PRESUMPTIVE DIAGNOSIS DENGUE CASE MANA

Live in/travel to dengue endemic area.

Fever and two of the following criteria:
• Anorexia and nausea
ASSESSMENT

• Rash
• Aches and pains
• Warning signs
• Leukopenia WARNING SIGNS*
• Tourniquet test positive • Abdominal pain or tenderness
• Persistent vomiting
Laboratory confirmed dengue • Clinical fluid accumulation
(important when no sign of plasma leakage) • Mucosal bleed
• Lethargy, restlessness
• Liver enlargment >2 cm
• Laboratory: increase in HCT concurrent
with rapid decrease in platelet count
*(requiring strict observation and medical intervention)
CLASSIFICATION

NEGATIVE

Co-existing conditions
POSITIVE
Social circumstances

NEGATIVE

DENGUE WITHOUT WARNING SIGNS DENGUE WITH WARNING SIGNS

Group A Group B
(May be sent home) (Referred for in-hospital care)

Group criteria Group criteria OR: Existing warning signs Group criter
Patients who do not have warning signs Patients with any of the following features: Patients with
AND • co-existing conditions such as Laboratory tests • severe pla
who are able: pregnancy, infancy, old age, diabetes • full blood count (FBC) • severe ble
• to tolerate adequate volumes of oral mellitus, renal failure • haematocrit (HCT) • severe org
fluids • social circumstances such as living
• to pass urine at least once every alone, living far from hospital Treatment Laboratory t
6 hours Obtain reference HCT before fluid therapy. • full blood
Laboratory tests Give isotonic solutions such as 0.9 % saline, • haematoc
Laboratory tests • full blood count (FBC) Ringer’s Lactate. Start with 5–7 ml/kg/hr for • other orga
• full blood count (FBC) • haematocrit (HCT) 1–2 hours, then reduce to 3–5 ml/kg/hr for
• haematocrit (HCT) 2–4 hr, and then reduce to 2–3 ml/kg/hr Treatment of
Treatment or less according to clinical response. Start IV fluid
Treatment • Encouragement for oral fluids. If not
If patient imp
Advice for: tolerated, start intravenous fluid Reassess clinical status and repeat HCT: • IV fluids sh
• adequate bed rest therapy 0,9% saline or Ringer’s Lactate • if HCT remains the same or rises only
MANAGEMENT

then to 2-
• adequate fluid intake at maintenance rate. minimally -> continue with 2–3 ml/kg/ • IV fluids c
• Paracetamol, 4 gram maximum per hr for another 2–4 hours;
day in adults and accordingly in Monitoring • if worsening of vital signs and rapidly If patient is s
children. Monitor: rising HCT -> increase rate to 5–10 • check HC
Patients with stable HCT can be sent home. • temperature pattern ml/kg/hr for 1–2 hours. • if HCT inc
• volume of fluid intake and losses Reassess clinical status, repeat HCT and • if there is
Monitoring • urine output (volume and frequency) review fluid infusion rates accordingly: • if HCT de
Daily review for disease progression: • warning signs • reduce intravenous fluids gradually when
• decreasing white blood cell count • HCT, white blood cell and platelet the rate of plasma leakage decreases Treatment of
• defervescence counts. towards the end of the critical phase. Initiate IV flui
• warning signs (until out of critical period). This is indicated by: If patient imp
Advice for immediate return to hospital if • adequate urine output and/or fluid • give a cry
development of any warning signs, and intake If patient is s
• written advice for management (e.g. • HCT deceases below the baseline value • review the
home care card for dengue). in a stable patient. • if HCT wa
the need t
Monitoring • if HCT wa
Monitor: reassess a
• vital signs and peripheral perfusion (1–4 • If patient
hourly until patient is out of critical phase • if patient’
• urine output (4–6 hourly) • If HCT de
• HCT (before and after fluid replacement, • if HCT inc
then 6–12 hourly) then reduc
• blood glucose
• other organ functions (renal profile, liver Treatment of
profile, coagulation profile, as indicated). Give 5–10 m
 CASE MANAGEMENT Days of illness 1 2 3 4 5 6 7 8 9 10

40°

Temperature

Dehydration Shock Reabsorption

Potential clinical issues
bleeding Fluid overload

Organ impairment

Platelet
Laboratory changes

Hematocrit

IgM/IgG
Serology and virology Viraemia

on)
Course of dengue illness: Febrile Critical Recovery phases

POSITIVE

SEVERE DENGUE

Group C
(Require emergency treatment)

Group criteria
Patients with any of the following features:
• severe plasma leakage with shock and/or fl uid accumulation with respiratory distress
• severe bleeding
• severe organ impairment

Laboratory tests
e fluid therapy. • full blood count (FBC)
as 0.9 % saline, • haematocrit (HCT)
–7 ml/kg/hr for • other organ function tests as indicated
–5 ml/kg/hr for
2–3 ml/kg/hr Treatment of compensated shock
response. Start IV fluid resuscitation with isotonic crystalloid solutions at 5–10 ml/kg/hr over 1 hour. Reassess patients’ condition.

If patient improves:
repeat HCT: • IV fl uids should be reduced gradually to 5–7 ml/kg/hr for 1–2 hours, then to 3–5 ml/kg/hr for 2–4 hours,
or rises only then to 2-3 ml/kg/hr for 2–4 hours and then reduced further depending on haemodynamic status;
h 2–3 ml/kg/ • IV fl uids can be maintained for up to 24–48 hours.

s and rapidly If patient is still unstable:

ate to 5–10 • check HCT after fi rst bolus;
• if HCT increases/still high (>50%), repeat a second bolus of crystalloid solution at 10–20 ml/kg/hr for 1 hour;
eat HCT and • if there is improvement after second bolus, reduce rate to 7–10 ml/kg/hr for 1–2 hours and continue to reduce as above;
ccordingly: • if HCT decreases, this indicates bleeding and need to cross-match and transfuse blood as soon as possible.
gradually when
ge decreases Treatment of hypotensive shock
itical phase. Initiate IV fluid resuscitation with crystalloid or colloid solution at 20 ml/kg as a bolus for 15 minutes.
If patient improves:
d/or fl uid • give a crystalloid/colloid solution of 10 ml/kg/hr for 1 hour, then reduce gradually as above.
If patient is still unstable:
e baseline value • review the HCT taken before the fi rst bolus;
• if HCT was low (<40% in children and adult females, <45% in adult males) this indicates bleeding,
the need to cross-match and transfuse (see above);
• if HCT was high compared to baseline value, change to IV colloids at 10–20 ml/kg as a second bolus over 30 minutes to 1 hour;
reassess after second bolus.
perfusion (1–4 • If patient is improving reduce the rate to 7–10ml/kg/hr for 1–2 hours, then back to IV cystalloids and reduce rates as above;
of critical phase • if patient’s condition is still unstable, repeat HCT after second bolus.
• If HCT decreases, this indicates bleeding (see above);
id replacement, • if HCT increases/remains high (>50%), continue colloid infusion at 10–20 ml/kg as a third bolus over 1 hour,
then reduce to 7–10 ml/kg/h 1–2 hours, then change back to crystalloid solution and reduce rate as above.

nal profi le, liver Treatment of haemorrhagic complications

e, as indicated). Give 5–10 ml/kg of fresh packed red cells or 10–20 ml/kg of fresh whole blood.