Dengue fever medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Currently, no effective antiviral agents are available to treat symptomatic dengue virus infection, and management remains supportive with emphasis on judicious fluid administration with oral rehydration solution or intravenous fluids. Acetyl-salicylic (aspirin) derivatives and other non-steroidal anti-inflammatory drugs should be avoided because of their potential to increase the risk of bleeding. Patients who have no complications and are able to tolerate oral fluids may be managed at home or as an outpatient. Development of any warning signs (See Group B or C below) suggests the need for intravenous fluid therapy and hospitalization. If the condition progresses to the Dengue shock syndrome, restoration of plasma volume with fluid boluses and/or blood transfusion is required to maintain adequate tissue perfusion.

General Measures

• Oral and intravenous fluids
• Avoid aspirin and non-steroidal anti-inflammatory medications. These drugs are often used to treat pain and fever though in this case they may actually aggravate the bleeding tendency associated with some of these infections. Patients should receive instead acetaminophen (tylenol) to deal with these symptoms [2] if Dengue is suspected.

Management of Complications

The presence of melena may indicate internal gastrointestinal bleeding requiring platelet and/or red blood cell transfusion. A platelet transfusion may be indicated in rare cases if the platelet count drops significantly (below 20,000) or if there is significant bleeding.

WHO Guideline

According to the guidelines published by the WHO, patients should be rapidly screened to identify those with severe dengue (who require immediate emergency treatment to avert death), those with warning signs (who should be given priority while waiting in the queue so that they can be assessed and treated without delay), and non-urgent cases (who have neither severe dengue nor warning signs). Based on the clinical manifestations and other circumstances, patients should be triaged into the following groups and managed accordingly (click to expand):

Group A (May be sent home)   ▸  Group criteria ❑ Patients who do not have warning signs PLUS ❑ Able to tolerate adequate volumes of oral fluids OR ❑ Able to pass urine at least once every 6 hours   ▸  Laboratory tests ❑ Complete blood count ❑ Hematocrit (Hct)   ▸  Management ❑ Adequate bed rest ❑ Adequate fluid intake ❑ Acetaminophen (Paracetamol)   ▸  Monitoring ❑ Patients with stable Hct may be sent home. ❑ Daily review for disease progression:    ❑ Decreasing white blood cell count    ❑ Defervescence    ❑ Warning signs (until out of critical period) ❑ Immediate return to hospital if development of any warning signs ❑ Written advice for management

Group B (Referred for in-hospital care)   ▸  Group criteria ❑ Patients with any of the warning signs:    ❑ Abdominal pain or tenderness    ❑ Persistent vomiting    ❑ Clinical fluid accumulation    ❑ Mucosal bleed    ❑ Lethargy, restlessness    ❑ Liver enlargment >2 cm    ❑ Increase in hematocrit with rapid decrease in platelet count   ▸  Laboratory tests ❑ Complete blood count ❑ Hematocrit (Hct)   ▸  Management ❑ Obtain reference Hct before fluid therapy ❑ Give isotonic solutions such as 0.9 % saline or Ringer’s Lactate    ❑ Start with 5–7 ml/kg/h for 1–2 h    ❑ Then reduce to 3–5 ml/kg/h for 2–4 h    ❑ Then reduce to 2–3 ml/kg/h or less according to clinical response Reassess clinical status and repeat Hct ❑ If Hct remains the same or rises only minimally:    ❑ Continue with 2–3 ml/kg/h for another 2–4 h ❑ If worsening of vital signs and rapidly rising Hct:    ❑ Increase rate to 5–10 ml/kg/h for 1–2 h Adjust fluid infusion rates ❑ Reduce intravenous fluids gradually when:    ❑ Adequate urine output and/or fluid intake    ❑ Hct deceases below the baseline value in a stable patient   ▸  Monitoring ❑ Vital signs and peripheral perfusion (q1–4 until out of critical phase):    ❑ Urine output (4–6 hourly)    ❑ Hct (before and after fluid replacement, then 6–12 hourly)    ❑ Blood glucose    ❑ Renal function    ❑ Liver function    ❑ Coagulation profile

Group C (Require emergency treatment)   ▸  Group criteria ❑ Patients with any of the warning signs:    ❑ Abdominal pain or tenderness    ❑ Persistent vomiting    ❑ Clinical fluid accumulation    ❑ Mucosal bleed    ❑ Lethargy, restlessness    ❑ Liver enlargment >2 cm    ❑ Increase in hematocrit with rapid decrease in platelet count   ▸  Laboratory tests ❑ Complete blood count ❑ Hematocrit (Hct) ❑ Other organ function tests as indicated   ▸  Management Management of compensated shock ❑ Resuscitation with isotonic crystalloid at 5–10 ml/kg/h over 1 hour ❑ If patient improves:    ❑ Reduce IV fluids gradually to 5–7 ml/kg/h for 1–2 h    ❑ Then to 3–5 ml/kg/h for 2–4 h    ❑ Then to 2–3 ml/kg/h for 2–4 h    ❑ Then reduced further depending on hemodynamic status    ❑ IV fluids can be maintained for up to 24–48 h ❑ If patient is still unstable:    ❑ Check Hct after first bolus    ❑ If Hct increases: repeat a second bolus at 10–20 ml/kg/h for 1 h    ❑ If Hct decreases: transfuse as soon as possible Management of hypotensive shock ❑ Resuscitation with crystalloid/colloid at 20 ml/kg for 15 min ❑ If patient improves:    ❑ Control rate at 10 ml/kg/h for 1 h, then reduce gradually ❑ If patient is still unstable:    ❑ Review the HCT taken before the first bolus    ❑ If HCT was low: transfuse as soon as possible    ❑ If HCT was high: IV colloids at 10–20 ml/kg for 0.5–1 h    ❑ If patient is improving: reduce the rate to 7–10 ml/kg/h for 1–2 h ❑ If patient is still unstable after second bolus:    ❑ If HCT decreases: transfuse as soon as possible    ❑ If HCT increases: continue colloid at 10–20 ml/kg for 1 h Management of hemorrhagic complications ❑ Give 5–10 ml/kg of packed red cells or 10–20 ml/kg of whole blood

References