What are the management strategies for dengue?

Management of Dengue Fever

Core Management Principle

Dengue management is primarily supportive with no specific antiviral therapy available; the cornerstone is judicious fluid resuscitation during the critical phase (days 3-7), with acetaminophen for symptom control and strict avoidance of aspirin/NSAIDs. 1, 2

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Classification and Risk Stratification

Dengue presents across a spectrum that determines management intensity 3, 4:

• Dengue without warning signs: Outpatient management with oral hydration 1
• Dengue with warning signs: Hospital admission for close monitoring 1
  • Persistent vomiting, severe abdominal pain, lethargy/restlessness 3, 1
  • High hematocrit with rapidly falling platelet count, mucosal bleeding 1
• Severe dengue: ICU admission required 1
  • Dengue shock syndrome (DSS), severe bleeding, or organ impairment 1, 2
  • Mortality 1-5% without proper management, reducible to <0.5% with appropriate care 1

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Diagnostic Approach

Confirm diagnosis early to guide management 3, 4:

• Days 1-7 of symptoms: Order dengue PCR/NAAT on serum 4
• After day 5-7: IgM capture ELISA if PCR unavailable or negative 3, 4
• Note: IgG antibodies persist for months to years and do not confirm acute infection alone 4

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Monitoring Protocol

Daily complete blood count monitoring is essential to track disease progression 3, 1:

• Platelet counts: Thrombocytopenia ≤100,000/mm³ with rapid decline requires hospitalization 4
• Hematocrit levels: Rising hematocrit (>20% increase) indicates plasma leakage and need for continued resuscitation 1
• Warning signs: Monitor for persistent vomiting, severe abdominal pain, lethargy, mucosal bleeding 3, 1

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Fluid Management Strategy

Outpatient Management (No Warning Signs)

Aggressive oral hydration is the foundation 1, 4:

• Target >2,500-3,000 mL daily (approximately 5+ glasses throughout the day) 1
• Use any locally available fluids: water, oral rehydration solutions, cereal-based gruels, soup, rice water 1
• Avoid soft drinks due to high osmolality 1

Dengue Shock Syndrome (DSS)

Administer 20 mL/kg isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes 3, 1:

• Reassess immediately after each bolus for signs of improvement: improved tachycardia, tachypnea, capillary refill 1
• Repeat crystalloid boluses up to total 40-60 mL/kg in first hour if shock persists 1
• Colloid solutions (dextran, gelafundin, or albumin) may be beneficial for severe shock with pulse pressure <10 mmHg—they achieve faster shock resolution (RR 1.09) and reduce total volume needed (31.7 vs 40.63 mL/kg) 1, 5

Refractory Shock Management

If shock persists despite 40-60 mL/kg crystalloid, switch strategy from fluids to vasopressors 1:

• Cold shock with hypotension: Titrate epinephrine as first-line 1
• Warm shock with hypotension: Titrate norepinephrine as first-line 1, 5
• Target mean arterial pressure appropriate for age and ScvO2 >70% 1

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Pain and Fever Management

Acetaminophen at standard doses is the only recommended analgesic 3, 1:

• Safe for all populations including pregnant women and children (dose by weight in pediatrics) 3, 4
• Never use aspirin or NSAIDs under any circumstances—they increase bleeding risk significantly 3, 1, 6

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Management of Complications

Bleeding

• Blood transfusion may be necessary for significant bleeding 3, 1
• Target hemoglobin >10 g/dL if ScvO2 <70% 1
• Prophylactic platelet transfusion is not recommended 2

Respiratory Support

• Non-invasive ventilation for respiratory distress/persistent hypoxemia if staff adequately trained 3
• Intubation: Use ketamine with atropine premedication to maintain cardiovascular stability 3

Fluid Overload

Stop fluid resuscitation immediately if signs of overload develop 1:

• Watch for hepatomegaly, pulmonary rales, respiratory distress 1
• Switch to inotropic support rather than continuing fluid boluses 1
• Evidence shows aggressive shock management followed by judicious 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

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Critical Pitfalls to Avoid

These errors significantly worsen outcomes 1:

1. Administering routine bolus IV fluids to patients with severe febrile illness who are NOT in shock—increases fluid overload and respiratory complications without benefit 1
2. Delaying fluid resuscitation in established DSS—once hypotension occurs, cardiovascular collapse may rapidly follow 1
3. Continuing aggressive fluid resuscitation after signs of fluid overload appear—switch to inotropic support instead 1
4. Failing to recognize the critical phase (typically days 3-7) when plasma leakage can rapidly progress to shock 1
5. Using restrictive fluid strategies in established DSS—no survival benefit and may worsen outcomes 1

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Discharge Criteria

Patients can be safely discharged when ALL criteria are met 4:

• Afebrile ≥48 hours without antipyretics 4
• Resolution or significant improvement of symptoms 4
• Stable hemodynamic parameters ≥24 hours without support (normal heart rate, blood pressure, capillary refill) 4
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults) 4
• Laboratory parameters returning to normal ranges 4

Post-discharge instructions 4:

• Monitor temperature twice daily 4
• Return immediately if fever ≥38°C on two consecutive readings or any warning signs develop 4

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Special Populations

Pregnant Women

• Hospitalize all pregnant women with confirmed or suspected dengue due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission 4
• Test by NAAT for both dengue and Zika virus regardless of outbreak patterns 4
• Acetaminophen remains safest analgesic option 3, 4

Children

• Acetaminophen dosing carefully calculated by weight 3, 4
• Careful fluid management particularly important in pediatric DSS 3
• Blood pressure alone not reliable endpoint in children 1