Dengue Fever

Acute febrile illness caused by 4

serotypes of dengue
virus
family of Flaviviridae
Vectors:
1. female Aedes aegypti
mosquito, the primary vector
and an important factor in
epidemics; a tropical and
subtropical sp found around the
globe

2.
Aedes albopictus, the
secondary vector
believed to be responsible
in maintaining the virus
in the environment

lives indoor; low-flying day-biting

variety

Aedes, The Vector

Biting:
generally daybiters with 2 peaks of biting time:
a) at dawn, just before sunrise
b) at dusk, just before sunset

Resting habit:
Aedes aegypti prefers to rest in cool, dark corners of the house.
Commonly, found in closets( where clothes are hung)., under beds, tables
and chairs.
Aedes albopictus adults usually rest outdoors in clearing vegetations;
also
noted indoors.
Flying habits:
average light range is 50 meters; farthest distance is only within
200- 400 meter radius from breeding places.

host- any age but common in

school children, peak age 4-6 yo

high incidence during rainy

months and is more prevalent in
urban areas

incubation period is 3-14 days,

more commonly 4-6 days

Period of communicabilityshortly before up to the end of

febrile period. (Ave. 6-7 days)
The mosquito becomes infective
8-12 days after a blood meal
and remains so for life.

Pathophysiology:

1. Increased capillary fragility

2. Thrombocytopenia
3. Decreased Blood Coagulation Factors

Increased capillary fragility

- Strong immune-complex reaction similar to
anaphylactoid reactions
- Produce substances like histamines, serotonins,
bradykinins
Thrombocytopenia
- faulty maturation of megakaryocytes-resulting in
diminished production
- acute excessive consumption of platelets due to
generalized intravascular clotting similar to DIC

Decreased blood coagulation factors

- Fibrinogen and factors II, V, VII, IX
- Prolonged CT-BT, PT, APTT

Dengue Fever

New classification
Dengue without warning signs
Dengue with warning signs
Severe dengue

Dengue Fever

Incubation period: 1-7 days

Clinical manifestations are influenced by
the age of the patient.
In infants and young children, the
disease may be characterized by fever
for 1-5 days, pharyngeal inflammation,
rhinitis and mild cough.
Older children and adults experience
sudden onset of fever, with temperature
rapidly increasing to 39.4-41.1 with
frontal or retro-orbital pain.

Phases of Dengue Fever

Febrile
Critical
Recovery

Febrile phase
Usually lasts 2-7 days
Monitoring for warning signs is crucial
to recognize its progression to critical
phase
The earliest abnormality in full blood
count is progressive decrease in total
white cell count.

Critical Phase

Defervescence occurs on day 3-7 of illness,

when temperature drops to 37.5-38 or less
and remains below this level.
Patients can either improve or deteriorate.
Warning signs are the result of significant
increase in capillary fragility.
Some patients may deteriorate to severe
dengue with severe plasma leakage leading
to shock respiratory distress, severe
bleeding and/or severe organ impairment.
The period of clinically significant plasma
leakage lasts for 24-48 hours.

Severe dengue
Plasma leakage that may lead to
shock and/or fluid accumulation, with
or without respiratory distress
Severe bleeding
Severe organ impairment

Recovery Phase
Gradual reabsorption of extravasate
fluid
from
intravascular
to
extravascular space by way of
lymphatics will take place in the next
48-72 hrs.
Classical rash of isles of white in the
sea of red
WBC starts to rise soon after
defervescence but normalization of
platelet count is later than that of

Clinical Problems encountered in

phases of Dengue
Febrile phase dehydration; high
fever may cause febrile seizures in
young children; neurological
disturbances.
Critical Phase shock from plasma
leakage; severe hemorrhage; organ
impairment.
Recovery phase - hypervolemia

Assessment

History
Date of onset
Quantity of oral
intake
Assess for warning
signs
Diarrhea
Seizures
Impaired

consciousness
Behavioural
changes
Urine utput
Family members
or neighbors with
dengue

Assessment

Physical examination

Assess mental state and GCS

Assess hydration status
Assess hemodynamic status
Look out for tachypnea/acidotic
breathing/pleural effusion
Check for abdominal
tenderness/hepatomegaly/ascites
Examine for rash and bleeding manifestations
Tourniquet test

Assessment

Investigation
Wbc
Dengue diagnostic tests: viral culture
isolation r PCR

Management
Group A may be sent home
Group B may be referred for inhospital management
Group C require emergency
treatment and urgent referral

Group A

Patients who are able to tolerate

adequate volumes of oral fluid and
pass urine at least once every 6 hrs,
and do not have warning signs,
particularly when fever subsides.

Treatment plan

Group B
Warning signs
Co-existing conditions that may make
management more complicated like
pregnancy, infancy and old age,
obesity, diabetes mellitus, renal
failure,chronic hemolytic diseases
Social circumstances such as living
alone, or living far from health facility
or without reliable means of transport.

Treatment plan
A. Dengue without warning signs
Encourage oral fluids
If not tolerated, start IV fluid therapy
0.9% NaCl (saline) or Ringers lactate
with or without dextrose at
maintenance rate
Patients may be able to take oral
fluids after a few hours of IV fluid
therapy

Fluid management for patients who are

admitted without shock
Isotonic Solutions (D5LRS, D5 Acetated
Ringers, D5NSS / D50.9%NaCl) are
appropriate for patients admitted without
danger signs
Maintenance IVF is computed using the
caloric-expenditure method (Hollida-Segar
Method) or Calculation Based on Weight
(Ludan method)

If the patient shows signs of mild

dehydration but is NOT in shock, the
volume needed for mild dehydration is
added to the maintenance fluids to
determine the total fluid requirement (TFR)
Formula:

TFR=maintenance IVF + Fluids as for Mild

Dehydration
Volume of fluids for mild dehydration
Infant
50ml / kg
Older Child/Adult
30ml / kg

 of the computed TFR is given in 8 hours

and the remaining is given in the next
16 hours
Clinical parameters should be monitored
closely and correlated with the hematocrit.
This will ensure adequate hydration,
avoiding over and under hydration.
The IVF rate may be decreased anytime
as necessary based on clinical
assessment.

B. Dengue with Warning Signs

Obtain a reference hematocrit before fluid
therapy
Give only isotonic solutions such as
0.9%NaCl, Ringers Lactate, Hartmanns
solution
Start with 5-7ml/kg/hr for 1-2 hrs, then
reduce to 3-5ml/kg/hr for 2-4 hrs, then
reduce to 2-3ml/kg/hr or less according to
clinical response

 Reassess

the clinical status and repeat

the hematocrit
If the hct remains the same or rises only
minimally, continue with the same rate
(2-3ml/kg/hr) for another 2-4 hrs
If there are worsening of vital signs and
rapidly rising of hct, increase the rate to
5-10ml/kg/hr for 1-2 hrs
Reassess the clinical status, repeat hct
and review fluid infusion rates accordingly

 Give

the minimum IV fluid volume required

to maintain good perfusion and urine
output of about 0.5ml/kg/hr. IV fluids are
usually needed for only 24-48 hours.
Reduce IV fluids gradually when the rate
of plasma leakage decreases towards the
end of critical phase. Indicated by:
1. urine output and/or oral fluid intake
is/are adequate or
2. hct decreases below the baseline value
in a stable patient

Monitoring by health care providers

Vital signs and peripheral perfusion (1-4
hourly until the patient is out of critical
phase)
Urine output (4-6 hourly)
Hematocrit (before and after fluid
replacement then 6-12 hourly)
Blood glucose
Other organ functions (renal profile, liver
profile, coagulation profile, as indicated)

GROUP C

Patients with severe dengue requiring

emergency treatment and urgent
referral

Treatment Plan
A. Management for patients admitted to
the hospital with Compensated Shock
Start IV fluid resuscitation with isotonic
crystalloid solutions at 5-10ml/kg/hr
over 1 hour, then reassess the
patients
condition
and
decide
depending on the situation:

 If

the patients condition improves IV fluids

should be gradually reduced to:
5-7 ml/kg/hr for 1-2 hrs, then
to 3-5 ml/kg/hr for 2-4 hrs, then
2-3 ml/kg/hr and then
to reduce further depending on the
hemodynamic status, which can be maintained
for up to 24 to 48 hours

 If

vital signs are still unstable (shock

persists), check the hematocrit after the
first bolus:
- if hct increases or is still high (>50%),
repeat a second bolus of crystalloid
solution at 10-20ml/kg/hr for 1 hour
- After this second bolus, if there is
improvement, then reduce the rate to 710 ml/kg/hr for 1-2 hrs, and then continue
to reduce as above

- if hct decreases compared to the initial

reference hct (<40% in children and adult
females, <45% in males), this indicates
bleeding and the need to crossmatch and
transfuse blood as soon as possible
Further

boluses of crystalloid or colloidal

solutions may need to be given during the
next 24 48 hours

B. Management for patients admitted to the

hospital with Hypotensive Shock
Initiate

IV fluid resuscitation with

crystalloid or colloid solutions (if available)
at 20ml/kg given over 15 minutes to bring
the patient out of shock as quickly as
possible

 If

the patients condition improves, give a

crystalloid/colloid infusion of 10 ml/kg/hr
for 1 hr, then continue with crystalloid
infusion and gradually reduce
To 5-7 ml/kg/hr for 1-2 hrs, then
to 3-5 ml/kg/hr for 2-4 hrs, then
2-3 ml/kg/hr or less, which can be maintained
for up to 24 -48 hrs

 If

vital signs are still unstable (shock

persists), check the hematocrit after the
first bolus:
- if hct increases compared to the
previous value or is still high (>50%),
change IV fluids to colloid solutions at 1020ml/kg as a second bolus at to 1
hour
- After this dose, reduce the rate to 7-10
ml/kg/hr for 1-2 hrs, then change back to
crystalloid solution and reduce rate of
infusion as mentioned above when the

- if hct decreases compared to the

previous value (<40% in children and adult
females, <45% in males), this indicates
bleeding and the need to crossmatch and
transfuse blood as soon as possible
Further

boluses of crystalloid or colloidal

solutions may need to be given during the
next 24 hours.

C. Treatment of Hemorrhagic Complications

Mucosal bleeding may occur but if the
patient
remains
stable
with
fluid
resuscitation, it should be considered as
minor
In
patients
with
profound
thrombocytopenia, ensure strict bed rest
Do not give IM injections
Note: prophylactic platelet transfusions for
severe thrombocytopenia in otherwise
hemodynamically stable patients are not

Who are at risk of major bleeding?

- patients with prolonged/refractory period
- patients with hypotensive shock and liver
or renal failure and/or severe metabolic
acidosis
- patients given with NSAIDs
- patient with pre-existing peptic ulcer
disease
- patients on anticoagulant therapy
- patients with any form of trauma,

Note: Patients with hemolytic conditions will

be at risk for acute hemolysis with
hemoglobinuria and will require blood
transfusion

How to recognize severe bleeding

1. Persistent and/or severe overt bleeding

in the presence of unstable hemodynamic
status regardless of hct level
2. A decrease in hct after fluid
resuscitation together with unstable
hemodynamic status

3.refractory shock that fail to respond to

consecutive fluid resuscitation of 40-60
ml/kg
4. hypotensive shock with low/normal
hematocrit before fluid resuscitation
5.persistent or worsening metabolic
acidosis well maintained systolic blood
pressure, especially in those with severe
abdominal tenderness and distention

Treatment Plan
Give

5-10 ml/kg of fresh PRBC or 1020 ml/kg FWB at an appropriate rate

and observe the clinical response

good clinical response includes

improving hemodynamic status and
acid-base balance

 Consider

repeating blood transfusion if

there is further blood loss or no
appropriate rise in hct after blood
transfusion

Although

there is little evidence to support

the practice of platelet concentrates and/or
fresh frozen plasma transfusion for severe
bleeding, they may be given judiciously

Discharge Criteria
ALL of the following conditions must be
present:
1. No fever for 48 hours
2. Improvement
in clinical status
(general
well-being,
appetite,
hemodynamic status, urine output, no
respiratory distress)
3. Increasing trend of platelet count
4. Stable hematocrit without IV fluids