What are the treatment protocols for managing dengue fever, including prescription templates for various case scenarios?

Dengue Management: Prescription Templates for All Clinical Scenarios

Classification-Based Treatment Algorithm

All dengue patients must be classified into one of three categories that determine management location and intensity: dengue without warning signs (outpatient), dengue with warning signs (inpatient observation), or severe dengue (ICU admission). 1, 2

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SCENARIO 1: Dengue Without Warning Signs (Outpatient Management)

Prescription Template - Outpatient

Diagnosis: Dengue fever without warning signs

Medications:

• Acetaminophen (Paracetamol) 500-1000 mg PO every 6 hours as needed for fever/pain (maximum 4 grams/24 hours) 1, 2
• DO NOT PRESCRIBE: Aspirin, NSAIDs (ibuprofen, naproxen, diclofenac) - contraindicated due to bleeding risk 1, 2

Hydration Instructions:

• Oral fluids: minimum 2,500-3,000 mL daily 1, 3
• Encourage 5 or more glasses throughout the day 3
• Acceptable fluids: water, oral rehydration solutions, cereal-based gruels, soup, rice water 3
• Avoid soft drinks (high osmolality) 3

Monitoring Requirements:

• Daily clinic visits for complete blood count (CBC) monitoring 1, 2
• Temperature monitoring twice daily at home 1
• Watch for warning signs (see return precautions below) 1, 2

Return Precautions - Immediate Emergency Department Visit if:

• Severe abdominal pain 1, 2
• Persistent vomiting (unable to keep fluids down) 1, 2
• Mucosal bleeding (nosebleeds, gum bleeding, blood in vomit/stool) 1, 2
• Lethargy or restlessness 1, 2
• Temperature ≥38°C on two consecutive readings 1
• Dizziness or fainting 2

Critical Phase Awareness:

• Days 3-7 of illness are the critical phase when plasma leakage can rapidly progress to shock 1, 2

Follow-up: Daily until afebrile for 48 hours without antipyretics 1

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SCENARIO 2: Dengue With Warning Signs (Inpatient Observation)

Prescription Template - Hospital Admission

Diagnosis: Dengue fever with warning signs

Warning Signs Present (document which):

• Severe abdominal pain
• Persistent vomiting
• Clinical fluid accumulation (ascites, pleural effusion)
• Mucosal bleeding
• Lethargy/restlessness
• Liver enlargement >2 cm
• Rising hematocrit with rapidly falling platelet count

Medications:

• Acetaminophen 500-1000 mg PO/IV every 6 hours as needed (maximum 4 grams/24 hours) 1, 2
• DO NOT ORDER: Aspirin, NSAIDs, routine anticoagulation 1, 2

Fluid Management:

• Oral hydration preferred if patient can tolerate: 2,500-3,000 mL daily 1, 3
• IV fluids ONLY if unable to maintain oral intake 2
• If IV required: 0.9% Normal Saline or Ringer's Lactate at maintenance rate 2
• Avoid routine bolus IV fluids in patients NOT in shock - increases fluid overload risk 2, 4

Monitoring Orders:

• CBC with differential every 12-24 hours (track hematocrit and platelets) 1, 2
• Vital signs every 4 hours 2
• Strict intake/output monitoring 2
• Urine output goal: >0.5 mL/kg/hour 1
• Assess for signs of shock: capillary refill, skin perfusion, mental status 2

Discharge Criteria:

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

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SCENARIO 3: Dengue Shock Syndrome (ICU Management)

Prescription Template - ICU Admission

Diagnosis: Dengue Shock Syndrome (DSS)

Shock Criteria Present (document):

• Hypotension for age
• Narrow pulse pressure (<20 mmHg)
• Tachycardia
• Cold/clammy extremities
• Prolonged capillary refill (>2 seconds)
• Altered mental status
• Decreased urine output

Initial Resuscitation Protocol

IMMEDIATE FLUID BOLUS:

• 0.9% Normal Saline or Ringer's Lactate 20 mL/kg IV over 5-10 minutes 1, 2, 5
• Reassess immediately after bolus completion 1, 2
• If shock persists: Repeat crystalloid boluses up to total 40-60 mL/kg in first hour 2

ESCALATION TO COLLOIDS (if shock persists after 40-60 mL/kg crystalloids):

• Dextran 40 or Dextran 70: 10-20 mL/kg IV 2
• Alternative colloids: Gelafundin or 5% Albumin if dextran unavailable 2
• Evidence: Colloids achieve faster shock resolution (RR 1.09) and reduce total volume needed (31.7 vs 40.63 mL/kg) 2

VASOPRESSOR THERAPY (if refractory shock despite adequate fluid resuscitation):

For Cold Shock (poor perfusion, cold extremities):

• Epinephrine 0.05-0.3 mcg/kg/min IV infusion, titrate to effect 2

For Warm Shock (bounding pulses, warm extremities with hypotension):

• Norepinephrine 0.05-0.3 mcg/kg/min IV infusion, titrate to effect 2

Target Parameters:

• Mean arterial pressure appropriate for age 2
• ScvO2 >70% 2

STOP FLUID RESUSCITATION IMMEDIATELY IF:

• Hepatomegaly develops 2
• Pulmonary rales on examination 2
• Respiratory distress 2
• Switch to inotropic support instead 2

Monitoring Orders - ICU

• Continuous cardiac telemetry 1
• Continuous pulse oximetry 1
• Vital signs every 15-30 minutes during resuscitation, then hourly 2
• CBC with hematocrit every 4-6 hours 1, 2
• Strict intake/output (Foley catheter) 2
• Capillary refill and perfusion assessment every 30 minutes 2
• Consider invasive monitoring (arterial line, central venous pressure) in refractory cases 2

Supportive Medications

Pain/Fever:

• Acetaminophen 500-1000 mg IV every 6 hours as needed 1, 2

Oxygen:

• Oxygen therapy to maintain SpO2 >95% 6

Blood Product Transfusion Criteria

Platelet Transfusion:

• Indicated for significant active bleeding with thrombocytopenia 1, 2
• NOT indicated for thrombocytopenia alone without bleeding 2

Packed Red Blood Cells:

• Indicated for significant blood loss with hemodynamic instability 1, 2

Fresh Frozen Plasma:

• Indicated for DIC with coagulopathy and active bleeding 6

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SCENARIO 4: Severe Dengue with Complications

A. Dengue with Ascites/Pleural Effusion

Prescription Template:

Diagnosis: Severe dengue with plasma leakage (ascites/pleural effusion)

Fluid Management:

• Oral rehydration first line if not in shock 4
• Avoid routine bolus IV fluids if hemodynamically stable 4
• If shock develops: Follow DSS protocol above (20 mL/kg crystalloid bolus) 4

CRITICAL:

• DO NOT drain ascites or pleural effusion - can cause severe hemorrhage and sudden circulatory collapse 6
• Monitor for progression to shock during critical phase (days 3-7) 4

Monitoring:

• CBC every 12 hours 4
• Watch for shock signs: tachycardia, hypotension, poor capillary refill 4

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B. Dengue with Significant Bleeding

Prescription Template:

Diagnosis: Severe dengue with hemorrhagic manifestations

Blood Product Support:

• Packed RBCs: Transfuse for hemodynamic instability or Hgb <7 g/dL with active bleeding 1, 2
• Platelets: Transfuse for active bleeding with severe thrombocytopenia 1, 2
• Fresh Frozen Plasma: For DIC with prolonged PT/PTT and active bleeding 6

Fluid Management:

• Continue crystalloid resuscitation as per DSS protocol 2
• Avoid fluid overload 2

Monitoring:

• CBC every 4-6 hours 2
• Coagulation panel (PT/PTT/INR) every 12 hours 6
• Type and crossmatch blood products 2

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C. Dengue with Organ Impairment

Prescription Template:

Diagnosis: Severe dengue with organ dysfunction

Specific Organ Support:

Hepatic Impairment:

• Reduce acetaminophen dose or avoid if severe hepatic dysfunction 2
• Monitor liver enzymes daily 2

Renal Impairment:

• Adjust fluid rate based on urine output 2
• Consider renal replacement therapy if acute kidney injury develops 2

Cardiac Impairment:

• Continuous cardiac monitoring 1
• Echocardiography if myocarditis suspected 2

Respiratory Failure:

• Mechanical ventilation if respiratory distress despite oxygen 2
• Careful fluid management to avoid pulmonary edema 2

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SCENARIO 5: Special Populations

A. Pregnant Women with Dengue

Prescription Template:

Diagnosis: Dengue fever in pregnancy

Testing:

• NAAT testing for BOTH dengue AND Zika virus regardless of outbreak patterns 1

Medications:

• Acetaminophen 500-1000 mg PO every 6 hours - safest analgesic in pregnancy 1, 2
• ABSOLUTELY AVOID: NSAIDs, aspirin 1

Fluid Management:

• Same as non-pregnant patients based on severity 1

Monitoring:

• Fetal monitoring as clinically indicated 1
• Watch for adverse pregnancy outcomes 1

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B. Pediatric Dengue Management

Prescription Template - Outpatient:

Diagnosis: Dengue fever without warning signs (pediatric)

Medications:

• Acetaminophen 10-15 mg/kg PO every 4-6 hours as needed (maximum 75 mg/kg/day) 1

Hydration:

• Age-appropriate fluids: 2,000-2,500 mL daily for adolescents 3
• Encourage frequent small volumes 3

Prescription Template - DSS (Pediatric ICU):

Initial Resuscitation:

• Crystalloid bolus: 20 mL/kg over 5-10 minutes 2, 5
• Repeat up to 40-60 mL/kg in first hour if needed 2

Colloid Escalation:

• Medium-molecular-weight colloid (Dextran 40/70 or Gelafundin) 10-20 mL/kg if shock persists 2, 5

Vasopressors:

• Epinephrine for cold shock: 0.05-0.3 mcg/kg/min 2
• Norepinephrine for warm shock: 0.05-0.3 mcg/kg/min 2

Critical Pitfall:

• Blood pressure is NOT a reliable endpoint in children - use perfusion markers instead 2

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SCENARIO 6: Persistent Fever in Dengue

Prescription Template:

Diagnosis: Dengue fever with persistent fever beyond 5 days

Assessment:

• Persistent fever typically resolves within 5 days of treatment initiation 1
• DO NOT change antibiotics based solely on fever pattern without clinical deterioration 1

Workup if Hemodynamically Unstable:

• Blood cultures 1
• Urine cultures 1
• Chest radiograph 1
• Broaden coverage for secondary bacterial infections 1

Continue:

• Acetaminophen for symptomatic relief 1
• Adequate hydration 1
• Close monitoring 1

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Critical Pitfalls to Avoid Across All Scenarios

1. NEVER use aspirin or NSAIDs - dramatically increases bleeding risk 1, 2, 4

2. NEVER give routine bolus IV fluids to patients NOT in shock - causes fluid overload and respiratory complications without benefit 2, 4

3. NEVER delay fluid resuscitation in established shock - cardiovascular collapse follows rapidly 2

4. NEVER continue aggressive fluids once fluid overload signs appear - switch to inotropes 2

5. NEVER drain ascites or pleural effusion - causes severe hemorrhage and circulatory collapse 6

6. NEVER miss the critical phase (days 3-7) - when plasma leakage rapidly progresses to shock 1, 2, 4

7. NEVER use restrictive fluid strategies in established DSS - no survival benefit, may worsen outcomes 2

8. NEVER transfuse platelets for thrombocytopenia alone - only for active bleeding 2