REVISED DENGUE CLINICAL MANAGEMENT GUIDELINES

NEW VS. OLD

Case Definition & Classification

OLD
Dengue Fever
Probable Dengue An acute febrile illness w/ 2 or more of the ff: Headache Retro-orbital pain Arthralgia Rash Hemorrhagic manifestations Leukopenia AND Supportive serology

NEW
Dengue w/o Warning Signs
Probable Dengue Lives in or travels to dengue-endemic area, w/ fever, plus 2 of the ff: Headache Retro-orbital pain Arthralgia, myalgia Rash (petechial, Hermanns sign) Anorexia Nausea, vomiting Diarrhea Flushed skin AND Laboratory test, at least CBC (leukopenia w/ or w/o thrombocytopenia) and/or dengue NS1 antigen test or dengue IgM antibody test (optional) Confirmed dengue: Viral culture isolation PCR

Confirmed dengue: A case confirmed by laboratory criteria

OLD
Dengue Hemorrhagic Fever (DHF)
The ff must all be present: Fever, or hx of fever, lasting 2-7 days, occasionally biphasic Hemorrhagic tendencies evidenced by at least one of the ff: (+) tourniquet test Petechiae, ecchymosis, purpura Bleeding from mucosa, GIT, injection sites or other locations Hematemesis or melena Thrombocytopenia (100,00cells/mm3 or less) Evidence of plasma leakage d/t inc. vascular permeability, manifested by at least 1 of the ff: Rise in hct >= 20% above ave for age, sex, popn Drop in hct ff volume replacement >= 20% of basline Pleural effusion, ascites, hypoproteinemia

NEW
Dengue w/ Warning Signs
Probable Dengue Lives in or travels to dengue-endemic area, w/ fever lasting 2-7 days, plus any of the ff: Headache Abdominal pain or tenderness Persistent vomiting Clinical signs of fluid accumulation Mucosal bleeding Lethargy, restlessness Liver enlargdement Labs: inc. hct and/or dec. PC Confirmed dengue: Viral culture isolation PCR

OLD
Dengue Shock Syndrome (DSS)
All of the 4 criteria for DHF must be present, plus evidence of circulatory failure manifested by: Rapid and weak pulse, AND Narrow pulse pressure (<20mmHg ) OR Manifested by: Hypotension for age, AND Cold clammy skin & restlessness

NEW
Severe Dengue
Lives in or travels to dengue-endemic area, w/ fever lasting 2-7 days and any of the above clinical manifestations for dengue w/ or w/o warning signs, plus any of the ff: Severe plasma leakage, leading to: Shock Fluid accumulation w/ respiratory distress Severe bleeding Severe organ impairment Liver: AST or ALT >= 1000 CNS: seizures, impaired consciousness Heart: myocarditis Kidneys: renal failure Confirmed dengue: Viral culture isolation PCR

OLD
Grading of Severity of DHF/DSS DHF Grade 1 Fever accompanied by non-specific constitutional S/Sx such as anorexia, vomiting, abdominal pain; the only hemorrhagic manifestation is a (+) tourniquet test and/or easy bruising DHF Grade 2 Spontaneous bleeding in addition to manifestations of grade 1 patients usually in the form of skin or other hemorrhages (mucocutaneous, gastrointestinal) DHF Grade 3 (DSS) Circulatory failure manifested by rapid, weak pulse and narrowing of pulse pressure or hypotension, w/ presence of cold clammy skin and restlessness DHF Grade 4 (DSS) Profound shock w/ undetectable blood pressure or pulse

GENERAL GUIDELINES

COURSE OF DENGUE ILLNESS

COURSE OF DENGUE ILLNESS

Clinical problems encountered per phase: Febrile: dehydration; high fever may cause febrile seizures in young children; neurologic deficits Critical: shock from plasma leakage; severe hemorrhage; organ impairment Recovery: hypovolemia (only if IVF therapy excessive and/or extended into this period)

SPECIFIC TREATMENT GUIDELINES

ASSESSMENT
Step 1 Overall Assessment History PE Labs Step 2 Diagnosis, Assessment of Disease Phase and Severity Determine
Is it dengue? Which phase of dengue? Are there warning signs? What is the hydration and hemodynamic status? Does the patient require admission?

Step 3 Management Disease notification Management decisions

Sent home (GROUP A); or may Referred for in-hospital mgt (GROUP B); or may Require emergency tx and urgent referral (GROUP C)

TREATMENT
Group A ORS given based on wt, using Ludan Method Reduce osmolarity of ORS containing sodium 45 to 60 mmol/liter Sports drinks NOT given d/t high osmolarity

Group A

Group B Dengue w/o Warning Signs Encourage oral fluids; if not tolerated start IVF w/ isotonic solution If pt shows signs of mild dehydration but NOT in shock, add volume for mild dehydration to maintenance fluids
Infants: 50ml/kg Older child or adult: 30ml/kg

Monitor: temperature, volume of fluid intake and losses, urine output (vol & freq), warning signs, hct, WBC, & PC

Group B Dengue w/ Warning Signs Obtain hct before fluid therapy Give only isotonic soln
Start w/ 5-7 ml/kg/hr for 1-2hrs, then Reduce to 3-5 ml/kg/hr for 2-4hrs, and then Reduce to 2-3 ml/kg/hr or less accdg to clinical response

Reassess clinical status & repeat hct

If hct remains same or rises minimally: 23ml/kg/hr for another 2-4hrs If w/ worsening VS & rapidly rising hct: inc to 510ml/kg/hr for 1-2hrs

 Reassess clinical status, repeat hct & review fluid infusion rates Give minimum IVF volume required to maintain good perfusion & UO of about 0.5ml/kg/hr Reduce IVF gradually when rate of plasma leakage decreases towards the end of the critical phase Monitor:
VS & peripheral perfusion every 1-4hrs UO every 4-6hrs Hct before & after fluid replacement, then every 612hrs Others (renal profile, liver profile, coagulation profile

Group C For patients w/ Compensated Shock Start w/ isotonic crystalloid solutions at 510ml/kg/hr over 1 hr; then reassess If pts condition improves, IVF gradually reduced If vital signs still unstable, check hct after 1st bolus
If hct inc or still high: 2nd bolus of crystalloid at 1020ml/kg/hr for 1hr; reduce to 7-10ml/kg/hr for 12hrs if there is improvement If hct dec: transfuse

For patients w/ Hypotensive Shock Start w/ crystalloid/colloid solutions at 20ml/kg/hr over 15min If pts condition improves, give crystalloid/colloid infusion of 10ml/kg/hr for 1hr, then continued and gradually reduced If vital signs still unstable, check hct after 1st bolus
If hct inc or still high: 2nd bolus of colloid at 1020ml/kg/hr for to 1hr; reduce to 7-10ml/kg/hr for 1-2hrs; change back to crystalloid and reduce rate If hct dec: transfuse

TREATMENT OF HEMORRHAGIC COMPLICATIONS

5-10ml/kg fresh PRBC or 10-20ml/kg fresh whole blood

DISCHARGE CRITERIA
No fever for 48hrs Improvement in clinical status Increasing trend of platelet count Stable hematocrit w/o IVF