What is the immediate management for a patient presenting with Dengue, particularly in those with severe symptoms or underlying medical conditions?

Immediate Management of Dengue

All patients with clinically suspected dengue should receive appropriate management to monitor for shock and reduce the risk for complications resulting from plasma leakage and organ damage without waiting for diagnostic test results 1.

Initial Assessment and Risk Stratification

Immediately classify the patient into one of three categories: dengue without warning signs, dengue with warning signs, or severe dengue, as this determines the entire management approach 2.

Warning Signs to Identify Immediately

• High hematocrit with rapidly falling platelet count 3
• Severe abdominal pain 3
• Persistent vomiting 3, 2
• Lethargy or restlessness 3
• Mucosal bleeding 3
• Cold, clammy extremities (early shock) 4
• Narrow pulse pressure ≤20 mmHg or hypotension 2, 4

Critical Timing Information

• Document the exact day of fever onset, as dengue follows a triphasic course with the critical phase (typically days 3-7) being when plasma leakage and shock occur 2, 4, 5.

Immediate Management Based on Severity

For Dengue WITHOUT Warning Signs (Outpatient Management)

• Aggressive oral hydration with target fluid intake of 2,500-3,000 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 3, 2
• Avoid soft drinks due to high osmolality 3
• Acetaminophen (paracetamol) at standard doses for pain and fever relief 3, 2
• Never use aspirin or NSAIDs under any circumstances due to high bleeding risk 3, 2
• Daily complete blood count monitoring to track platelet counts and hematocrit levels 3, 2

For Dengue WITH Warning Signs (Hospitalization Required)

• Immediate hospitalization for close monitoring 2
• Daily complete blood count monitoring, particularly tracking platelet counts and hematocrit levels 3, 2
• Oral rehydration if tolerated, otherwise intravenous crystalloid maintenance fluids 3, 2
• Do NOT give routine bolus IV fluids to patients with warning signs who are not yet in shock, as this increases fluid overload and respiratory complications without improving outcomes 3
• Monitor for clinical indicators of progression: normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, baseline mental status, and adequate urine output 3

For SEVERE DENGUE or Dengue Shock Syndrome (Immediate ICU Management)

Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes with immediate reassessment after each bolus 3, 2.

Initial Fluid Resuscitation Protocol

• Reassess immediately after the first bolus for signs of improvement: improvement in tachycardia, tachypnea, capillary refill time, and blood pressure 3
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 3
• For severe dengue shock with pulse pressure <10 mmHg, consider colloid solutions (dextran, gelafundin, or albumin), as 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) 3

Critical Monitoring During Resuscitation

• Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop 3
• Watch for signs of fluid overload: hepatomegaly, rales on lung examination, or respiratory distress 3
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 3
• Falling hematocrit suggests successful plasma expansion 3

Management of Refractory Shock

• If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch strategy from aggressive fluid administration to inotropic support rather than continuing fluid boluses 3
• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 3
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 3
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 3
• 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 3

Management of Complications

Bleeding Management

• Blood transfusion may be necessary for significant bleeding 3, 2
• Target hemoglobin >10 g/dL if ScvO2 <70% 3
• Prophylactic platelet transfusion is not recommended 6

Fluid Overload Management

• After initial shock reversal, fluid removal may be necessary, as evidence shows aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 3, 7
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when CRRT is initiated early 3

Abdominal Compartment Syndrome

• Proactively monitor for symptomatic abdominal compartment syndrome, which may necessitate invasive percutaneous drainage 7

Special Populations

Pregnant Women

• Test by NAAT for both dengue and Zika virus, regardless of outbreak patterns, due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission 1, 2
• Acetaminophen remains the safest analgesic option 2
• Hospitalization is recommended for all pregnant women with confirmed or suspected dengue 2

Children

• Acetaminophen dosing should be carefully calculated based on weight 2
• Blood pressure alone is not a reliable endpoint in children, as hypotension is a late finding 3

Critical Pitfalls to Avoid

• Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality, as cardiovascular collapse may rapidly follow once hypotension occurs 3
• Administering excessive fluid boluses in patients without shock leads to fluid overload and respiratory complications 3
• Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 3
• Continuing aggressive fluid resuscitation once signs of fluid overload appear instead of switching to inotropic support 3
• Using aspirin or NSAIDs, which worsen bleeding tendencies 3, 2

Diagnostic Testing (Do Not Delay Treatment)

• For symptoms ≤7 days: Nucleic acid amplification test (NAAT/PCR) on serum 2
• For symptoms >7 days: IgM capture ELISA (MAC-ELISA) 2
• Rapid diagnostic tests combining NS1 antigen and IgG have very high positive likelihood ratios 2

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
• Adequate oral intake
• Adequate urine output (>0.5 mL/kg/hour in adults)
• Laboratory parameters returning to normal ranges