1. Cause and transmission - dengue virus types, Aedes mosquito transmission, incubation
2. Clinical course - febrile, critical, and recovery phases
3. Symptoms and examination findings
4. Diagnosis - NS1 antigen, PCR, IgM, CBC, hematocrit, liver tests
5. Classification - dengue without warning signs, dengue with warning signs, severe dengue
6. Treatment protocol - oral/IV fluids, monitoring, admission, shock management
7. Platelets and bleeding - when transfusion is and is not appropriate
8. Complications and high-risk groups - pregnancy, children, older adults, diabetes, kidney/heart disease
9. Prevention - mosquito control and vaccination

High-level overview

Day-by-day dengue monitoring and treatment plan

Every day: record these items

Days 1-2: early febrile phase

At home, if drinking well and no warning signs

• Hydrate regularly: take small, frequent amounts of ORS or other fluids. Do not force excessive amounts if there is heart or kidney disease.
• Eat light foods as tolerated. Avoid alcohol.
• Fever/pain: use paracetamol (acetaminophen) only, following the package dose or your clinician's instructions. Keep at least 6 hours between doses. Do not exceed the label maximum, and use extra caution in liver disease or heavy alcohol use.
• Avoid aspirin and NSAIDs, including ibuprofen, diclofenac, naproxen, ketorolac, and mefenamic acid. They can worsen gastritis and bleeding risk.
• Avoid intramuscular injections unless a clinician determines they are necessary.
• Use mosquito precautions even while sick, because mosquitoes can acquire virus from an infected person and transmit it to others.

Medical review

Day 3: begin closer surveillance

Continue

• Fluids, rest, paracetamol only if needed.
• Record fluid intake, vomiting, and urination.
• Clinical review or daily follow-up is sensible if dengue is confirmed or strongly suspected, especially if fever is declining.

Tests

Days 4-6: critical phase risk window

Go to an emergency department or hospital immediately for any of these

• Severe or persistent abdominal pain or tenderness
• Persistent vomiting or inability to drink
• Bleeding from gums/nose, vomiting blood, black stools, heavy menstrual bleeding, or blood in urine
• Drowsiness, confusion, marked weakness, restlessness, fainting, or dizziness on standing
• Cold, clammy, pale hands/feet; rapid pulse; severe thirst
• Little or no urine, or no urine for more than 4-6 hours
• Breathing difficulty, chest discomfort, abdominal swelling
• Fever settling but the patient looks worse
• A clinician reports rising hematocrit with falling platelets

If admitted: what treatment generally involves

• Frequent monitoring of pulse, blood pressure, mental state, capillary refill, breathing, fluid balance, and urine output.
• Repeat hematocrit and CBC, often at intervals based on severity.
• Carefully titrated isotonic IV crystalloid fluids if there are warning signs, dehydration with inability to drink, compensated shock, or hypotensive shock.
• Fluid amounts are adjusted to clinical state, urine output, and hematocrit. Giving too much fluid can cause pulmonary edema or fluid overload, especially as the leak resolves.
• Oxygen, critical care support, and blood products may be needed for severe bleeding or shock.
• Platelet transfusion is not routinely given just for a low platelet count. It is generally reserved for clinically significant bleeding or selected clinician-determined situations. Treating a laboratory number alone can expose patients to unnecessary risk.

Days 6-8: recovery phase

Plan

• Continue oral fluids, but do not overdrink.
• Resume regular food gradually.
• A clinician may reduce or stop IV fluids because of the risk of fluid overload during recovery.
• Continue monitoring for breathlessness, swelling, or sudden worsening, particularly if IV fluids were used.
• Repeat CBC only as advised. Platelet recovery can lag behind clinical improvement.

Day 8 onward

Quick home checklist

• Drinking adequately and keeping fluids down
• Passing urine at least every 6 hours
• No warning signs
• Alert and able to walk/stand normally
• Reliable access to urgent medical care and daily reassessment if needed

Dengue fluid management in hospital

1. Initial hospital assessment

Baseline monitoring

• Vital signs: pulse, blood pressure, pulse pressure, temperature, respiratory rate, oxygen saturation
• Mental status and capillary refill
• Body weight, fluid input/output, and examination for ascites or pleural effusion
• CBC including platelet count and hematocrit (Hct)
• Blood grouping/cross-match if severe disease or bleeding is possible
• Glucose, electrolytes, renal and liver function, and coagulation tests as indicated

2. Which fluid is used?

• 0.9% saline
• Ringer's lactate/Hartmann's solution

3. Dengue with warning signs, but no shock

General inpatient approach

1. Start isotonic crystalloid, commonly about 5-7 mL/kg/hour for 1-2 hours.
2. Reassess after 1-2 hours:
   • pulse and blood pressure
   • pulse pressure
   • capillary refill, limb temperature, mental status
   • urine output
   • respiratory examination and oxygen saturation
   • Hct trend
3. If improving, reduce stepwise, for example to:
   • 3-5 mL/kg/hour for 2-4 hours
   • then 2-3 mL/kg/hour or lower as clinically appropriate
4. Stop IV fluid as soon as the plasma-leakage period has ended and oral intake is adequate.

4. Compensated shock

• Narrow pulse pressure, often less than 20 mmHg
• Tachycardia
• Cold extremities, prolonged capillary refill
• Weak pulse, restlessness, reduced urine output
• Rising Hct

Typical approach

• Start isotonic crystalloid 5-10 mL/kg over about 1 hour.
• Reassess at the end of the bolus, sooner if unstable.
• If circulation improves, reduce the rate stepwise and continue close monitoring.
• If there is inadequate improvement and Hct is rising or remains high, ongoing leakage is likely. A further fluid bolus may be needed under the treating team's protocol.
• If Hct falls while the patient remains unstable, think of occult or overt bleeding rather than simply giving more crystalloid. Cross-match and blood transfusion may be needed.

5. Hypotensive shock

Usual resuscitation framework

• Give a rapid isotonic crystalloid bolus, commonly 20 mL/kg over about 15 minutes, with immediate reassessment.
• If there is improvement, reduce the infusion promptly, for example to 10 mL/kg/hour for 1 hour, then taper over subsequent hours.
• If shock persists:
  • Recheck Hct, ideally compared with the pre-resuscitation value.
  • High/rising Hct suggests continuing plasma loss, so further protocol-based fluid resuscitation may be required.
  • Low/falling Hct with persistent shock suggests significant bleeding. The priority is to locate bleeding and provide blood products as clinically indicated, rather than giving repeated large crystalloid volumes.
• Consider ICU support, oxygen/ventilation, treatment of acidosis or hypoglycemia, and vasoactive medication when shock remains fluid-refractory or another cause of shock, such as myocarditis, is suspected.

6. Monitoring while fluids are running

7. How clinicians interpret hematocrit

8. Preventing fluid overload

• Breathlessness, tachypnea, falling oxygen saturation
• New/worsening pleural effusions or pulmonary edema
• Crackles on chest examination
• Puffy eyelids, peripheral edema, increasing weight
• Enlarged liver or raised jugular venous pressure in appropriate settings

9. Platelets, plasma, and blood transfusion

• Do not transfuse platelets solely because the platelet count is low.
• Platelets do not correct plasma leakage and routine prophylactic platelet transfusion has no established benefit.
• Use blood products for clinically important bleeding, shock with a falling Hct suggesting hemorrhage, or specific coagulation abnormalities under clinician guidance.
• Fresh whole blood or packed red cells may be appropriate for substantial bleeding. The decision is based on hemodynamics, bleeding, Hct/hemoglobin trend, and transfusion availability.

Key practical point

Is the patient underfilled from plasma leakage, bleeding, or becoming fluid overloaded?