This document provides guidance on diagnosing and managing dengue fever and its potential complications. It outlines criteria for classifying dengue cases into three groups - dengue without warning signs, dengue with warning signs, and severe dengue - and recommends different treatment approaches depending on the classification. For all groups, careful monitoring of vital signs, fluid balance, and hematocrit levels is important. Intravenous fluid therapy may be needed and rates should be adjusted based on the patient's condition and response. Blood transfusion may be required for severe bleeding. The goal is early detection of potential complications and providing the right level of supportive care and intervention.

1. Dengue Case Management
Presumptive Diagnosis:
Live in / travel to endemic area plus
Fever and two of the following:
Assessment
• Anorexia and nausea
• Rash
• Aches and pains
• Warning signs
• Leucopenia Warning signs:
• Tourniquet test positive • Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation
• Mucosal bleed
Lab.confirmed dengue • Lethargy; restlessness
(important when no sign • Liver enlargement >2cm
• Laboratory: Increase in HCT concurrent with rapid
of plasma leakage)
decrease of platelet count
negative positive
Classification
Co-existing conditions
positive
Social circumstances
negative
Dengue without Dengue with
warning signs warning signs Severe Dengue
Group A Group B Group C
May be sent home Referred for in-hospital care Require emergency treatment
Group criteria Group criteria OR Group criteria
Patients who do not have warning signs Patients with any of the following Existing warning signs: Patients with any of the following features.
AND features: o A b d o minal pain or tenderness o S e v ere plasma leakage with shock and/or fluid accumulation with
who are able: o C o-existing conditions such o P ersistent vomiting respiratory distress
o T o tolerate adequate volumes of oral as pregnancy, infancy, old o C l i nical fluid accumulation o S e v ere bleeding
fluids age, diabetes mellitus o M u c o sal bleeding o S e v ere organ impairment
o T o pass urine at least once every 6 o S o cial circumstances such as o L ethargy/ restlessness
hours living alone, living far from o L i ver enlargement >2cm
hospital o L a b oratory: increase in Hct
Laboratory tests Laboratory tests Laboratory tests
o Full blood Count (FBC) o Full blood Count (FBC) o Full blood Count (FBC) o O t h er organ function tests as
o H a e matocrit (Hct ) o H a e matocrit (Hct) o H a e matocrit (Hct) indicated
Treatment Treatment Treatment Treatment of compensated shock:
Advice for: o E n c ouragement for oral o O btain reference Hct before fluid therapy o Start I.V. fluid resuscitation with isotonic crystalloid solutions at 5-10
o A d e quate bed rest fluids o G i v e isotonic solutions such as 0,9% ml/kg/hr over 1 hr
o A d e quate fluid intake o I f not tolerated, start saline, Ringer lactate, start with 5-7 o R eassess patient’s condition,
o P a r a c etamol, 4 gram max. per day in intravenous fluid therapy ml/kg/hr for 1-2 hours, then reduce to 3- If patient improves:
adults and accordingly in children 0,9% saline or Ringer Lactate 5 ml/kg/hr for 2-4 hr, and then reduce to o I . V. fluids should be reduced gradually to 5-7 ml/kg/hr for 1-2 hr, then to 3-
Management
at maintenance rate 2-3 ml/kg/hr or less according to clinical 5 ml/kg/hr for 2-4 hr, then to 2-3 ml/kg/hr for 2-4 hr and then reduced
Patients with stable Hct can be sent home response further depending on haemodynamic status
Reassess clinical status and repeat Hct o I . V. fluids can be maintained for up to 24 - 48 hours
o I f Hct remains the same or rises only If patient still unstable:
minimally -> continue with 2-3 ml/kg/hr o C h eck Hct after first bolus
for another 2-4 hours o If Hct increases/ still high (>50%), repeat a second bolus of crystalloid
o I f worsening of vital signs and rapidly solution at 10-20 ml/kg/hr for 1 hr.
rising Hct -> increase rate to 5-10 o I f improvement after second bolus, reduce rate to 7-10 ml/kg/hr for 1-2 hr,
ml/kg/hr for 1-2 hours continue to reduce as above.
Reassess clinical status, repeat Hct and o If Hct decreases, this indicates bleeding and need to cross-match and
review fluid infusion rates accordingly transfuse blood as soon as possible
o R e duce intravenous fluids gradually Treatment of hypotensive shock
when the rate of plasma leakage o I nitiate I.V. fluid resuscitation with crystalloid or colloid solution at 20
decreases towards the end of the critical ml/kg as a bolus for 15 min
phase. If patient im p r o v e s
This is indicated by: o G i v e a crystalloid / colloid solution of 10 ml/kg/hr for 1 hr, then reduce
o A d e quate urine output and/or fluid intake gradually as above
o H ct decreases below the baseline value in If patient still unstable
a stable patient o R e view the Hct taken before the first bolus
Monitoring Monitoring Monitoring o If Hct was low (<40% in children and adult females, < 45% in adult males)
o D a i l y review for disease progression: o T emperature pattern o V ital signs and peripheral perfusion (1-4 this indicates bleeding, the need to crossmatch and transfuse (see above)
! D e creasing WBC o V olume of fluid intake and hourly until patient is out of critical o If HCT was high compared to the baseline value, change to I.V. colloids at
! D e f ervescence losses phase 10-20 ml/kg as a second bolus over to 1 hour; reassess after second bolus
! W a r ning signs (until out of critical o U rine output – volume and o U rine output (4-6 hourly) o If improving reduce the rate to 7-10 ml/kgt/hr for 1-2 hours, then back to
period) frequency o H ct (before and after fluid replacement, I.V. crystalloids and reduce rates as above
o A d vice for immediate return to o W a r ning signs then 6-12 hourly) o I f condition still unstable, repeat Hct after second bolus
hospital if development of any warning o H ct, white blood cell and o B l o o d glucose o If Hct decreases, this indicates bleeding, see above
signs platelet counts o O t h er organ functions (renal profile, liver o If Hct increases/ remains high (> 50%), continue colloid infusion at 10-20
o W r i t t e n advice of management (e.g. profile, coagulation profile, as indicated) ml/kg as athird bolus over 1 hr, then reduce to 7-10 ml/kg /hr for 1-2 hours,
home care card for dengue) then change back to crystalloid solution and reduce rate as above
Treatment of haemorrhagic complications:
o G i v e 5-10 ml/kg of fresh packed red cells or 10-20 ml/kg fresh whole blood
Discharge criteria: o No fever for 48 hours o I n c r e asing trend of platelet count o S t able haematocrit without intravenous fluids
-> all of the following criteria must be o Improvement in clinical o No respiratory distress
present picture