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Management of Dengue Hemorrhagic Fever (DHF)

Overview

1. Fever lasting 2-7 days
2. Hemorrhagic tendencies (positive tourniquet test, petechiae, ecchymoses, spontaneous bleeding)
3. Thrombocytopenia (platelet count ≤ 100,000/mm³)
4. Evidence of plasma leakage - rising hematocrit ≥20% from baseline, pleural effusion, ascites, or hypoproteinemia

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WHO Grading of DHF

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Disease Phases - Key to Management

• Febrile phase (Day 1-3): High fever, myalgia, headache, retro-orbital pain. Minor bleeding possible. Manage symptomatically.
• Critical phase (Day 3-6, lasts 24-48 hours): Plasma leakage begins at defervescence. Hematocrit rises. This is when shock and hemorrhage occur. Intensive monitoring and fluid therapy required.
• Convalescent/reabsorption phase: Plasma reabsorption begins - watch for fluid overload. Bradycardia is common. Hematocrit falls due to dilution.

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Management by Group

Group A - Dengue Without Warning Signs (Outpatient)

• Oral rehydration: ORS, fruit juice, electrolyte-containing fluids
• Paracetamol for fever; keep temperature below 39°C. Space doses ≥6 hours apart
• Avoid: Aspirin, NSAIDs (ibuprofen) - aggravate gastritis and bleeding; aspirin may cause Reye's syndrome
• Monitor daily: temperature, fluid intake/output, urine frequency, platelet count, hematocrit
• Return to hospital immediately if: no improvement, deterioration at defervescence, severe abdominal pain, persistent vomiting, cold extremities, restlessness, black stools/coffee-ground vomiting, no urine for >4-6 hours

Group B - DHF Grades I and II (Hospitalize)

• Oral rehydration continued; IV fluids if vomiting or unable to tolerate orals
• Serial hematocrit every few hours - a rising Hct signals plasma leakage
• If Hct rises ≥20% from baseline: initiate IV isotonic crystalloid (normal saline or Ringer's lactate)

• Start at 6 ml/kg/h crystalloid for 1-2 hours
• If improvement (Hct falls, pulse/BP stable, urine output rises): reduce stepwise - 6 → 3 → 1.5 ml/kg/h over 6-8 hours; discontinue after 24-48 hours
• If no improvement (Hct rises, pulse pressure falls, urine output falls):
  • Increase to 10 ml/kg/h crystalloid for 2 hours
  • If Hct falls (suspect internal hemorrhage): blood transfusion 10 ml/kg whole blood or 5 ml/kg packed RBCs

Group C - DHF Grades III and IV / DSS (Emergency Management)

• Start IV therapy immediately at 10-20 ml/kg/h crystalloid for 1 hour
• Oxygen for all patients in shock
• Monitor vital signs (VS) and Hct every 30-60 minutes

• Check hematocrit:
  • Hct rises (>45%): Switch to colloid (Dextran 40 or polygeline) 10-20 ml/kg over 1 hour
  • Hct falls: Suspect bleeding - give blood transfusion (10 ml/kg whole blood or 5 ml/kg packed RBCs)

• A - Acidosis
• B - Bleeding
• C - Calcium (electrolyte imbalance: Na⁺, K⁺)
• S - Sugar (hypoglycemia)

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Fluid Therapy - Key Principles

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Blood Product Transfusions

Red Cell Transfusion - Indications:

1. Overt blood loss ≥10% of total blood volume
2. Refractory shock despite adequate fluid administration with declining hematocrit
3. Replace at 10 ml/kg body weight at a time; check coagulogram
4. Packed cells if fluid overload is present

Platelet Transfusion - Indications:

• In general, no prophylactic platelet transfusion even at <20,000/mm³
• Prophylactic transfusion may be given at <10,000/mm³
• Prolonged shock with coagulopathy and abnormal coagulogram
• Systemic massive bleeding (in addition to red cell transfusion)

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Monitoring Parameters

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Specific Complications and Their Management

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Contraindicated/Avoid

• Aspirin and NSAIDs - increase bleeding risk; aspirin may precipitate Reye's syndrome
• Steroids - randomized studies show no benefit in dengue shock syndrome; not recommended
• Intramuscular injections - risk of hematoma at injection sites
• Hypotonic IV fluids - worsen plasma leakage physiology
• Excessive fluid - can cause pulmonary edema/fluid overload, especially in reabsorption phase
• Prophylactic platelet transfusion at modest thrombocytopenia (not indicated unless <10,000/mm³ or active bleeding)

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Clinical Warning Signs Requiring Urgent Hospitalization

• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation (ascites, pleural effusion)
• Mucosal bleeding
• Lethargy or restlessness
• Liver enlargement >2 cm
• Rising hematocrit concurrent with rapid fall in platelet count
• No urine for >4-6 hours

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Criteria for Discharge

1. Afebrile for ≥24 hours without antipyretics
2. Return of appetite
3. Visible clinical improvement
4. Good urine output
5. Minimum 2-3 days after recovery from shock
6. No respiratory distress from pleural effusion or ascites
7. Platelet count >50,000/mm³

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Dengue Shock Syndrome (DSS) - Quick Reference Summary

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• Park's Textbook of Preventive and Social Medicine, pp. 293-298 (WHO Classification, fluid algorithms)
• Rosen's Emergency Medicine: Concepts and Clinical Practice, p. 2630 (Management overview)
• Red Book 2021 - Report of the Committee on Infectious Diseases, pp. 520-524 (Pediatric management, shock therapy)
• Creasy & Resnik's Maternal-Fetal Medicine, p. 1565 (Supportive care principles)
• Xu et al. (2024): High IV fluid volume associated with worse outcomes in hospitalized dengue patients
• StatPearls - Dengue Fever (NCBI): Cornerstone is judicious fluid therapy with isotonic crystalloids