What are the treatment guidelines for a patient suspected of having Dengue hemorrhagic fever?

Management of Dengue Hemorrhagic Fever

For patients with suspected dengue hemorrhagic fever (DHF), immediately classify them into one of three categories—dengue without warning signs, dengue with warning signs, or severe dengue—as this determines the entire management approach, with aggressive fluid resuscitation (20 mL/kg isotonic crystalloid bolus over 5-10 minutes) being life-saving for dengue shock syndrome. 1, 2

Immediate Assessment and Classification

Upon presentation, rapidly identify warning signs that indicate progression to severe disease 1, 2:

• High hematocrit with rapidly falling platelet count
• Severe abdominal pain
• Persistent vomiting
• Lethargy or restlessness
• Mucosal bleeding
• Cold, clammy extremities (early shock)

Critical pitfall: The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock—failure to recognize this window significantly increases mortality 1, 2.

Fluid Management Strategy

For Patients WITHOUT Shock

• Aggressive oral hydration with target fluid intake of 2,500-3,000 mL daily using any locally available fluids (water, oral rehydration solutions, cereal-based gruels, soup, rice water) 1, 2
• Avoid soft drinks due to high osmolality 1, 2
• Do NOT give routine bolus IV fluids to patients with severe febrile illness who are not in shock—this increases fluid overload and respiratory complications without improving outcomes 1

For Dengue Shock Syndrome

Initial resuscitation protocol 1, 2:

1. Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes
2. Reassess immediately after each bolus for signs of improvement (tachycardia and tachypnea improvement)
3. If shock persists, repeat crystalloid boluses up to total of 40-60 mL/kg in first hour before escalating therapy
4. Moderate-quality evidence shows colloids (gelafundin, albumin, or dextran) provide 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) 1

Stop fluid resuscitation immediately if 1:

• Hepatomegaly develops
• Pulmonary rales appear
• Respiratory distress occurs

These signs indicate fluid overload—switch to inotropic support rather than continuing fluid boluses 1.

Monitoring Parameters

Daily Laboratory Monitoring

• Complete blood count monitoring is essential, particularly tracking platelet counts and hematocrit levels 1, 3
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 1
• Falling hematocrit suggests successful plasma expansion 1

Clinical Monitoring for Adequate Perfusion 1:

• Normal capillary refill time
• Absence of skin mottling
• Warm and dry extremities
• Well-felt peripheral pulses
• Return to baseline mental status
• Adequate urine output (>0.5 mL/kg/hour in adults)

Management of Refractory Shock

If shock persists despite 40-60 mL/kg of crystalloid in first hour, switch strategy from aggressive fluid administration to vasopressor support 1:

• For cold shock with hypotension: Titrate epinephrine as first-line vasopressor
• For warm shock with hypotension: Titrate norepinephrine as first-line vasopressor
• Target mean arterial pressure appropriate for age and ScvO2 >70%

Critical pitfall: Delaying vasopressor therapy is associated with major increases in mortality—begin peripheral inotropic support immediately if central venous access is not readily available 1.

Supportive Care and Medications

Pain and Fever Management

• Acetaminophen (paracetamol) at standard doses for pain and fever relief 1, 3
• Never use aspirin or NSAIDs when dengue cannot be excluded—these worsen bleeding tendencies due to antiplatelet effects and increased bleeding risk 1, 2, 3

Management of Bleeding Complications

• Blood transfusion may be necessary for significant bleeding 1, 2
• Target hemoglobin >10 g/dL if ScvO2 <70% 1
• Prophylactic platelet transfusion is not routinely recommended 2
• Special consideration: Patients with hemophilia may exhibit bleeding from the early febrile stage and at higher platelet levels than other dengue patients—intravenous factor VIII should be given to achieve 100% factor correction over 24 hours if bleeding occurs 4

Recovery Phase Management

After initial shock reversal, judicious fluid removal may be necessary during the recovery phase 1, 2:

• 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, as outcomes are better when CRRT is initiated early 1

Critical pitfall: Avoid overhydration during recovery phase, which can lead to pulmonary edema 1.

Hospitalization Criteria

Admit patients with 2, 3:

• Severe plasma leakage, severe bleeding, organ failure, or dengue shock syndrome
• Narrow pulse pressure ≤20 mmHg or hypotension
• Rising hematocrit (>20% increase from baseline)
• Thrombocytopenia ≤100,000/mm³, particularly when declining rapidly
• Pregnant women with confirmed or suspected dengue (due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission)

Discharge Criteria

Patients can be safely discharged when ALL of the following are met 2, 3:

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

Post-discharge instructions 2:

• Monitor and record temperature twice daily
• Return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop (persistent vomiting, severe abdominal pain, bleeding, lethargy)

Special Populations

Pregnant Women

• Test by NAAT for both dengue and Zika virus, regardless of outbreak patterns 2, 3
• Acetaminophen remains the safest analgesic option 1, 2
• Hospitalization recommended for all pregnant women with confirmed or suspected dengue 2

Severe Complications

For intracranial hemorrhage (rare but fatal complication) 5:

• High index of suspicion required, especially during convalescence in patients who are disoriented with altered sensorium
• Should not be misinterpreted as fever delirium or toxic encephalopathy
• Timely diagnosis and neurosurgical intervention can be life-saving