What are the initial management steps for a patient admitted with dengue?

Dengue Admission Orders

For patients admitted with dengue, initiate daily complete blood count monitoring, ensure oral hydration targeting 2,500-3,000 mL daily, prescribe acetaminophen for fever/pain, strictly avoid aspirin and NSAIDs, and closely monitor for warning signs of progression to severe disease. 1

Initial Assessment and Risk Stratification

Upon admission, classify the patient into one of three categories to guide management 1, 2:

• Dengue without warning signs: Mild febrile illness with headache, retro-orbital pain, myalgia, arthralgia, and possible rash 3
• Dengue with warning signs: Persistent vomiting, severe abdominal pain, lethargy/restlessness, mucosal bleeding, rising hematocrit with rapidly falling platelet count 1, 4
• Severe dengue: Dengue shock syndrome (DSS), severe bleeding, or organ impairment 1

Check for shock indicators including tachycardia, hypotension, poor capillary refill (<2 seconds), altered mental status, cold extremities, and narrow pulse pressure 4

Laboratory Monitoring

• Order daily complete blood count with particular attention to platelet counts and hematocrit levels 1, 2
• A rise in hematocrit of 20% along with continuing drop in platelet count signals onset of shock 5
• Confirm diagnosis with PCR if symptoms present <5 days, or IgM capture ELISA if symptoms present >5-7 days 3, 2

Fluid Management for Non-Shock Dengue

For patients without shock, oral rehydration is the cornerstone of management 1:

• Encourage oral intake of approximately 2,500-3,000 mL daily, which evidence shows reduces hospitalization rates 1, 4
• Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1, 4
• Avoid soft drinks due to high osmolality 1, 4
• Critical pitfall: Do NOT give routine bolus IV fluids to patients with febrile illness who are not in shock, as this increases fluid overload and respiratory complications without improving outcomes 1

Pain and Fever Management

• Prescribe acetaminophen (paracetamol) at standard doses for pain and fever relief 1, 2
• Strictly avoid aspirin and NSAIDs under any circumstances due to increased bleeding risk 1, 2
• Resume age-appropriate diet as soon as appetite returns 1

Monitoring Parameters During Admission

Track the following clinical endpoints indicating adequate tissue perfusion 1, 4:

• Normal capillary refill time
• Absence of skin mottling
• Warm and dry extremities
• Well-felt peripheral pulses
• Return to baseline mental status
• Adequate urine output

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

Management of Dengue Shock Syndrome

If shock develops, this becomes a medical emergency requiring immediate intervention 1, 5:

Initial Resuscitation

• Administer 20 mL/kg of isotonic crystalloid (0.9% normal saline or Ringer's lactate) as a rapid bolus over 5-10 minutes 1, 4
• Reassess immediately after each bolus for signs of improvement (tachycardia and tachypnea improvement) 1
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour 1, 4
• Moderate-quality evidence shows colloids (gelafundin or albumin) provide faster resolution of shock and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids), though clinical outcomes are similar 1, 6

Monitoring During Resuscitation

• Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop 1
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 1, 4
• Falling hematocrit suggests successful plasma expansion 1

Management of Refractory Shock

If shock persists despite 40-60 mL/kg of crystalloid in the first hour 1:

• Switch from aggressive fluid administration to inotropic support rather than continuing fluid boluses 1, 4
• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 4
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 4, 7
• Target mean arterial pressure appropriate for age and ScvO2 >70% 1

Management of Complications

Bleeding

• Blood transfusion may be necessary for significant bleeding 1, 2
• Target hemoglobin >10 g/dL if ScvO2 <70% 1
• Platelet transfusion may be needed in cases of DIC 5

Fluid Overload

• Avoid overhydration, particularly during the recovery phase, which can lead to pulmonary edema 1
• After initial shock reversal, judicious fluid removal may be necessary; evidence shows aggressive shock management followed by fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops 1

Respiratory Support

• For respiratory distress and/or persistent hypoxemia despite oxygen therapy, consider non-invasive ventilation if available and staff adequately trained 2
• If intubation necessary, use ketamine with atropine premedication to maintain cardiovascular stability 2

Critical Pitfalls to Avoid

• Do not delay fluid resuscitation in established dengue shock syndrome—cardiovascular collapse may rapidly follow once hypotension occurs 1
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 1
• Do not give routine bolus IV fluids to patients without shock—this increases complications without benefit 1
• Do not fail to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress 1
• Avoid drainage of pleural effusion and ascites as it can lead to severe hemorrhages and sudden circulatory collapse 5