What is the recommended management for a patient with suspected or confirmed dengue fever?

Dengue Management

Dengue management centers on immediate risk stratification into three categories (dengue without warning signs, dengue with warning signs, or severe dengue), aggressive oral hydration for mild cases, and rapid crystalloid resuscitation for shock, while strictly avoiding aspirin and NSAIDs due to bleeding risk. 1, 2

Initial Assessment and Risk Stratification

Classify every patient immediately into one of three categories as this determines the entire management approach: 2

• Dengue without warning signs: Outpatient management with aggressive oral hydration
• Dengue with warning signs: Hospital admission for close monitoring
• Severe dengue: ICU admission with aggressive fluid resuscitation 1, 2

Warning Signs Requiring Immediate Recognition

Monitor for these indicators of progression to severe disease: 1, 2

• High hematocrit with rapidly falling platelet count (>20% rise in hematocrit) 1, 3
• Severe abdominal pain
• Persistent vomiting
• Lethargy or restlessness
• Mucosal bleeding
• Cold, clammy extremities (early shock) 2

Outpatient Management (Dengue Without Warning Signs)

Hydration Protocol

Target 2,500-3,000 mL of oral fluids daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water. 1, 2, 4

• Encourage 5 or more glasses of fluid throughout the day 1
• Avoid soft drinks due to high osmolality 1, 2
• Evidence shows this volume reduces hospitalization rates 1, 4

Pain and Fever Management

Use acetaminophen (paracetamol) at standard doses for pain and fever relief. 1, 5

• Never use aspirin or NSAIDs when dengue cannot be excluded due to increased bleeding risk. 1, 5, 2
• This is a critical pitfall that can worsen bleeding tendencies 1

Monitoring Requirements

Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels. 1, 5

• Rising hematocrit indicates ongoing plasma leakage 1
• Falling platelet count combined with rising hematocrit signals need for hospitalization 1, 2

Discharge Criteria

Patients can be safely discharged when: 1, 5

• 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

Hospital Admission Indications

Hospitalize patients with any of the following: 1, 2

• Warning signs (severe abdominal pain, persistent vomiting, lethargy/restlessness, mucosal bleeding)
• Rising hematocrit (>20% increase from baseline) 1
• Thrombocytopenia ≤100,000/mm³, particularly when declining rapidly 1
• Pregnant women with confirmed or suspected dengue 1, 2
• Severe plasma leakage, severe bleeding, or organ failure 1

Management of Dengue Shock Syndrome

Initial Fluid Resuscitation

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. 1, 2, 6

• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy. 1, 2
• Evidence demonstrates near 100% survival with appropriate aggressive fluid management 1
• Reassess for signs of improvement including tachycardia and tachypnea resolution 1

Colloid Solutions for Refractory Shock

For severe dengue shock with pulse pressure <10 mmHg or persistent shock after 40-60 mL/kg crystalloid, switch to colloid solutions. 1, 6

• Moderate-quality evidence shows colloids provide faster resolution of shock (RR 1.09,95% CI 1.00-1.19) 1
• Colloids reduce total volume of initial bolus needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1
• Alternative colloids include gelafundin or albumin if dextran is unavailable 1

Vasopressor Therapy for Refractory Shock

If shock persists despite adequate fluid resuscitation (40-60 mL/kg in first hour), switch strategy from aggressive fluid administration to inotropic support rather than continuing fluid boluses. 1, 6

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

Critical Monitoring During Resuscitation

Watch for signs of adequate tissue 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

Stop fluid resuscitation immediately if signs of fluid overload develop: 1, 6

• Hepatomegaly
• Pulmonary rales on lung examination
• Respiratory distress

Post-Resuscitation Fluid 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 1

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 Populations

Pregnant Women

All pregnant women with confirmed or suspected dengue should be hospitalized due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission. 1, 2

• Test by NAAT for both dengue and Zika virus, regardless of outbreak patterns 1, 2
• Acetaminophen remains the safest analgesic option 1, 2

Pediatric Patients

Use the same fluid resuscitation protocol (20 mL/kg crystalloid boluses) with careful monitoring for fluid overload. 1

• Acetaminophen dosing should be carefully calculated based on weight 5
• Blood pressure alone is not a reliable endpoint in children 1

Critical Pitfalls to Avoid

The following errors significantly increase morbidity and mortality: 1, 2

1. Delaying fluid resuscitation in established dengue shock syndrome - cardiovascular collapse may rapidly follow once hypotension occurs 1, 2

2. Administering 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

3. Continuing aggressive fluid resuscitation once signs of fluid overload appear - switch to inotropic support instead 1, 2

4. Failing to recognize the critical phase (typically days 3-7 of illness) - plasma leakage can rapidly progress to shock during this period 1, 2

5. Using aspirin or NSAIDs - these worsen bleeding tendencies 1, 5, 2

6. Using restrictive fluid strategies in established dengue shock syndrome - moderate-quality evidence shows no survival benefit from colloid restriction, and aggressive fluid management improves outcomes 1