Recommendations on Dengue Fever & Dengue Hemorrhagic Fever

From the 2001 Revised National Consensus on the Case Management of Dengue Fever & Dengue Hemorrhagic Fever

This article starts below.

Who has dengue fever and dengue hemorrhagic fever?

The WHO deems it not appropriate to adopt a detailed clinical definition of dengue fever because of the variability in the clinical illness associated with dengue infection. There is a need for laboratory confirmation if technology exists. Otherwise it has proposed the following classification:

Case definition for dengue fever

An acute febrile illness of 2-7 days duration with 2 or more of the following:

  • Headache
  • Retro-orbital pain
  • Myalgia
  • Arthralgia
  • Rash
  • Hemorrhagic manifestations
  • Leukopenia

How is the tourniquet test done?

Place the cuff of a sphygmomanometer around the arm in the usual manner and inflate to a pressure halfway between systolic and diastolic levels. Maintain compression for five minutes and wait two minutes or more before observation. Describe an area 1-square inch on the volar surface of the forearm 1-1/2 inches distal from the antecubital fossa. Count the petechiae within this prescribed area. A positive tourniquet test is > 20 petechiae.

Who will need hospitalization?

It is not necessary to hospitalize all patients with suspected DHF, since shock develops in less than 1/3 of cases. The finding of a continuing drop in the platelet count concurrent with a rise in the hematocrit is an important indicator of the onset of shock. Repeated platelet and hematocrit determinations are needed. The critical period is usually on the day of defervescence, typically after the third day of illness. All patients presenting with dengue shock syndrome should be hospitalized. Those who will require treatment at home should be monitored for danger signs. The presence of any of the following danger signs requires hospitalization:

  • Spontaneous bleeding (epistaxis, gum bleeding, hematemesis, coffee-ground material per nasogastric tube, bleeding from venepuncture sites, hematuria, melena, hematochezia, menorrhagia)
  • Persistent abdominal pain
  • Persistent vomiting
  • Listlessness
  • Changes in mental status
  • Restlessness
  • Weak and rapid pulse
  • Cold, clammy skin
  • Circumoral cyanosis
  • Difficulty of breathing
  • Seizures
  • Hypotension or narrowing of pulse pressure (<20 mm Hg)
  • Platelet count < 100,000 cells per mm3 or 1-2 platelet per oil immersion field
  • Hemoconcentration
  • Prolonged bleeding time (>5 minutes by Ivy method)

How do you give fluids in dengue hemorrhagic fever?

Fluids must be given for replacement and maintenance purposes. In the febrile stage of DHF, fluid loss should be replaced with oral rehydrating salt solution. As much as 75 ml/kg body weight can be given in 4 hours.

Intravenous fluid therapy is recommended when danger signs are present, especially during defervescence. Crystalloids (D5LRS or D5NSS or PLRS or PNSS) can be given at 5-15 ml/kg/hour, with periodic adjustment according to patient's subsequent response. The vital signs and urine output are important parameters to monitor response to IVF therapy. It is suggested that you start at a rate of 5 ml/kg/hour and gradually increase this to 15 ml/kg/hr by 3-5 ml/hr increments until you achieve the desired response.

When the patient is in shock, IVF must be given at a faster rate and bigger volume, the 20/20 rule, that is, 20ml/kg in 20-30 minutes. The patient usually responds after this dose. If you do not improve the situation, colloids at 20 ml/kg in 20 minutes may be given. Meanwhile, look for other causes of shock such as bleeding, which may or may not be obvious.

After adequately replacing the fluid losses, maintenance IVF therapy should be instituted. D5LRS or D5IMB if < 2 yrs old may be used and should be given at 3 ml/kg/hr up to 2-3 liters per day in adults. Patients usually require IVF therapy for 24-48 hours.

When do you give blood/blood products in dengue hemorrhagic fever?

Whole blood is indicated to correct anemia and shock, if fluids are not able to provide adequate fluid resuscitation. When disseminated intravascular coagulation (DIC) is suspected, fresh frozen plasma or cryoprecipitate is given. A prolonged PTT is also an indication to give these blood products.

Platelet concentrates are not routinely administered. They are useful in the presence of significant bleeding with platelet counts < 50,000/cu mm or as prophylaxis against spontaneous bleeding when platelet counts are below 20,000/cu mm.

How often should we monitor platelet count and hematocrit in dengue hemorrhagic fever?

Baseline platelet count should be available at any stage of dengue hemorrhagic fever. Serial determinations may be required during the defervescence stage to anticipate the onset of shock or to detect occult bleeding. After recovery with fluid replacement, platelet count and hematocrit may be repeated just before discharge.

When do you send home patients with dengue hemorrhagic fever?

The absence of danger signs allows the treatment of dengue hemorrhagic fever at home. Hospitalized patients may be sent home if they have remained afebrile for at least 72 hours or if the danger signs have resolved.

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