Clinical Care of Dengue

Outpatient management is recommended for patients who:

• Do not exhibit warning signs of severe dengue

• Are hemodynamically stable, have normal urine output, and can tolerate oral fluids

• Have no significant co-morbidities or social risk

Recommended Management

• Recommend bed rest.

• Follow up with outpatients regularly (ideally daily).

• Monitor complete blood counts (CBC) daily or as clinically indicated.

• Encourage abundant oral fluid intake.

• Control fever with acetaminophen. Tepid sponging may also help reduce fever.

• Avoid aspirin (acetylsalicylic acid) and NSAIDs (e.g., ibuprofen).

• Educate patients and caregivers to:
  • Return immediately to medical care if warning signs appear
  • Be aware that the critical phase typically occurs 3-8 days after fever onset
  • Prevent the spread of dengue within the home. The patient should sleep under a mosquito bed net, and everyone in the house should use Environmental Protection Agency (EPA)-registered insect repellent for 3 weeks.

Important considerations

• Assess appropriate oral fluids intake and monitor for signs of dehydration.

• Avoid corticosteroids on a routine basis or prophylactic platelet transfusions.

• Don't assume IV fluids are needed. Oral hydration is usually sufficient for patients with dengue without warning signs.

Inpatient management is recommended for patients who do not have warning signs but have co-existing conditions that can increase the risk of severe dengue, including:

• Pregnancy
• Acute renal failure
• Coagulopathy
• Clinical presentation that requires inpatient care such as shortness of breath or intolerance to oral fluids.

Inpatient management can be considered on a case-by-case basis, for patients meeting any of the following criteria:

• Co-existing conditions: hypertension, diabetes, asthma, chronic kidney disease, chronic liver disease, peptic ulcer disease or other gastritis, obesity (body-mass index ≥30kg/m2), or receiving anticoagulation medications
• Age <1 year or >65 years
• Live alone or have poor access to healthcare facilities, lack of transportation, or live in extreme poverty

Recommended management

• Actively encourage and monitor oral fluid intake.
• Use acetaminophen (paracetamol) for fever.
• Monitor vital signs, urine output, and for warnings signs and compensated shock.
• Recommend IV fluids if oral intake is inadequate or the patient clinical status worsens.

Important considerations

• Maintain adequate hydration and hemodynamic stability, guided by frequent clinical and lab oratory assessment.
• Promptly identify warning signs or progression to severe dengue. Both require additional interventions.

Inpatient management is recommended for patients with warning signs

Recommended management

• Baseline labs: CBC
• Monitor vital signs, intake, urine output, and hematocrit: every 4–6 hours or more frequently as needed based on clinical status.
  • This is particularly important during the critical phase, which usually begins around defervescence (when fever resolves).
• Administer an initial IV fluid bolus
  • Start with isotonic crystalloids (e.g., normal saline or Ringer's lactate).
    

• IV fluids should be adjusted based on the patient's clinical condition and hematocrit trends, and gradually reduced as the patient improves.
  • As capillary permeability normalizes (—often around 48 hours after defervescence, though this can vary—) IV fluid rates should be progressively decreased.
  • Careful clinical monitoring is needed to avoid both inadequate hydration and fluid overload.

Important considerations

• Maintain adequate hydration and hemodynamic stability, guided by frequent clinical and lab oratory assessment.
• Promptly identify signs of progression to severe dengue.

Patients in this group have life-threatening complications and require intensive care. Severe dengue is defined by one or more of the following:

• Severe plasma leakage leading to shock or respiratory distress

• Severe bleeding (clinically significant)

• Severe organ involvement, such as liver (AST or ALT >1000 UI/L), CNS (impaired consciousness), or heart (myocarditis or arrhythmias)

Recommended management

• Admit to a facility capable of close monitoring and rapid fluid management, ideally an intensive care setting.
• Monitor vital signs continuously or at least every 1–2 hours during the critical phase.
• Track pulse pressure (difference between systolic and diastolic blood pressure), capillary refill, and changes in mental status.
• Track hematocrit and other laboratory markers frequently to assess plasma leakage and response to fluids.
• Administer a first dose of IV crystalloid solution (e.g., Ringer's lactate or normal saline).
  • Administer up to 2 additional doses of IV crystalloid solution.
  • Consider administration of colloids (such as albumin) for patients who do not respond to 2–3 boluses of crystalloid solutions.

Important considerations

• Carefully titrate IV fluids by using frequent hemodynamic and laboratory assessment to balance resuscitation and avoid fluid overload.
• Gradually reduce IV fluids as the patient stabilizes, with close monitoring during and after the critical phase.
• Maintain close hemodynamic surveillance of all patients. Severe dengue may present with shock due to plasma leakage rather than overt bleeding.
• Prophylactic platelet transfusions are not recommended.
• Blood transfusions are indicated if clinically significant active bleeding is occurring, particularly when accompanied by hemodynamic instability, or if hematocrit falls despite adequate fluid replacement, which suggests occult bleeding.
• Corticosteroids are not recommended routinely for patients with dengue unless they have a co-existing immune-mediated condition (e.g., HLH or ITP).