What is the recommended treatment for a patient with suspected Dengue?

Recommended Treatment for Suspected Dengue

The cornerstone of dengue management is symptomatic treatment with rigorous fluid management and acetaminophen for fever control, as there is no specific antiviral therapy currently approved. 1, 2, 3

Initial Assessment and Risk Stratification

Classify patients into one of three categories to guide management 1, 3:

• Dengue without warning signs: Outpatient management with aggressive oral hydration
• Dengue with warning signs: Hospital admission for close monitoring
• Severe dengue (shock syndrome, severe bleeding, organ impairment): Immediate ICU admission

Warning Signs Requiring Hospitalization 1, 2

• Persistent vomiting or inability to tolerate oral fluids
• Severe abdominal pain or tenderness
• Lethargy or restlessness
• Mucosal bleeding
• Rising hematocrit (>20% increase from baseline) with rapidly falling platelet count (<100,000/mm³)
• Clinical fluid accumulation (ascites, pleural effusion)

Outpatient Management (Dengue Without Warning Signs)

Hydration Protocol 1, 2

• 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 2
• Encourage 5 or more glasses of fluid throughout the day 2
• Avoid soft drinks due to high osmolality 2

Pain and Fever Management 1, 2, 3

• Acetaminophen (paracetamol) at standard doses is the ONLY recommended analgesic 1, 2
• Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk and platelet dysfunction 1, 2, 3

Daily Monitoring Requirements 1, 3

• Complete blood count to track platelet counts and hematocrit levels 1, 3
• Monitor for warning signs of progression to severe disease 1, 2
• Patients should return immediately if fever persists beyond 5 days, warning signs develop, or temperature rises to ≥38°C on two consecutive readings after initial improvement 1

Inpatient Management (Dengue With Warning Signs)

Fluid Management 1, 2

• Ensure adequate oral hydration if patient can tolerate 1
• Use oral rehydration solutions for moderate dehydration 1, 3
• Avoid routine bolus IV fluids in patients NOT in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes 2
• Monitor for signs of adequate tissue perfusion: normal capillary refill time, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output (>0.5 mL/kg/hour in adults) 2

Critical Phase Monitoring (Days 3-7) 1, 2

• Daily complete blood count to track platelet counts and hematocrit 1, 3
• Watch for rising hematocrit indicating ongoing plasma leakage 2
• Monitor for progression to shock: narrow pulse pressure ≤20 mmHg, hypotension, or hemodynamic instability 1

Management of Dengue Shock Syndrome (Severe Dengue)

Initial Fluid Resuscitation 1, 2, 3

Immediate aggressive fluid resuscitation is life-saving and achieves near 100% survival when properly administered 2:

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes 1, 2, 3
• Reassess immediately after each bolus for signs of improvement: decreased tachycardia, improved blood pressure, improved capillary refill 2
• Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists 2

Escalation to Colloid Solutions 1, 2

• For severe shock with pulse pressure <10 mmHg or refractory to crystalloids, consider colloid solutions (dextran, gelafundin, or albumin) 1, 2
• 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) 2

Vasopressor Therapy for Refractory Shock 1, 2

If shock persists despite 40-60 mL/kg of fluid in the first hour, switch from aggressive fluid administration to inotropic support 2:

• For cold shock with hypotension: Titrate epinephrine as first-line vasopressor 2
• For warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 2
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy increase mortality 2

Critical Monitoring During Resuscitation 1, 2

Stop fluid resuscitation immediately if signs of fluid overload develop 2:

• Hepatomegaly
• Pulmonary rales on lung examination
• Respiratory distress

Management of Bleeding Complications 1, 2

• Blood transfusion may be necessary for significant bleeding 1, 2
• Target hemoglobin >10 g/dL if ScvO2 <70% 2
• Prophylactic platelet transfusion is NOT recommended 4

Post-Resuscitation and Recovery Phase Management

Fluid Removal Strategy 2

• After initial shock reversal, judicious fluid removal may be necessary during the recovery phase 2
• Evidence shows that aggressive shock management followed by fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 2
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops 2

Discharge Criteria 1, 3

Patients can be safely discharged when ALL of the following are met 1, 3:

• 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

Post-Discharge Instructions 1

• Monitor and record temperature twice daily 1
• Return immediately for persistent or recurrent vomiting, fever ≥38°C on two consecutive readings, or any warning signs 1
• Repeat complete blood count and liver function tests at 3-5 days post-discharge if transaminases were elevated 1

Special Populations

Pregnant Women 1, 3

• 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, 3
• Acetaminophen remains the safest analgesic option 1, 3
• Consider hospitalization for all pregnant women with confirmed or suspected dengue 1

Pediatric Patients 2

• Acetaminophen dosing should be carefully calculated based on weight 1
• Same fluid resuscitation protocol applies: 20 mL/kg boluses up to 40-60 mL/kg in first hour 2
• Monitor hematocrit closely as rising hematocrit indicates ongoing plasma leakage 2

Critical Pitfalls to Avoid

• Never delay fluid resuscitation in established dengue shock syndrome - cardiovascular collapse may rapidly follow once hypotension occurs 2
• Never use aspirin or NSAIDs when dengue cannot be excluded 1, 2
• Never give routine bolus IV fluids to patients with severe febrile illness who are NOT in shock - this increases fluid overload without improving outcomes 2
• Never continue aggressive fluid resuscitation once signs of fluid overload appear - switch to inotropic support instead 2
• Never fail to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress to shock 2
• Never prescribe antibiotics empirically without evidence of bacterial co-infection, as bacterial co-infection occurs in less than 10% of cases 1