What are the admitting orders for a patient with mild dengue fever?

Admitting Orders for Mild Dengue Fever

For mild dengue fever without warning signs, admit to a general medical ward with daily monitoring, aggressive oral hydration targeting >2500ml daily, acetaminophen for symptom control, and daily complete blood counts to track platelet and hematocrit trends. 1

Initial Assessment and Admission Criteria

Mild dengue patients require hospitalization when they exhibit warning signs including persistent vomiting, severe abdominal pain, clinical fluid accumulation, lethargy/restlessness, mucosal bleeding, rising hematocrit with falling platelet count, or rapidly declining platelets (≤100,000/mm³). 1, 2

• Pregnant women with confirmed or suspected dengue should be hospitalized regardless of severity due to risks of maternal death, hemorrhage, preeclampsia, and vertical transmission. 1
• A rising hematocrit (>20% increase from baseline) combined with declining platelet count is a critical indicator requiring admission and close monitoring. 1, 3

Admission Orders

Monitoring Parameters

• Daily complete blood count to track platelet counts and hematocrit levels—this is the single most important monitoring parameter. 1, 2, 4
• Vital signs every 4-6 hours including temperature, blood pressure, heart rate, and capillary refill time. 1
• Strict intake and output monitoring with target urine output >0.5 mL/kg/hour in adults. 1
• Daily weight to assess fluid status and detect plasma leakage. 5

Fluid Management

• Aggressive oral hydration with oral rehydration solutions for moderate dehydration, targeting fluid intake exceeding 2500ml daily. 1, 2
• Ensure adequate oral intake of fluids containing electrolytes to prevent dehydration and support blood volume. 4
• Avoid prophylactic IV fluids in mild cases without warning signs—oral hydration is sufficient and safer. 1

Medications

• Acetaminophen at standard doses exclusively for pain and fever relief. 1, 2, 4
• Absolute contraindication to aspirin and NSAIDs due to increased bleeding risk and platelet dysfunction—this is a critical safety measure. 1, 2, 4
• No prophylactic antibiotics—empiric antibiotics like azithromycin contribute to antimicrobial resistance without clinical benefit, as bacterial co-infection occurs in <10% of cases. 1

Laboratory Orders

• Daily CBC with differential to monitor platelet count and hematocrit trends. 1, 2, 4
• Baseline liver function tests and renal function to detect organ involvement. 5
• Dengue PCR/NAAT on serum if symptoms present for 1-7 days for diagnostic confirmation. 1, 2
• IgM capture ELISA if symptoms present for >5-7 days or if PCR unavailable. 1, 2

Activity and Diet

• Bed rest during the febrile phase with gradual mobilization as tolerated. 3
• Regular diet as tolerated with emphasis on adequate fluid intake. 4
• Avoid intramuscular injections due to bleeding risk. 3

Warning Signs Requiring Escalation of Care

Monitor continuously for these warning signs that indicate progression to severe dengue:

• Persistent vomiting preventing adequate oral intake. 1, 2, 4
• Severe abdominal pain or tenderness. 1, 4
• Clinical fluid accumulation (pleural effusion, ascites). 1, 3
• Lethargy, restlessness, or altered mental status. 1, 2
• Mucosal bleeding (epistaxis, gum bleeding, hematemesis, melena). 1, 2
• Rising hematocrit (>20% increase) with rapidly falling platelet count. 1, 3
• Liver enlargement >2 cm. 4

Critical Pitfalls to Avoid

• Never use prophylactic platelet transfusion in dengue with thrombocytopenia—a landmark trial showed no benefit in preventing bleeding and increased adverse events including anaphylaxis, transfusion-related acute lung injury, and fluid overload. 6
• Do not drain pleural effusions or ascites unless absolutely necessary, as drainage can lead to severe hemorrhages and sudden circulatory collapse. 3
• Avoid changing management based solely on persistent fever without clinical deterioration—fever typically resolves within 5 days and persistent fever alone does not indicate bacterial co-infection. 1
• Do not delay recognition of shock—a narrow pulse pressure ≤20 mmHg or hypotension requires immediate escalation to ICU-level care with fluid resuscitation. 1

Discharge Criteria

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

• Afebrile for ≥48 hours without antipyretics. 1, 2
• Resolution or significant improvement of symptoms. 1, 2
• Stable hemodynamic parameters for ≥24 hours without support. 1, 2
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults). 1, 2
• Laboratory parameters returning to normal ranges, particularly platelet count >100,000/mm³ without rapid decline and stable hematocrit. 1

Post-Discharge Instructions

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