What is the management approach for a patient with dengue fever, including fluid resuscitation, medication, and monitoring for complications such as hemorrhage and shock?

Management of Dengue Fever

General Management Principles

Symptomatic management is the cornerstone of dengue treatment, as no specific antiviral therapy is currently approved. 1

• Avoid aspirin and NSAIDs entirely due to increased bleeding risk; use acetaminophen (paracetamol) only for pain and fever management 1
• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels, particularly during the critical phase (days 3-7 of illness) when plasma leakage can rapidly progress to shock 1
• Monitor for warning signs of progression to severe disease: high hematocrit with rapidly falling platelet count, severe abdominal pain, persistent vomiting, lethargy or restlessness, and mucosal bleeding 1

Fluid Management Algorithm

For Patients WITHOUT Shock

Oral rehydration is appropriate and should be the first-line approach. 1

• Encourage 5 or more glasses of fluid throughout the day, targeting approximately 2,500-3,000 mL daily 1
• Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water; avoid soft drinks due to high osmolality 1
• Critical pitfall: Do NOT give routine bolus IV fluids to patients with severe febrile illness who are not in shock, as this increases fluid overload and respiratory complications without improving outcomes 1

For Patients WITH Dengue Shock Syndrome

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

Initial Resuscitation Protocol:

• Reassess immediately after each bolus for signs of improvement: improvement in tachycardia and tachypnea, normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output 1
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 1
• Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop—this signals fluid overload and the need to switch to inotropic support 1

Escalation to Colloids (if shock persists after 40-60 mL/kg crystalloid):

For severe dengue shock syndrome, colloid solutions provide faster resolution of shock and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids; RR 1.09,95% CI 1.00-1.19). 1

• Dextran 70 provides the most rapid normalization of hematocrit and restoration of cardiac index, though it carries more adverse reactions than alternatives 2, 3
• 6% hydroxyethyl starch may be preferable to dextran 70 given similar efficacy with fewer adverse reactions in severe shock 3
• Alternative colloids include gelafundin or albumin if other options are unavailable 1

Management of Refractory Shock

If shock persists despite adequate fluid resuscitation (40-60 mL/kg in first hour), switch strategy from aggressive fluid administration to vasopressor support rather than continuing fluid boluses. 1

Vasopressor Selection:

• For cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1
• For warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1
• 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 1

Monitoring Parameters During Critical Phase

Track hematocrit levels closely, as rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation, while falling hematocrit suggests successful plasma expansion. 1

• Watch for clinical indicators of adequate tissue perfusion: normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output 1
• Monitor for signs of fluid overload: hepatomegaly, rales on lung examination, or respiratory distress 1
• In resource-rich settings with persistent shock, consider invasive monitoring to guide therapy 1

Management of Complications

Bleeding:

• Blood transfusion may be necessary in cases of significant bleeding 1
• Target hemoglobin >10 g/dL if ScvO2 <70% 1

Fluid Overload During Recovery Phase:

After initial shock reversal, judicious fluid removal may be necessary during the recovery phase. Evidence shows that aggressive shock management followed by fluid removal decreased pediatric ICU mortality from 16.6% to 6.3%. 1

• Avoid overhydration, which can lead to pulmonary edema, particularly during the recovery phase 1
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when CRRT is initiated early 1

Critical Pitfalls to Avoid

• Do NOT delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow 1
• Do NOT use restrictive fluid strategies in established dengue shock syndrome—moderate-quality evidence shows no survival benefit and may worsen outcomes, with three RCTs demonstrating near 100% survival with aggressive fluid management 1
• Do NOT continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 1
• Do NOT fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1
• Do NOT administer excessive fluid boluses in patients without shock—this leads to fluid overload and respiratory complications 1