What are the treatment protocols for dengue patients in both inpatient (IPD) and outpatient (OPD) departments?

Dengue Treatment: IPD and OPD Protocols

Outpatient (OPD) Management

For dengue patients without warning signs, manage with oral rehydration, acetaminophen for fever/pain, and daily monitoring—hospitalization is not required unless warning signs develop. 1

Patient Selection for OPD

• Patients with dengue fever without warning signs can be safely managed as outpatients 1
• Warning signs requiring hospitalization include: severe abdominal pain, persistent vomiting, clinical fluid accumulation (ascites/pleural effusion), mucosal bleeding, lethargy or restlessness, liver enlargement >2 cm, and rising hematocrit with rapidly falling platelet count 1, 2

OPD Treatment Protocol

• Hydration strategy: Encourage 5 or more glasses of fluid throughout the day, targeting approximately 2,500-3,000 mL daily 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
• Pain and fever management: Use acetaminophen (paracetamol) only—strictly avoid aspirin and NSAIDs due to increased bleeding risk 1, 2
• Resume age-appropriate diet as soon as appetite returns 1

OPD Monitoring Requirements

• Daily complete blood count to track platelet counts and hematocrit levels 1
• Critical phase awareness: Days 3-7 of illness represent the highest risk period when plasma leakage can rapidly progress to shock 1, 2
• Educate patients to return immediately if warning signs develop 1

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Inpatient (IPD) Management

For dengue with warning signs or severe dengue, admit for IV fluid management with isotonic crystalloids as first-line therapy, escalating to colloids and vasopressors only if shock persists despite adequate crystalloid resuscitation. 1

Indications for Hospitalization

• Dengue with warning signs (listed above) 1
• Severe dengue: dengue shock syndrome, severe bleeding, or organ impairment 1
• Mortality rate is 1-5% without proper management but can be reduced to <0.5% with appropriate clinical care 1

IPD Fluid Management Algorithm

For Dengue with Warning Signs (No Shock)

• Avoid routine bolus IV fluids in patients NOT in shock—this increases risk of fluid overload and respiratory complications without improving outcomes 1
• Provide maintenance IV fluids if oral intake is inadequate 1
• Monitor closely for progression to shock 1

For Dengue Shock Syndrome (Hypotension/Poor Perfusion)

Initial resuscitation:

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes 1, 3
• Reassess after each bolus for signs of improvement: improved tachycardia, tachypnea, capillary refill, mental status, and urine output 1
• If shock persists, repeat crystalloid boluses up to total of 40-60 mL/kg in the first hour before escalating therapy 1, 3

Escalation to colloids:

• If shock persists despite adequate crystalloid resuscitation (40-60 mL/kg), switch to colloid solutions 1, 4
• Moderate-quality evidence shows colloids achieve faster resolution of shock (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, 3
• Options include dextran, gelafundin, or albumin 1

Vasopressor therapy for refractory shock:

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 3
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 3
• Begin peripheral inotropic support immediately if central venous access is not readily available—delays in vasopressor therapy are associated with major increases in mortality 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1, 3

IPD Monitoring Parameters

• Perfusion indicators: 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 1, 2
• Daily complete blood count to track hematocrit and platelet trends 1, 2
• Signs of fluid overload: Hepatomegaly, rales on lung examination, or respiratory distress—stop fluid resuscitation immediately if these develop and switch to inotropic support 1, 3

Management of Complications

• Severe bleeding: Blood transfusion may be necessary 1, 2
• Pulmonary edema: Avoid overhydration, particularly during the recovery phase 1
• Polyserositis (pleural effusion/ascites): Avoid drainage as it can lead to severe hemorrhage and sudden circulatory collapse 5
• Secondary hemophagocytic lymphohistiocytosis: Consider steroids or intravenous immunoglobulin if this potentially fatal complication is recognized 6

Critical Pitfalls to Avoid in IPD

• Do not delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow 1
• Do not use restrictive fluid strategies in dengue shock syndrome—moderate-quality evidence shows no survival benefit and may worsen outcomes 1, 3
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 1, 3
• Do not give routine bolus IV fluids to patients with severe febrile illness who are NOT in shock 1, 2
• Do not fail to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress to shock 1, 2