What is the approach to managing a patient with hemorrhagic dengue?

Management of Hemorrhagic Dengue Fever

Hemorrhagic dengue requires immediate aggressive fluid resuscitation with isotonic crystalloids, strict avoidance of NSAIDs and aspirin, early blood product transfusion guided by specific thresholds, and intensive monitoring for shock—with the critical understanding that dengue-specific coagulopathy differs fundamentally from traumatic hemorrhage and requires a tailored approach.

Immediate Resuscitation and Stabilization

For patients presenting with dengue shock syndrome, administer 20 mL/kg isotonic crystalloid bolus over 5-10 minutes with immediate reassessment after each bolus 1, 2. This differs from trauma protocols as dengue shock results from plasma leakage rather than blood loss 3.

• Secure large-bore IV access (largest bore possible including central access if needed) and maintain high FiO2 to ensure adequate oxygenation 4, 1
• Apply direct pressure to obvious bleeding sites (pressure, tourniquet, haemostatic dressings) while initiating systemic resuscitation 4, 1
• Consider colloid solutions for severe shock with pulse pressure <10 mmHg when crystalloids alone are insufficient 1, 2
• Actively warm the patient and all transfused fluids using warming devices to prevent hypothermia-induced coagulopathy 4, 1

Blood Product Transfusion Strategy

The transfusion approach in dengue differs critically from trauma protocols because the coagulopathy is primarily consumptive and thrombocytopenic rather than dilutional 5.

Platelet Transfusion

• Maintain platelet count above 50 × 10⁹/L in actively bleeding patients 1, 2
• Target platelet count above 100 × 10⁹/L in patients with traumatic brain injury 4
• A minimum target of 75 × 10⁹/L is appropriate for severe hemorrhagic dengue 4
• Initial dose of 4-8 single platelet units or one apheresis pack may be used 4

Red Blood Cell Transfusion

• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL, with a target of 9 g/dL in massive bleeding or cardiovascular disease 1, 6
• Use warmed blood products to prevent hypothermia 4, 1
• Group-specific blood can be issued without performing an antibody screen; O negative blood should only be used if blood is needed immediately 4

Coagulation Factor Replacement

• Target fibrinogen levels above 1.5 g/L using fibrinogen concentrate or cryoprecipitate 1, 6
• Fibrinogen <1 g/L represents established haemostatic failure and predicts microvascular bleeding 4
• Initial fibrinogen supplementation of 3-4 g equivalent to fibrinogen concentrate may be administered 4
• Maintain PT ratio <1.5 during active bleeding 1
• PT and aPTT >1.5 times normal represents established haemostatic failure 4

Massive Transfusion Protocol

• For massive hemorrhage requiring >6 units of blood, activate massive transfusion protocol with 1:1:1 ratio (RBC:FFP:platelets) 1, 6
• Early infusion of FFP at 15 ml/kg should be used to prevent dilutional coagulopathy if massive haemorrhage is anticipated 4
• Established coagulopathy will require more than 15 ml/kg of FFP to correct 4

Critical Medication Considerations

Never administer aspirin or NSAIDs under any circumstances in dengue due to severe bleeding risk—this is an absolute contraindication 1, 2.

• Use acetaminophen exclusively for fever and pain control 1, 2
• Avoid anticoagulants including prophylactic heparin during active bleeding 1
• Patients receiving ibuprofen before hospitalization have significantly lower effective responses to hemostatic interventions (28.6% vs 75.0%) 7

Fluid Management Nuances

Dengue requires careful fluid balance as both under-resuscitation causes shock and over-resuscitation worsens plasma leakage 3, 7.

• Ensure oral hydration exceeds 2,500 mL daily in patients without shock 1, 2
• Use warmed crystalloids and blood products to prevent hypothermia-induced coagulopathy 4, 1
• Avoid excessive crystalloid administration as this causes dilutional coagulopathy and worsens outcomes 1
• Volume expanders of low molecular weight dextran or urea-linked gelatin are associated with lower effective responses to hemostatic therapy 7

Physiologic Optimization

• Monitor and maintain ionised calcium levels within normal range; administer calcium chloride to correct hypocalcaemia from citrate toxicity during massive transfusion 4, 1
• Normalize acid-base status, but avoid vasopressors until bleeding is controlled 4, 1
• Once bleeding control is achieved, aggressively normalize blood pressure, acid-base status, and temperature 4, 1

Laboratory Monitoring

Obtain baseline bloods immediately: full blood count, PT, aPTT, Clauss fibrinogen (not derived fibrinogen which is misleading), and cross-match 4.

• Monitor coagulation parameters using standard laboratory values (PT, aPTT, fibrinogen, platelets) with repeated measurements 4
• If available, undertake near-patient testing with thromboelastography (TEG) or thromboelastometry (ROTEM) 4
• Monitor serum lactate or base deficit to estimate and monitor extent of bleeding and shock 4
• Single haematocrit measurements should not be employed as isolated markers for bleeding 4

Critical Care Monitoring

• Admit all patients with active bleeding to intensive care for continuous monitoring of vital signs, coagulation parameters, and hemoglobin 4, 1
• Use continuous cardiac telemetry and pulse oximetry for patients with dengue shock syndrome 2
• Monitor urine output targeting >0.5 mL/kg/hour as indicator of adequate perfusion 1, 2
• Following treatment, patients should be admitted to critical care for monitoring of coagulation, haemoglobin, blood gases, and wound drain assessment 4

Advanced Hemostatic Interventions

Endoscopic injection therapy is NOT effective for upper GI bleeding in dengue patients, unlike in non-dengue peptic ulcer disease 8.

• Medical treatment with blood transfusion is the mainstay of management of upper GI bleeding in dengue 8
• Patients with peptic ulcer and recent hemorrhage require more transfusions with packed red blood cells (P=0.002) and fresh frozen plasma (P=0.05) than those without recent hemorrhage 8
• Recombinant activated factor VII (rFVIIa) at 100 μg/kg may be considered for life-threatening bleeding refractory to conventional therapy, with higher effectiveness when initiated early in grade III DHF (66.7%) versus delayed initiation in grade IV DHF (33.3%) 7
• Off-label use of rFVIIa may be considered only if major bleeding persists despite all other attempts to control bleeding and best practice use of coagulation products 4
• Intravenous anti-D globulin has shown dramatic improvement in case reports of DSS with severe thrombocytopenia (<10,000/mm³) and bleeding refractory to routine measures 9

Common Pitfalls to Avoid

Do not delay blood product administration while waiting for laboratory results in obvious massive hemorrhage—this worsens outcomes 1, 6.

• Do not use hemoglobin level as the sole transfusion trigger; consider clinical context and ongoing bleeding 1
• Do not administer prophylactic anticoagulation during active bleeding phase, even though patients develop prothrombotic state after hemorrhage resolves 4, 1
• Do not use derived fibrinogen levels as they are misleading; use Clauss fibrinogen 4
• Do not perform endoscopic injection therapy for upper GI bleeding in dengue as it is ineffective and may worsen outcomes 8
• Avoid volume expanders like low molecular weight dextran or urea-linked gelatin as they reduce hemostatic effectiveness 7

Venous Thromboprophylaxis

Standard venous thromboprophylaxis should be commenced as soon as possible after bleeding has been controlled, as patients rapidly develop a prothrombotic state 4, 1, 6.

• Temporary inferior vena cava filtration may be necessary in select cases 4

Discharge Criteria

Patients can be safely discharged when ALL of the following criteria are met 1, 2:

• Afebrile for ≥48 hours without antipyretics 1, 2
• Hemodynamic stability for ≥24 hours without support (normal heart rate, blood pressure, capillary refill) 1, 2
• Platelet count >100,000/mm³ without rapid decline and stable hematocrit 1, 2
• Adequate oral intake and urine output >0.5 mL/kg/hour 1, 2
• Resolution of bleeding manifestations and laboratory parameters returning toward normal 1, 2