What are the admitting orders for a patient with dengue?

Admitting Orders for Dengue Fever

For patients admitted with dengue fever, immediately initiate daily complete blood count monitoring, ensure adequate oral or intravenous hydration based on clinical status, use acetaminophen for fever control, and strictly avoid aspirin and NSAIDs due to bleeding risk. 1, 2

Initial Assessment and Diagnostic Testing

Upon admission, obtain the following baseline investigations:

• Complete blood count (CBC) with platelet count and hematocrit - this must be repeated daily to track disease progression 1, 2
• Dengue PCR/NAAT on serum if symptoms present for ≤7 days 3, 1
• Dengue IgM capture ELISA if symptoms present for >5-7 days or if PCR is unavailable/negative 3, 1
• Blood glucose monitoring to detect hypoglycemia, particularly in severe cases 1
• Liver function tests if warning signs present 1

Fluid Management Orders

For Patients WITHOUT Shock (Dengue with Warning Signs):

• Oral rehydration solutions targeting >2,500 mL daily intake 1, 2
• If unable to tolerate oral fluids due to persistent vomiting, initiate intravenous isotonic crystalloid (0.9% normal saline or Ringer's lactate) at maintenance rates 2, 4
• Critical pitfall to avoid: Do NOT give routine bolus IV fluids to patients who are not in shock, as this increases fluid overload and respiratory complications without improving outcomes 2

For Patients WITH Dengue Shock Syndrome:

• Immediate fluid bolus of 20 mL/kg isotonic crystalloid (0.9% normal saline or Ringer's lactate) over 5-10 minutes 1, 2
• Reassess immediately after each bolus for signs of improvement (improved pulse pressure, decreased tachycardia, improved capillary refill) 2
• If shock persists, repeat crystalloid boluses up to 40-60 mL/kg in the first hour before escalating therapy 2
• For severe shock with pulse pressure <10 mmHg or refractory to crystalloids, consider colloid solutions (6% hydroxyethyl starch preferred over dextran 70 due to fewer adverse reactions) 2, 5
• Stop fluid resuscitation immediately if hepatomegaly, pulmonary rales, or respiratory distress develop - switch to inotropic support 2

Pain and Fever Management

• Acetaminophen (paracetamol) at standard doses for fever and pain control 1, 2
• Absolutely contraindicated: Aspirin and all NSAIDs due to increased bleeding risk and platelet dysfunction 1, 2, 6

Monitoring Parameters

Order the following monitoring schedule:

• Vital signs every 4 hours (or more frequently if in critical phase): temperature, blood pressure, heart rate, respiratory rate 1
• Daily CBC with attention to rising hematocrit (>20% increase suggests plasma leakage) and falling platelet count 1, 6
• Fluid intake and output charting with target urine output >0.5 mL/kg/hour in adults 1
• Watch for warning signs indicating progression to severe dengue: persistent vomiting, severe abdominal pain, lethargy or restlessness, mucosal bleeding, clinical fluid accumulation, liver enlargement >2 cm, rising hematocrit with rapidly falling platelets 1, 6

The critical phase typically occurs days 3-7 of illness around the time of defervescence - this is when plasma leakage and shock are most likely to occur 1, 6

Transfusion Thresholds

• Platelet transfusion is NOT routinely indicated based on platelet count alone 1
• Blood transfusion indicated for significant bleeding with hemodynamic compromise or hemoglobin <7 g/dL with ongoing bleeding 1, 2
• Target hemoglobin >10 g/dL if central venous oxygen saturation <70% 2

Vasopressor Support (if needed)

For refractory shock despite adequate fluid resuscitation (40-60 mL/kg):

• Cold shock with hypotension: Epinephrine as first-line vasopressor 2
• Warm shock with hypotension: Norepinephrine as first-line vasopressor 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 2

Dietary Orders

• Nothing by mouth (NPO) if persistent vomiting or altered mental status 1
• Resume age-appropriate diet as soon as appetite returns and vomiting resolves 1
• Encourage oral fluids including water, oral rehydration solutions, soup, and rice water (avoid soft drinks due to high osmolality) 2

Activity Orders

• Bed rest during febrile and critical phases 1
• May ambulate as tolerated once afebrile for 48 hours and hemodynamically stable 1

Nursing Orders

• Strict intake/output monitoring 1
• Tourniquet test on admission if not already performed 7
• Monitor for signs of bleeding: petechiae, ecchymoses, mucosal bleeding, melena, hematemesis 1, 6
• Assess capillary refill time and peripheral perfusion every 4 hours 2

Common Pitfalls to Avoid

• Never delay fluid resuscitation in patients with established dengue shock syndrome - cardiovascular collapse can occur rapidly 2
• Do not continue aggressive fluid boluses once signs of fluid overload appear (hepatomegaly, pulmonary rales) - switch to inotropic support instead 2
• Do not prescribe antibiotics empirically without evidence of bacterial co-infection, as bacterial co-infection occurs in <10% of cases and empiric antibiotics contribute to antimicrobial resistance 1
• Do not fail to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress to shock 1

Discharge Criteria

Patients may be discharged when ALL of the following are met:

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

Instruct patients to return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 1