This document provides guidelines for diagnosing and managing dengue fever. It discusses diagnosing dengue through virus isolation, nucleic acid detection, antigen detection and antibody testing. It recommends symptomatic and supportive care for management, including antipyretics, oral or IV fluids based on three groups of patients. Group A can be sent home with oral rehydration, Group B requires in-hospital monitoring with or without IV fluids depending on symptoms, and Group C needs emergency treatment including rapid IV fluid resuscitation. It provides criteria for administering platelets and blood transfusions and discusses monitoring patients closely during the critical phase of illness.

2. Course of illness

4. Dengue classification

5. Diagnosis of dengue
 Virus isolation in cell culture More accurate
 Nucleic acid detection by PCR
 Viral Ag detection(e.g., NS1)-day 1, 60-80% in 2° infec.
 Specific antibodies (IgM, IgG)- after D5
 IgM-persists 30-90 days
 IgG-Remains detectable for 60 yrs. Diagnostic if >4
fold rise in titer in samples collected 14 days apart.

6. Management of dengue
 No specific antivirals
 Symptomatic, supportive
 Fever- tepid sponging/ Paracetamol
 Maintain proper fluid balance. Oral/i.v.
 i.v. hydration usually needed for 24-48 hrs
 Titrate fluids according to urine output, vitals and hct.
 Early blood transfusion in patients with unstable vitals
in the face of decreasing hematocrit.

7. Approach to the Management
Groups A
• may be sent
home
• tolerate
adequate
volumes of
oral fluids and
pass urine at
least once
every 6 hours
• no warn signs
Groups B
• referred for
in-hospital
management
• with warning
signs, co-existing
conditions,
• with certain
social
circumstances
Groups C
• require
emergency
treatment
and urgent
referral
• severe
dengue (in
critical phase)
Management Decisions

8. Group A Action Plan
• Encourage intake of ORS, fruit juice and other fluids
• Paracetamol for fever
• Advise to come back if warning signs develop
no clinical improvement
severe abdominal pain
persistent vomiting
cold and clammy extremities,
lethargy or irritability or restlessness,
bleeding
not passing urine for more than 4–6 hours.
monitor:
temperature , volume of fluid intake and losses, warning signs, signs of plasma leakage and
bleeding, haematocrit, and white blood cell and platelet counts

9. Group B (without warning signs)
Action Plan
• If not tolerating oral fluids, start intravenous fluid
therapy of 0.9% saline or Ringer’s lactate with or
without dextrose at maintenance rate
Patients may be able to take oral fluids after a few hours of
intravenous fluid therapy.
• Close monitoring

10. Group B (with warning signs)
Action Plan
• reference hematocrit before fluid therapy
• isotonic solutions
5–7 ml/kg/hour for 1–2 hours, then reduce to
3–5 ml/kg/hr for 2–4 hours, and then reduce to
2–3 ml/kg/hr or less according to the clinical
response
reassess:
• haematocrit remains the same or rises only minimally  2–3 ml/kg/hr
for another 2–4 hours
• worsening vital signs and rising haematocrit rising  5–10 ml/kg/hour for
1–2 hours

11. Group B (with warning signs)
Action Plan
Give minimum intravenous fluid volume:
maintain good perfusion and urine output of
about 0.5 ml/kg/hr
• Intravenous fluids are usually needed for only 24–48
hours.
monitor:
• vital signs and peripheral perfusion (1–4 hourly until the patient
is out of the critical phase)
• urine output (4–6 hourly)
• hematocrit (before and after fluid replacement, then 6–12 hourly)
• blood glucose
• organ functions (renal profile, liver profile, coagulation profile)

12. Group C Action Plan
• admit in ICU
• plasma losses should be replaced immediately and
rapidly with isotonic crystalloid solution or, in
the case of hypotensive shock, colloid solutions
• blood transfusion: with suspected/severe bleeding
• judicious intravenous fluid
resuscitation: sole intervention
required

13. Parameters Stable circulation Compensated
shock
Hypotensive shock
Conciousnes level Clear & lucid Clear & Lucid Restless,combative
CRT Brisk<2 s Prolonged >2 s prolonged,mottled
Extremities Warm & pink Cool peripherals Cold, clammy
Periph pulse vol Good volume Weak & thready Feeble or absent
Heart rate Normal for age Tachycardia for age Severe tachycardia or
bradycardia in late
shock
Blood pressure N B.P. or pulse
pressure for age
N sys. But rising dias.
Psr ,
Narrowing pulse psr
Postural hypotension
Narrow pulse
psr(<20 m hg)
Hypotension
Unrecordable
RR N Tachypnea Hyperpnea/ kussu
Urine output N Reduced trend Oliguria/Anuria

16. When to stop i.v. fluids
 Signs of cessation of plasma leakage
 Stable B.P., pulse and peripheral perfusion
 Hematocrit decreases in the presence of good pulse vol
 Apyrexia(without antipyretics)for more than24-48 hr
 Resolving bowel/abdominal symptoms
 Improving urine output

17. Indications of platelet Tx in Dengue
 Platelet count- <20,000/cmm
 21-40,000- only if hemorrhagic symptoms

18. Treatment of Hemorrhagic Complications
• Do not wait for the haematocrit to drop too low before
deciding on blood transfusion
• 5-10 ml/kg of PRBC or 10-20 ml/kg FWB
• little evidence to support transfusion of platelet
concentrate and FFP

19. Management of Complications
• Fluid Overload
Causes:
– excessive / too rapid i.v. fluids;
– hypotonic rather than isotonic crystalloid solutions;
– inappropriate use of large volumes of i.v. fluids in patients with
unrecognized severe bleeding;
– inappropriate transfusion of FFP, platelets, cryoprecipitates
– continuation of IVF after plasma leakage has resolved
TREATMENT OF FLUID OVERLOAD
Oxygen
Stop i.v. fluids
Diuretics

20. Monitoring – Critical Phase
 Vitals - hourly
 Fluid balance chart - 3 hourly
 HCT - 6 hourly

21. Monitoring During Shock
 15 minute monitoring of vital signs.
 HCT immediately before and after each fluid bolus
and then at least two to four hourly

22. 1.Afebrile for 24 hrs without antipyretics
2.Good appetite, clinically improved condition
3.Adequate urine output
4.At least 48 hrs sice recovery from shock
5.No respiratory distress
6.Platelet count>50000 and stable hematocrit without i.v. fluids

23. SUMMARY
DO‘s and DON’Ts Management
 Don’t use corticosteroids
 Don’t give platelet transfusion for low platelets
 Don’t give half (o.45%) saline
 Don’t assume that IV fluids are necessary
 Do tell outpatients when to return
 Do recognize the critical period
 Do closely monitor fluid intake and output, vital signs,
and hematocrit levels

24. Contd…..
 Do recognize and treat early shock
 Do administer colloids for refractory shock
 Do give PRBCs or whole blood for clinically significant
bleeding.