What is the management for Dengue (Dengue fever)?

Management of Dengue Fever

Dengue management centers on aggressive oral hydration for uncomplicated cases and immediate fluid resuscitation with 20 mL/kg isotonic crystalloid boluses for dengue shock syndrome, with acetaminophen as the only acceptable analgesic. 1, 2

Initial Assessment and Risk Stratification

• Classify patients into three categories: dengue without warning signs, dengue with warning signs, or severe dengue (including dengue shock syndrome, severe bleeding, or organ impairment). 3
• Confirm diagnosis with PCR or nucleic acid amplification tests on serum collected within 1-7 days of symptom onset, or IgM capture ELISA if symptoms have been present for more than 5-7 days. 1, 3
• Rapid diagnostic tests combining NS1 antigen and IgG have very high positive likelihood ratios and can optimize management decisions. 1

Outpatient Management (Dengue Without Warning Signs)

• Manage as outpatients with aggressive oral hydration targeting more than 2,500-3,000 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water. 1, 2
• Prescribe acetaminophen at standard doses exclusively for pain and fever relief. 1, 3
• Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk and platelet dysfunction. 1, 2, 3
• Instruct patients to monitor temperature twice daily and return immediately if fever rises to ≥38°C on two consecutive readings or if warning signs develop. 1

Daily Monitoring Requirements

• Obtain daily complete blood counts to track platelet counts and hematocrit levels, particularly during days 3-7 of illness (the critical phase when plasma leakage can rapidly progress to shock). 1, 2
• Watch continuously for warning signs: persistent vomiting, severe abdominal pain, lethargy or restlessness, mucosal bleeding, and rising hematocrit with rapidly falling platelet count. 1, 2
• A rise in hematocrit of 20% along with a continuing drop in platelet count is an important indicator for the onset of shock. 4

Management of Dengue Shock Syndrome

Initial Fluid Resuscitation

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes with immediate reassessment after each bolus. 1, 2
• Repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour if shock persists before escalating therapy. 2
• Moderate-quality evidence shows colloids achieve faster resolution of shock compared to crystalloids alone (RR 1.09,95% CI 1.00-1.19) and reduce the total volume of initial bolus needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids). 2
• Consider switching to colloid solutions (dextran, gelafundin, or albumin) for severe shock with pulse pressure <10 mmHg or if shock persists despite adequate crystalloid resuscitation. 1, 2

Monitoring During Resuscitation

• Assess for signs of adequate tissue perfusion: normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output (>0.5 mL/kg/hour in adults). 2
• Stop fluid resuscitation immediately if hepatomegaly, pulmonary rales, or respiratory distress develop, as these signal fluid overload requiring a switch to inotropic support. 2
• Use continuous cardiac telemetry and pulse oximetry for all patients with dengue shock syndrome. 1, 3

Management of Refractory Shock

• For persistent tissue hypoperfusion despite adequate fluid resuscitation, initiate vasopressors: epinephrine for cold shock with hypotension or norepinephrine for warm shock with hypotension. 1, 2
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy are associated with major increases in mortality. 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%. 2

Management of Complications

• Blood transfusion may be necessary for significant bleeding, though prophylactic platelet transfusion is not recommended. 2, 5
• Obtain blood and urine cultures and chest radiograph if fever persists beyond 5 days to diagnose secondary bacterial infections. 1
• Avoid drainage of pleural effusion and ascites when possible, as it can lead to severe hemorrhages and sudden circulatory collapse. 4
• Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication requiring specific management with steroids or intravenous immunoglobulin. 5

Critical Pitfalls to Avoid

• Do not administer 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. 2
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear; switch to inotropic support instead. 2
• Do not delay fluid resuscitation in patients with dengue shock syndrome, as cardiovascular collapse may rapidly follow once hypotension occurs. 2
• Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock. 2
• Do not use restrictive fluid strategies in established dengue shock syndrome, as moderate-quality evidence shows no survival benefit and may worsen outcomes. 2

Discharge Criteria

• Afebrile for at least 48 hours without antipyretics. 1, 3
• Resolution or significant improvement of symptoms including resolving cough and respiratory symptoms. 1
• Stable hemodynamic parameters for at least 24 hours without support (normal heart rate, stable blood pressure, normal capillary refill time). 1, 3
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults). 1, 3
• Laboratory parameters returning to normal ranges. 1, 3

Special Populations

• For pregnant women, test by nucleic acid amplification tests for both dengue and Zika virus regardless of outbreak patterns due to risk of adverse outcomes, and use acetaminophen as the safest analgesic option. 1, 3
• In children, calculate acetaminophen dosing carefully based on weight. 1, 3