DENGUE FEVER

MANAGEMENT GUIDELINES

	Presumptive diagnosis of Dengue Fever: Fever and two of the following signs: Anorexia and nausea Rash Aches and pains Warning signs Leucopenia Positive Tourniquet test

 

Tourniquet Test: Apply BP cuff to upper arm Raise the BP to a level between systolic and diastolic. Keep it for 5 minutes. Mark an area of one inch square and look for and count the number of petechiae. >20 petechiae is diagnostic

	WARNING SIGNS: Abdominal pain and tenderness Persistent vomiting Clinical fluid accumulation (edema, ascites and pleural effusion) Mucosal bleeding Lethargy or restlessness Liver enlargement >2cm Rapid decrease in platelet count and corresponding increase in Hematocrit

Group A

May be sent home

[Patients do not have warning signs]

Group Criteria:

Patients who do not have warning signs;

able to drink adequate volumes of oral fluids; and pass urine at least once every 6 hours.

Laboratory Test:

White Cell count on day 3 of fever

Platelet count on day 3 and every third day there after [should be >1,00,000]

Hematocrit if facility is available

Treatment:

Adequate bed rest

Plenty of oral fluids

Oral rehydration solution or fruit juices

Or other fluids containing electrolytes

Paracetamol up to 4g in an adult not frequent than at 6 hour intervals

(10 mg/kg for children.)

Tepid sponging if high fever persists.

Caution:

Do not give aspirin, ibuprofen or NSAIDs

(they aggravate gastritis and bleeding)

Fluids contaning sugar can exacerbate hyperglycemia in diabetic patients.

Monitoring

Daily review for disease progression

Defervescence

Look for warning signs

Strict advice to return to hospital if any warning signs develop.

Need for reassessment:

No clinical improvement

Deterioration at time of defervescence

Severe abdominal pain and vomiting

Cold and clammy extremities

Lethargy irritability/restlessness

Bleeding tendencies:

[petechiae, purpurae or ecchymoses]

[epistaxis  or gum bleeding]

[menorrhagia in women]

[coffee ground vomitus/melena]

If any of above is present, refer to Secondary Care Center for further management

 Group B

Admit in secondary care center

[Patients who have warning signs]

Group Criteria:

Patients with any of the following features: co-existing conditions like pregnancy, infancy, old age, diabetes mellitus chronic hemolytic disease and renal failure

Patients who are living alone or away from hospital.

Laboratory Test:

White Cell count/Platelet count

Get a basic Hematocrit value and

look at reference value for age and sex.

Evidence for plasma leakage:

A rise in average HCT for age and sex by 20% or a >20% drop in HCT following volume replacement.

Presence of clinical signs of plasma leakage: ascites, pleural effusion

Treatment:

Give encouragement for oral fluids

If not tolerated start IV fluids

0.9% normal saline or

Ringer lactate

5-7ml/kg/hour for 1-2 hours

3-5ml/kg/hour for 2-4 hours

2-3ml/kg/hour as per clinical response

Run at maintenance slow rate only

Repeat the hematocrit and reassess the clinical status and review fluid infusion rate accordingly

Monitoring;

Monitor the patient till risk period is over for the following parameters:

Monitor temperature 4hrly

Maintain a fluid intake output chart

Look for warning signs frequently

Blood sugar, RFT, LFT, Chest X-ray and

Coagulation parameters if indicated.

Discharge from hospital, if visible clinical improvement, return of appetite and platelet count >50,000

Refer to Tertiary Care Center if patient does not improve

Group C:

Admit in tertiary care center

[Severe cases of Dengue Fever]

Group Criteria:

Severe bleeding tendencies such as upper GI bleeding/clinical or ultra sound scan evidence of internal bleed.

Severe plasma leakage leading to dengue shock syndrome

Severe organ dysfunction in the form of hepatic dysfunction, renal dysfunction, myocarditis  or encephalitis.

Laboratory Test:

White Cell count/Platelet count/HCT

Other tests for detecting organ dysfunction such as: LFT RFT INR

Treatment of DHF:

[Generally platelet transfusions are not advisable in the absence of bleeding]

Platelet count <10,000 without bleed

Platelet count <50,000 with bleeding

Give platelet transfusions

3-5 units of PRP (platelet rich plasma) per day or PC (platelet concentrate) in patients with high cardiovascular risk.

Treatment of compensated shock:

IV fluids: Normal saline or ringer lactate  @5-10ml/kg/hr for first hour.

[In infants and children 10-20ml/kg/in the 1st hour]

If patient improves reduce dose to 5-7ml/kg/hr for 2 hour  and then reduce further to 3-5ml/kg/hr

IV fluids to be maintained for not more than  24-48hrs

Check HCT after initial bolus and if HCT increases  give IV fluid Normal saline @10-20ml/kg/hr. Consider treatment with colloids like IV dextran.

If HCT falls with unstable vital signs give blood transfusion (whole fresh blood /PRC

Treatment of hypotensive shock:

More vigorous IV fluid administration:

Normal saline  20ml/kg administered as bolus for 15min. Gradually reduce as in case of compensated shock.