What are the guidelines for managing dengue (Dengue Fever)?

Guidelines for Management of Dengue

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, while strictly avoiding aspirin and NSAIDs due to bleeding risk. 1, 2

Classification and Risk Stratification

Dengue is classified into three categories that determine management approach 2:

• Dengue without warning signs: Outpatient management with oral hydration
• Dengue with warning signs: Close monitoring, possible hospitalization
• Severe dengue: Immediate ICU admission required

Warning signs requiring hospitalization include 1, 2:

• Persistent vomiting or severe abdominal pain
• Lethargy or restlessness
• Mucosal bleeding
• Rising hematocrit (>20% increase) with rapidly falling platelet count (<100,000/mm³)
• Narrow pulse pressure ≤20 mmHg or hypotension

Fluid Management for Non-Shock Patients

For patients without shock, aggressive oral hydration is the cornerstone of management 1, 2:

• Target fluid intake of 2,500-3,000 mL daily (approximately 5 or more glasses throughout the day)
• 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

Critical pitfall: Do NOT give routine bolus IV fluids to patients with severe febrile illness who are not in shock, as this increases fluid overload and respiratory complications without improving outcomes 1

Management of Dengue Shock Syndrome

Immediate resuscitation protocol 1, 2:

1. Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes
2. Reassess immediately after each bolus for signs of improvement (improved tachycardia, tachypnea, capillary refill)
3. Repeat crystalloid boluses up to total of 40-60 mL/kg in the first hour if shock persists
4. If shock persists after 40-60 mL/kg crystalloid, switch to colloid solutions (gelafundin or albumin) rather than continuing crystalloid alone

Evidence strongly supports this aggressive approach: Three randomized controlled trials demonstrate near 100% survival with appropriate fluid management in dengue shock syndrome 1. Moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1.

Monitoring During Resuscitation

Essential monitoring parameters 1, 2:

• Daily complete blood count to track platelet counts and hematocrit levels
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation
• Falling hematocrit suggests successful plasma expansion
• Watch 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, adequate urine output (>0.5 mL/kg/hour in adults)

Stop fluid resuscitation immediately if 1:

• Hepatomegaly develops
• Pulmonary rales appear on lung examination
• Respiratory distress occurs

These signs indicate fluid overload and necessitate switching from fluids to inotropic support 1.

Management of Refractory Shock

If shock persists despite adequate fluid resuscitation 1:

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%
• 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

Pain and Fever Management

Acetaminophen (paracetamol) is the ONLY acceptable analgesic 1, 2, 3:

• Use at standard doses for pain and fever relief
• Calculate dosing carefully based on weight in children
• Acetaminophen remains the safest option for pregnant women

Never use aspirin or NSAIDs under any circumstances 1, 2, 3: These medications worsen bleeding tendencies due to antiplatelet effects and are absolutely contraindicated when dengue cannot be excluded.

Post-Resuscitation Fluid Management

After initial shock reversal, judicious fluid removal may be necessary 1:

• Evidence shows that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1, 4
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when CRRT is initiated early 1

Management of Bleeding Complications

Blood transfusion may be necessary for significant bleeding 1, 2:

• Target hemoglobin >10 g/dL if ScvO2 <70%
• Prophylactic platelet transfusion is NOT recommended 5
• Transfuse platelets only for active bleeding with severe thrombocytopenia

Discharge Criteria

Patients can be safely discharged when ALL of the following are met 2:

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

Post-discharge instructions 2:

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

Critical Pitfalls to Avoid

1. Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality; once hypotension occurs, cardiovascular collapse may rapidly follow 1

2. Continuing aggressive fluid resuscitation once signs of fluid overload appear - switch to inotropic support instead 1

3. Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1

4. Using restrictive fluid strategies in established dengue shock syndrome - moderate-quality evidence shows no survival benefit from colloid restriction, and restrictive fluids may worsen outcomes 1

5. Administering excessive fluid boluses in patients without shock leads to fluid overload and respiratory complications 1

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