng/mL associated with poor prognosis) 4

Special Considerations

• Watch for multi-organ dysfunction: shock, severe liver dysfunction, severe metabolic acidosis 4
• High white cell counts may indicate secondary bacterial infection or severe inflammation 4
• Only 4/11 patients in fatal cases had hemoconcentration, so absence of hemoconcentration does not rule out severe dengue 4
• Median time to death is 2 days after hospitalization despite good supportive care in severe cases 4

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Critical Pitfalls to Avoid

• Never use aspirin or NSAIDs when dengue cannot be excluded - increases bleeding risk and platelet dysfunction 1, 3, 2
• Do not delay fluid resuscitation in patients with dengue shock syndrome - cardiovascular collapse may rapidly follow once hypotension occurs 3
• Avoid administering excessive fluid boluses in patients without shock - leads to fluid overload and respiratory complications 3
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear - switch to inotropic support instead 3
• Do not fail to recognize the critical phase (days 3-7 of illness) when plasma leakage can rapidly progress to shock 3
• Avoid restrictive fluid strategies in established dengue shock syndrome - no survival benefit and may worsen outcomes 3
• Do not change management based solely on persistent fever without clinical deterioration - fever typically resolves within 5 days of treatment initiation 1

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Special Populations

Pregnant Women

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

Children

• Acetaminophen dosing should be carefully calculated based on weight 1
• Crystalloids as first-line fluid for resuscitation, with colloids reserved for severe cases 3
• Evidence from Indian pediatric ICU shows that early albumin for crystalloid-refractory shock, proactive monitoring for symptomatic abdominal compartment syndrome, and judicious fluid removal decreased mortality from 16.6% to 6.3% 5