What is the management of dengue (Dengue fever)?

Management of Dengue Fever

Dengue management is primarily supportive with aggressive oral hydration for uncomplicated cases, careful fluid resuscitation for shock, acetaminophen for symptom relief, and strict avoidance of aspirin and NSAIDs—there is no specific antiviral therapy available. 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) to determine the appropriate management setting 1, 2
• Hospitalize patients who exhibit warning signs including persistent vomiting, severe abdominal pain, lethargy or restlessness, mucosal bleeding, rising hematocrit (>20% increase from baseline) with rapidly falling platelet count (≤100,000/mm³), or any signs of plasma leakage 1, 2
• Pregnant women with confirmed or suspected dengue require hospitalization due to risks of maternal death, hemorrhage, preeclampsia, and vertical transmission 1

Diagnostic Confirmation

• Order dengue PCR/NAAT on serum for patients with symptoms present for 1-7 days after onset 1, 3
• Order IgM capture ELISA if PCR is unavailable or negative, particularly for patients with symptoms for more than 5-7 days 1, 3
• Document vaccination history to identify potential cross-reactivity with other flaviviruses such as yellow fever, Japanese encephalitis, and tick-borne encephalitis 1

Management of Uncomplicated Dengue (Without Warning Signs)

• Manage as outpatients with aggressive oral hydration using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water—avoid soft drinks due to high osmolality 1, 2
• Target fluid intake of approximately 2,500-3,000 mL daily, encouraging 5 or more glasses of fluid throughout the day 1, 2
• Use acetaminophen at standard doses exclusively for pain and fever relief 1, 2, 3
• Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk and platelet dysfunction 1, 2, 3
• Resume age-appropriate diet as soon as appetite returns 2

Monitoring Requirements

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

Management of Dengue Shock Syndrome

Dengue shock syndrome is a medical emergency requiring immediate aggressive fluid resuscitation—delays in treatment significantly increase mortality. 2, 4

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 1, 2, 3
• Reassess immediately after each bolus for signs of improvement including improved tachycardia, tachypnea, capillary refill time, warm and dry extremities, well-felt peripheral pulses, and return to baseline mental status 2
• Repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour if shock persists before escalating therapy 2
• Colloid solutions (dextran, gelafundin, or albumin) may provide faster resolution of shock and require less total volume compared to crystalloids alone, particularly for severe shock with pulse pressure <10 mmHg 1, 2

Management of Refractory Shock

• If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch strategy from aggressive fluid administration to inotropic support rather than continuing fluid boluses 2
• For cold shock with hypotension, titrate epinephrine as first-line vasopressor 2
• For warm shock with hypotension, titrate norepinephrine as first-line vasopressor 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 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

Critical Monitoring During Resuscitation

• Use continuous cardiac telemetry and pulse oximetry for patients with dengue shock syndrome 1, 3
• Track hematocrit monitoring closely—rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation, while falling hematocrit suggests successful plasma expansion 2
• Stop fluid resuscitation immediately if hepatomegaly, pulmonary rales, or respiratory distress develop, which signals the need to switch from fluids to inotropic support 2

Management of Complications

• Blood transfusion may be necessary for significant bleeding; target hemoglobin >10 g/dL if ScvO2 <70% 1, 2, 3
• For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required 1, 3
• Avoid drainage of pleural effusion and ascites when possible, as it can lead to severe hemorrhages and sudden circulatory collapse 4
• If fluid overload >10% develops, consider continuous renal replacement therapy (CRRT), as outcomes are better when CRRT is initiated early 2

Post-Resuscitation Fluid Management

• After initial shock reversal, fluid removal may be necessary—evidence shows that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 2
• Avoid overhydration during the recovery phase, which can lead to pulmonary edema and respiratory complications 2
• Once hemodynamics stabilize and clinical improvement occurs, reduce and discontinue fluids appropriately to avoid congestion and other complications 5

Critical Pitfalls to Avoid

• Do not administer routine bolus IV fluids to 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 delay fluid resuscitation in patients with established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow 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 continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 2
• Blood pressure alone is not a reliable endpoint in children—use multiple clinical indicators of adequate tissue perfusion 2

Discharge Criteria

Patients can be safely discharged when ALL of the following criteria are met: 1, 2, 3

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

Post-Discharge Instructions

• Monitor and record temperature twice daily after discharge 1
• Return to the healthcare facility immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 1

Special Populations

• For pregnant women with dengue fever, acetaminophen remains the safest analgesic option 1, 3
• Test pregnant women by NAAT for both dengue and Zika virus, regardless of outbreak patterns, due to the risk of adverse outcomes 1
• In children, acetaminophen dosing should be carefully calculated based on weight 1, 3