Dengue Author: Suranjith L. Seneviratne, MD, DPhil, MRCP, FRCPath; Panduka Karunanayake, MD, MRCP; Bandula Wijesiriwardena, MD, FRCP, FCCP, FCMSA, FRACP, FACP
Editorial changes - 2009-11-13
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  • Recognize that the cornerstone of management of severe dengue is judicious fluid replacement.
  • Use blood transfusions only in patients with significant hemorrhagic manifestations.
  • Use platelet transfusions appropriately.

Recognize that the cornerstone of management of severe dengue is judicious fluid replacement.A

  • Begin appropriate fluid replacement in patients with dengue.
    • Use oral rehydration in patients able to take fluids orally
    • Consider intravenous fluid administration only in patients with dehydration due to severe or persistent vomiting or refusal of all food and drink
    • Discontinue intravenous fluids as soon as dehydration is corrected and when oral intake is adequate
    • If intravenous fluids are to be given for more than a day, limit the amount to the minimum required
  • In patients with signs of plasma leakage:
    • Administer intravenous fluids (Ringer's lactate or normal saline) at a rate of 7 mL/kg·h
    • Once improvement is noted, gradually decrease the rate of intravenous fluids from 7 mL/kg·h to 5 mL/kg·h to 3 mL/kg·h and discontinue after 24 to 48 hours
    • If patients fail to respond to treatment or their status worsens:
      • Gradually increase the rate of intravenous fluids from 7 mL/kg·h to 10 mL/kg·h to 15 mL/kg·h and then change to colloid solution if the hematocrit is increasing or blood if the hematocrit decreases and bleeding is suspected
      • Once improvement is noted, gradually decrease the rate of intravenous fluids to 5 mL/kg·h and then to 3 mL/kg·h and discontinue after 24 to 48 hours
  • In patients with signs of circulatory compromise:
    • Provide immediate, rapid volume replacement with 10 to 20 mL/kg·h of Ringer's lactate or normal saline
    • If no improvement is noted, replace the crystalloid solution with colloid solution if the hematocrit is increasing or blood if the hematocrit decreases
    • Once improvement is noted, gradually decrease the rate of intravenous fluids from 10 mL/kg·h to 5 mL/kg·h to 3 mL/kg·h and discontinue after 24 to 48 hours
  • Consider immediate administration of a colloid solution in more severely ill patients with very narrow pulse pressures (<10 mm Hg).
  • Assess for improvement by looking for stable or gradually decreasing hematocrit in conjunction with stable pulse rate and blood pressure and increasing urine output.
  • Use invasive devices and procedures only when strictly necessary.
  • See figure Algorithm for Intravenous Fluid Infusion in Dengue Hemorrhagic Fever.
  • See figure Algorithm for Intravenous Fluid Infusion in Dengue Shock Syndrome.
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Use blood transfusions only in patients with significant hemorrhagic manifestations.C

  • Determine blood grouping and cross-matching as a routine precaution in all patients in shock, particularly those with prolonged shock.
  • Consider blood transfusion (10 mL/kg·h) in patients with persistent shock despite a decline in hematocrit after adequate initial crystalloidal and colloidal resuscitation.
  • See table Crystalloids, Colloids, and Blood Products for the Treatment of Dengue.
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Use platelet transfusions appropriately.C

  • Consider using platelet transfusions when the platelet count is <10 × 109/L; use a higher threshold count when there is significant mucocutaneous bleeding.
  • Give one adult therapeutic dose of platelet concentrate when platelets are given prophylactically to increase the count by 20 × 109/L.
  • Consider infusion of platelet concentrates and fresh frozen plasma in patients with disseminated intravascular coagulation complicating severe dengue.
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FAQs
Bandula Wijesiriwardena, MD, FRCP, FCCP, FCMSA, FRACP, FACP has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Panduka Karunanayake, MD, MRCP has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Suranjith L. Seneviratne, MD, DPhil, MRCP, FRCPath has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Steven E. Weinberger, MD, FACP, Acting Editor, PIER, has stock holdings in Glaxosmithkline and Abbott.

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