What are the treatment recommendations for a patient diagnosed with dengue, including medication and supportive care?

SOAP Notes for Dengue

Subjective

Chief Complaint:

• Fever, headache, body aches, and rash (typical presentation) 1

History of Present Illness:

• Document fever onset and duration (critical phase typically occurs days 3-7) 1
• Severe retroocular pain, intense myalgias and arthralgias ("breakbone fever") 2
• Warning signs requiring immediate attention: persistent vomiting, severe abdominal pain, lethargy or restlessness, mucosal bleeding 1, 3
• Recent travel to endemic areas (tropical/subtropical zones) 4
• Mosquito exposure history 2

Review of Systems:

• Bleeding manifestations: epistaxis, gum bleeding, petechiae, menorrhagia 1
• Gastrointestinal: vomiting, abdominal pain, ascites 5
• Respiratory: dyspnea (suggests fluid overload or pleural effusion) 1
• Neurological: altered mental status, seizures (severe dengue) 1

Objective

Vital Signs:

• Shock indicators: tachycardia, hypotension, narrow pulse pressure (<20 mmHg), poor capillary refill (>2 seconds) 3
• Temperature pattern (typically high fever in febrile phase) 4

Physical Examination:

• Skin: maculopapular rash (similar to measles), petechiae, ecchymoses 2, 6
• Perfusion assessment: capillary refill time, skin mottling, extremity temperature (cold extremities indicate shock) 1, 3
• Abdominal: hepatomegaly (indicates fluid overload if developing during resuscitation), tenderness, ascites 1, 5
• Respiratory: pulmonary rales (fluid overload), pleural effusion 1
• Tourniquet test (positive if ≥20 petechiae per square inch) 4

Laboratory Data:

• Daily complete blood count: rising hematocrit with rapidly falling platelets indicates plasma leakage and critical phase 1, 3
• Thrombocytopenia (<150 x 10⁹/L, severe if <50 x 10⁹/L) 7
• Liver enzymes (may show hepatic involvement) 4
• Diagnostic confirmation: RT-PCR (up to day 5 of illness) or dengue serology (IgM/IgG after day 5) 4

Assessment

Risk Stratification (WHO Classification):

1. Dengue without warning signs: Outpatient management appropriate 4

   • Fever, typical symptoms, no warning signs
   • Stable vital signs and hematocrit

2. Dengue with warning signs: Hospital admission required 5

   • Clinical fluid accumulation (ascites, pleural effusion)
   • Persistent vomiting, severe abdominal pain
   • Mucosal bleeding, lethargy/restlessness
   • Liver enlargement >2 cm
   • Rising hematocrit with concurrent thrombocytopenia

3. Severe dengue: ICU admission mandatory 1

   • Dengue shock syndrome (DSS)
   • Severe bleeding requiring transfusion
   • Organ impairment (liver, CNS, heart)
   • Mortality 1-5% without proper management, <0.5% with appropriate care 1

Plan

Non-Shock Dengue Management

Fluid Management:

• Target 2,500-3,000 mL daily oral intake (approximately 5 or more glasses throughout the day), which evidence demonstrates reduces hospitalization rates 1, 3
• Use any locally available fluids: water, oral rehydration solutions, cereal-based gruels, soup, rice water 1, 3
• Avoid soft drinks due to high osmolality 1, 3
• Critical: Avoid routine bolus IV fluids in patients NOT in shock—this increases fluid overload and respiratory complications without improving outcomes 1, 3

Symptomatic Treatment:

• Acetaminophen (paracetamol) ONLY for fever and pain 1, 3
• Absolutely avoid aspirin and NSAIDs—these worsen bleeding tendencies 1, 5
• Resume age-appropriate diet as appetite returns 1

Monitoring:

• Daily CBC to track hematocrit and platelet trends 1, 5
• Daily clinical assessment for warning signs during critical phase (days 3-7) 1, 5

Dengue Shock Syndrome Management

Initial Resuscitation (First Hour):

• Administer 20 mL/kg of isotonic crystalloid (0.9% normal saline or Ringer's lactate) as rapid bolus over 5-10 minutes 1, 3
• Reassess immediately after each bolus for improvement in tachycardia, tachypnea, capillary refill 1
• If shock persists, repeat crystalloid boluses up to total 40-60 mL/kg in first hour before escalating therapy 1, 3
• Moderate-quality evidence shows colloids achieve faster shock resolution (RR 1.09) and reduce total volume needed (31.7 mL/kg vs 40.63 mL/kg for crystalloids) 1

Resuscitation Endpoints:

• Normal capillary refill time, absence of skin mottling 1, 3
• Warm and dry extremities, well-felt peripheral pulses 1, 3
• Return to baseline mental status 1, 3
• Adequate urine output (>0.5 mL/kg/hr) 1, 3
• Declining hematocrit indicates successful plasma volume restoration 3

Management of Refractory Shock:

• STOP fluid resuscitation immediately if hepatomegaly or pulmonary rales develop—switch to inotropic support 1, 3
• 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 access unavailable—delays in vasopressor therapy significantly increase mortality 1
• Target age-appropriate mean arterial pressure and ScvO2 >70% 1

Transfusion Thresholds:

• Blood transfusion necessary for significant bleeding 1, 5
• Maintain hemoglobin ≥10 g/dL in bleeding patients (oxygen delivery depends on hemoglobin concentration) 3

Critical Pitfalls to Avoid

Fluid Management Errors:

• Never continue aggressive fluid boluses once fluid overload signs appear (hepatomegaly, rales, respiratory distress)—this causes pulmonary edema, particularly during recovery phase 1, 3
• Never delay fluid resuscitation in established DSS—cardiovascular collapse may rapidly follow once hypotension occurs 1
• Never use restrictive fluid strategies in DSS—three RCTs demonstrate near 100% survival with aggressive fluid management 1

Medication Errors:

• Never use aspirin or NSAIDs—these significantly worsen bleeding risk 1, 5, 2

Monitoring Failures:

• Never fail to recognize critical phase (days 3-7) when plasma leakage rapidly progresses to shock 1, 5
• Blood pressure alone is unreliable endpoint in children—use perfusion parameters instead 1

Disposition

Outpatient (Dengue without warning signs):

• Daily follow-up during critical phase 4
• Return precautions for warning signs 1
• Fluid chart to track intake (simple, inexpensive tool that may reduce hospitalization) 7

Hospital Admission (Dengue with warning signs):

• Continuous monitoring during critical phase 5
• IV access for potential rapid resuscitation 1

ICU Admission (Severe dengue/DSS):

• Invasive monitoring in resource-rich settings if shock persists 1
• Aggressive shock management combined with judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1