Dengue Case Management

Presumptive Diagnosis:

Assessment

Neighbourhood dengue/
travel to endemic area plus
Fever and two of the following:
Anorexia and nausea
Rash
Aches and pains
+/- warning signs
Leucopenia
Tourniquet test +/-

Warning signs:
Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation
Mucosal bleed
Lethargy; restlessness
Liver enlargement >2cm
Laboratory: Increase in HCT concurrent with rapid
decrease of platelet count

Lab.confirmed dengue
(important when no sign
of plasma leakage)

Classification

negative

positive

Co-existing conditions
Social circumstances

positive

negative

Dengue without
warning signs

Dengue with
warning signs

Group A
May be sent home
Group criteria
Patients who do not have warning
signs

AND

Management

who are able:

o To tolerate adequate volumes
of oral fluids
o To pass urine 3-4 times per day
Laboratory tests
o Full blood Count (FBC)
o Haematocrit (Hct)
Treatment
Advice for:
o Adequate bed rest
o Adequate fluid intake
o Paracetamol, 4 gram max. per
day
Patients with stable Hct can be sent
home

o
o

Monitoring
Daily review for warning signs
(until out of critical period)
Advice for immediate return to
hospital if development of any
warning signs
Written advice of management
(e.g. home card for dengue)

Severe Dengue

Group B

Group C

Referred for in-hospital care

Group criteria
Patients with any of the following features:
o

Existing warning signs

OR

Co-existing conditions such as

pregnancy, infancy, old age, diabetes
mellitus, renal failure
Social circumstances such as living
alone, living far from hospital

Require emergency treatment

Group criteria
Patients with any of the following features.
o Severe plasma leakage with shock and/or fluid
accumulation with respiratory distress
o Severe bleeding
o Severe organ impairment

Laboratory tests
o
o

Full blood Count (FBC)

Haematocrit (Hct)

Treatment
Obtain reference Hct before fluid therapy
Give isotonic solutions such as 0,95 saline, Ringer
lactate, start with 5-7 ml/kg/hr for 1-2 hours, then
reduce to 2-3 ml/kg/hr or less according to clinical
response
Reassess clinical status and repeat Hct
o If Hct remains the same or rises only minimally ->
continue with 2-3 ml/kg/hr for another 2-4 hours
o If worsening of vital signs and rapidly rising Hct ->
increase rate to 5-10 ml/kg/hr for 1-2 hours
Reassess clinical status, repeat Hct and review fluid
infusion rates accordingly
o Reduce intravenous fluids gradually when the rate
of plasma leakage decreases towards the end of the
critical phase.
This is indicated by:
o Adequate urine output and/or fluid intake
o Hct deceases below the baseline value in a stable
patient
Monitoring
o Vital signs and peripheral perfusion (1-4 hourly
until patient is out of critical phase
o Urine output (4-6 hourly)
o Hct (before and after fluid replacement, then 6-12
hourly)
o Blood glucose (before fluid replacement and repeat
as indicated
o Other organ functions (renale profile, liver profile,
coagulation profile, before fluid replacement and as
indicated)
o
o

o
o

o
o

Treatment
Encouragement for oral fluids
If not tolerated, start intravenous
fluid therapy 0,9% saline or
Ringer Lactate at maintenance rate

Laboratory tests
Full blood Count (FBC)
Haematocrit (Hct)

Treatment of shock:
Start intravenous fluid resuscitation with isotonic
crystalloid solutions at 5-10 ml/kg/hr
o Reassess patients s condition,
If patient improves:
o Intravenous fluids should be reduced gradually to 35 ml/kg/hr, then to 2-3 ml/kg/hr and then depending
on haemodynamic status
o Can be maintained for up to 24 - 48 hours
If patient still unstable:
o Check Hct after first bolus
o If Hct increases/ still high (>50%), repeat a second
bolus of crystalloid solution at 10-20 ml/kg/hr.
o If improvement after second bolus, reduce rate to 710 ml/kg/hr, continue to reduce as above
o If Hct decreases, this indicates bleeding and need to
cross-match and transfuse blood as soon as possible

Treatment of hypotensive shock

o
o
o
o
o

Monitoring
Temperature pattern
Volume of fluid intake and losses
Urine output volume and
frequency
Warning signs
Hct, white blood cell and platelet
counts

Initiate IV fluid resuscitation with crystalloid or

colloid solution at 20 ml/kg as a bolus for 15 min
If patient improves
o Give a crystalloid / colloid solution of 10 ml/kg/hr,
them reduce gradually
If patient still unstable
o Check Hct after the first bolus
o If Hct increases/ still high (>50%), change IV fluids
to colloid solutions at 10 ml/kg/hr, then reduce to 710 ml/kg/h, then change back to crystalloid solution
and reduce rate as above
o If HCT decreases, this indicates bleeding, see above

Treatment of haemorrhagic complications:

Give 5-10 ml/kg of fresh packed red cells or 10-20
ml/kg of fresh whole blood

Dengue case classification by severity

Without

with
warning
signs

Criteria for dengue warning signs

Probable dengue
Live in/travel to
dengue endemic
area. Fever and 2 of
the following criteria:
Nausea, vomiting
Rash
Aches and pains
Tourniquet test
positive
Leucopenia
Any warning sign
Laboratory
confirmed dengue
(important when no sign of
plasma leakage)

Warning signs*
Abdominal pain or
tenderness
Persistent vomiting
Clinical fluid
accumulation
Mucosal bleed
Lethargy;
restlessness
Liver enlargement
>2cm
Laboratory:
Increase in HCT
concurrent with rapid
decrease in platelet
count
* Requiring strict observation
and medical intervention

Severe dengue

1.Severe plasma
leakage
2.Severe
haemorrhage
3.Severe organ
impairment

Criteria for severe dengue

1. Severe plasma
leakage leading to:
Shock (DSS)
Fluid accumulation
with
respiratory distress
2. Severe bleeding
as evaluated by
clinician
3. Severe organ
involvement
Liver: AST or
ALT>=1000
CNS: Impaired
consciousness
Heart and other
organs

WHO/TDR 2009

Dengue warning
signs