What is the appropriate management for a patient with dengue hemorrhagic fever?

Management of Dengue Hemorrhagic Fever

Aggressive fluid resuscitation with isotonic crystalloids is the cornerstone of dengue hemorrhagic fever management, with immediate administration of 20 mL/kg boluses over 5-10 minutes for patients showing signs of shock, while avoiding routine bolus fluids in hemodynamically stable patients to prevent fatal fluid overload. 1

Initial Assessment and Risk Stratification

Classify disease severity immediately using WHO criteria to guide management intensity: 1, 2

• Dengue hemorrhagic fever requires evidence of plasma leakage (≥20% hematocrit rise from baseline), thrombocytopenia, and minor or major bleeding 1, 2
• Dengue shock syndrome adds hypotension or pulse pressure ≤20 mmHg to DHF criteria 1, 2
• Monitor for warning signs during the critical phase (days 3-7) when plasma leakage rapidly progresses: persistent vomiting, severe abdominal pain, lethargy/restlessness, mucosal bleeding, high hematocrit with rapidly falling platelets 1

Fluid Management Protocol

For Patients WITHOUT Shock

Oral rehydration is first-line therapy with a target of 2,500-3,000 mL daily using water, oral rehydration solutions, cereal-based gruels, soup, or rice water—avoid soft drinks due to high osmolality. 1, 2

Critical pitfall: Do NOT administer routine bolus intravenous 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

Immediate resuscitation algorithm: 1

1. Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes 1
2. Reassess immediately after each bolus for signs of improvement: decreased tachycardia, decreased tachypnea, improved capillary refill (<3 seconds), warming of extremities, improved mental status 1
3. Repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour if shock persists 1
4. Switch to colloid solutions (dextran 70, gelafundin, or albumin) if shock persists after adequate crystalloid resuscitation—colloids provide faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1, 3

Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop, signaling fluid overload. 1

Monitoring Parameters

Daily complete blood count is essential to track: 1, 2

• Hematocrit levels: Rising hematocrit indicates ongoing plasma leakage; falling hematocrit suggests successful plasma expansion 1
• Platelet counts: Rapidly declining platelets with rising hematocrit signal progression to severe disease 1

Clinical perfusion indicators to assess resuscitation adequacy: 1

• Capillary refill time <3 seconds
• Absence of skin mottling
• Warm, dry extremities
• Well-felt peripheral pulses
• Return to baseline mental status
• Adequate urine output (>0.5 mL/kg/hour in adults) 1

Note: Blood pressure alone is NOT a reliable endpoint in children—shock can be present with normal blood pressure. 1

Management of Refractory Shock

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

• 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: Age-appropriate mean arterial pressure and ScvO2 >70% 1

Begin peripheral inotropic support immediately if central venous access is not readily available—delays in vasopressor therapy are associated with major increases in mortality. 1

Supportive Care

Pain and fever management: 1, 2

• Acetaminophen (paracetamol) at standard doses is the ONLY acceptable analgesic 1, 2
• NEVER use aspirin or NSAIDs under any circumstances due to increased bleeding risk and potential for worsening thrombocytopenia 1, 2, 4

Blood product transfusion: 1

• Blood transfusion may be necessary for significant bleeding 1
• Target hemoglobin >10 g/dL if ScvO2 <70% 1
• Prophylactic platelet transfusion is NOT recommended 5

Recovery Phase Management

After initial shock reversal, judicious fluid removal may be necessary—evidence shows that 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

Avoid overhydration during the recovery phase, which can lead to pulmonary edema, particularly as capillary permeability normalizes. 1

Critical Pitfalls to Avoid

• Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality—once hypotension occurs, cardiovascular collapse may rapidly follow 1
• Continuing aggressive fluid resuscitation once signs of fluid overload appear (hepatomegaly, rales, respiratory distress)—switch to inotropic support instead 1
• Failing to recognize the critical phase (typically days 3-7) when plasma leakage can rapidly progress to shock 1
• Using restrictive fluid strategies in established dengue shock syndrome—moderate-quality evidence shows no survival benefit from colloid restriction, and restrictive fluids showed harm in severe illness 1

Discharge Criteria

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

• 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 2

Post-discharge instructions: Monitor temperature twice daily and return immediately if fever ≥38°C on two consecutive readings or any warning signs develop. 2