DENGUE:
PAHO/WHO GUIDELINES FOR DIAGNOSIS
AND TREATMENT
PRESENTED BY HSPI BRANCH
MINISTRY OF HEALTH, JAMAICA
JANUARY 2019
OBJECTIVES
• DISCUSS THE CLINICAL MANIFESTATION
• DISCUSS THE CLINICAL CLASSIFICATION
• DISCUSS THE CLINICAL COURSE
• DISCUSS THE SEVERITY RISK ASSESSMENT
• DISCUSS THE CLINICAL MANAGEMENT
DENGUE CLINICAL SYMPTOMS
• EPIDEMIOLOGICAL LINK
• FEVER +2 OR MORE OF
• NAUSEA, VOMITING
• MYALGIA , ARTHALGIA
• RASH
• RETRO-ORBITAL PAIN
• SORE THROAT
• COUGH
DIFFERENTIAL DIAGNOSIS
• LEPTOSPIROSIS
• ARBOVIRUSES –CHIK V, ZIKA, YELLOW FEVER
• RESPIRATORY INFECTIONS
• MEASLES
• RUBELLA (GERMAN MEASLES)
• MALARIA
• MENINGOENCEPHALITIS
• PYELONEPHRITIS
• SEPTICEMIA
DENGUE FEVER
• WIDE SPECTRUM OF CLINICAL
PRESENTATION,
• WITH UNPREDICTABLE CLINICAL
COURSE
CLINICAL CLASSIFICATION
• PREVIOUSLY CLASSIFIED INTO:-
• UNDIFFERENTIATED FEVER
• DENGUE FEVER
• DHF- GRADE 1-IV
DENGUE HAEMORRHAGIC FEVER
• GRADE 1: FEVER, NON SPECIFIC CONSTITUTIONAL
SYMPTOMS; (+) TT- ONLY HAEMORRHAGIC
MANIFESTATION
• GRADE 2: GRADE 1 MANIFESTATION +
SPONTANEOUS BLEEDING
• GRADE 3: SIGNS OF CIRCULATORY FAILURE (RAPID
WEAK PULSE, NARROW PULSE PRESSURE,
HYPOTENSION, COLD CLAMMY SKIN)
• GRADE 4: PROFOUND SHOCK WITH
UNDETECTABLE PULSE AND BP
PATHOPHYSIOLOGY
• IMMUNE MEDIATED
• CYTOKINES GENERATED
• ENDOTHELIAL INJURY
• GLYCOCALYX INTEGRITY COMPROMISED
• PLATELETTES CONSUMED
• INCREASED CAPILLARY PERMEABILITY
• PLASMA LEAKAGE
CLINICAL CLASSIFICATION
Severity Classification
DNWS DWWS SD
DENGUE CLINICAL SYMPTOMS
• EPIDEMIOLOGICAL LINK
• FEVER +2 OR MORE OF
• NAUSEA, VOMITING
• MYALGIA , ARTHALGIA
• RASH
• HEADACHE/ RETRO-ORBITAL PAIN
• PETECHIAE/HAEMORRHAGIC MANIFESTATIONS
• (SORE THROAT/COUGH - NOT CRITERIA BUT FREQUENT SYMPTOMS)
WARNING SIGNS• 1. INTENSE ABDOMINAL PAIN OR TENDERNESS
• 2. PERSISTENT VOMITING
• 3. FLUID ACCUMULATION (ASCITES, PLEURAL EFFUSION, PERICARDIAL
EFFUSION, PERIPHERAL EDEMA)
• 4. MUCOSAL BLEED
• 5. LETHARGY/RESTLESSNESS
• 6. POSTURAL HYPOTENSION (SYSTOLIC BP FALLS BY 20MMHG)
• 7. LIVER ENLARGEMENT >2 CM
• 8. PROGRESSIVE INCREASE IN HEMATOCRIT
• 9. INCREASED VASCULAR PERMEABILITY AS EVIDENCED BY
HEMOCONCENTRATION, ≥ 20% RISE IN HEMATOCRIT ABOVE DESCRIBED
AS PLASMA LEAKAGE SYNDROME.
CLINICAL CLASSIFICATION
Severity Classification
DNWS DWWS SD
SEVERE DENGUE
• SEVERE PLASMA LEAKAGE
• SEVERE HAEMORRHAGE
• SEVERE ORGAN IMPAIRMENT
CLINICAL COURSE
• THREE PHASES
• FEBRILE PHASE
• CRITICAL PHASE
• RECOVERY PHASE
THE CLINICAL PHASES
Febrile Phase
Critical Phase
Recovery Phase
FEBRILE PHASE
facial flushing
skin erythema
generalized body ache
myalgia and arthralgia
headache
sorethroat, injected pharynx,
and conjunctival injection
anorexia, nausea and
vomiting
• Sudden onset of
high-grade fever
• Lasts for 2-7 days
FEBRILE PHASE
• (+) TT increases the
probability of dengue• Tourniquet test
• (+) hemorrhagic
manifestations
• enlarged and tender
liver
earliest abnormality: progressive decrease in total
wbc
LAB CHANGES IN FEBRILE PHASE
• DECREASE INN WBC
• LYMPHOCYTOSIS
• INCREASE IN HAEMATOCRIT (PCV) DUE TO HAEMOCONCENTRATION
• THROMBOCYTOPENIA (FALL IN PLATELETS)
CRITICAL PHASE
• temperature drops to 37.5-38 (days 3-7)
• (+) increase in capillary permeability with increasing hematocrit levels
• significant plasma leakage lasts for 24-48 hours
• progressive leukopenia followed by rapid decrease in platelet precedes plasma leakage
CRITICAL PHASE
• if (-) increase in capillary permeability →
improve
• if (+) increase in capillary permeability →
pleural , pericardial effusion and ascites
• degree of increase above the baseline
hematocrit reflects the severity of plasma
leakage
CRITICAL PHASE
• shock: critical volume of plasma is lost
• temperature may be subnormal
• prolonged shock → organ hypoperfusion → organ
impairment, metabolic acidosis, and DIC → severe
hemorrhage
• severe hepatitis, encephalitis or myocarditis
RECOVERY PHASE
• gradual reabsorption of extravascular compartment
fluid (48-72 hours)
• general well-being improves, appetite returns, GI
symptoms abate, hemodynamic status stabilizes and
diuresis ensues
• (+) rash: “isles of white in the sea of red”
RECOVERY PHASE
• hematocrit stabilizes or may be lower due to dilutional
effect of reabsorbed fluid
• wbc starts to rise
• recovery of platelet count occurs later
Severity Classification
DNWS DWWS SD
DENGUE WITHOUT WARNING SIGNS• TRAVELED TO AREAS WITH DENGUE TRANSMISSION IN <14 DAYS, A
FEVER 2 - 7 DAYS +
• 2 OR MORE OF THE FOLLOWING CRITERIA:
• 1. NAUSEA/ VOMITING
• 2. EXANTHEMA
• 3. HEADACHE/ RETRO-ORBITAL PAIN
• 4. MYALGIA AND ARTHRALGIA
• 5. PETECHIAE OR POSITIVE TOURNIQUET TEST
• 6. LEUKOPENIA
DENGUE WITHOUT WARNING SIGNS
• INCLUDE ANY CHILD COMING FROM OR LIVING IN AN AREA WITH
DENGUE
• FEVER 2-7 DAYS
• NO APPARENT FOCUS
DENGUE WITH WARNING SIGNS• EVERY DENGUE CASE THAT, NEAR AND PREFERABLY AT DEFERVESCENCE,
WITH ONE OR MORE OF :
• 1. INTENSE ABDOMINAL PAIN OR TENDERNESS
• 2. PERSISTENT VOMITING
• 3. FLUID ACCUMULATION (ASCITES, PLEURAL EFFUSION, PERICARDIAL
EFFUSION)
• 4. MUCOSAL BLEED
• 5. LETHARGY/RESTLESSNESS 6. POSTURAL HYPOTENSION (LIPOTHYMIA)
• 7. LIVER ENLARGEMENT >2 CM
• 8. PROGRESSIVE INCREASE IN HEMATOCRIT
SEVERE DENGUE
• EVERY DENGUE CASE THAT HAS ONE OR MORE OF THE
• 1. SHOCK OR RESPIRATORY DISTRESS DUE TO SEVERE PLASMA LEAKAGE.
• WEAK OR UNDETECTABLE PULSE, TACHYCARDIA, COLD EXTREMITIES
• CAPILLARY PERFUSION >2 SECONDS
• PULSE PRESSURE ≤ 20 MMHG: HYPOTENSION IN LATE PHASE.
• ACIDOSIS MAY COMPLICATE
SEVERE DENGUE
• 2.SEVERE BLEEDING: BASED ON EVALUATION BY THE ATTENDING
PHYSICIAN
• E.G. HEMATEMESIS (VOMITING BLOOD), MELENA ( BLACK TARRY
STOOL)
• AMPLE METRORRHAGIA (HEAVY VAGINAL BLEEDING)
• CENTRAL NERVOUS SYSTEM [CNS] BLEEDING – PRESENTS WITH
STROKE, COMA, SEIZURES
SEVERE DENGUE
3. SEVERE ORGAN INVOLVEMENT
• LIVER IMPAIRMENT (AST OR ALT ≥1000 IU),
• CNS (IMPAIRED MENTAL STATE),
• HEART (MYOCARDITIS),
• PANCREATITIS
• OTHER ORGANS
REQUIRING STRICT OBSERVATION AND MEDICAL INTERVENTION
APPROACH TO THE MANAGEMENT
• AT PRIMARY AND SECONDARY LEVELS, HEALTH CARE FACILITIES ARE RESPONSIBLE
FOR EMERGENCY/ AMBULATORY TRIAGE ASSESSMENT AND TREATMENT
• TRIAGE IS THE PROCESS OF RAPIDLY SCREENING PATIENTS
SOON AFTER THEIR ARRIVAL IN THE HOSPITAL OR HEALTH
FACILITY IN ORDER TO IDENTIFY THOSE
– SEVERE DENGUE
– WITH WARNING SIGNS
– NON-URGENT CASES
APPROACH TO THE MANAGEMENT
HISTORY• DATE OF ONSET OF FEVER, RASH
• FAMILY OR COMMUNITY DENGUE, TRAVEL TO DENGUE ENDEMIC AREAS
• QUANTITY OF ORAL INTAKE
• NAUSEA, VOMITING OR DIARRHEA
• ASSESSMENT FOR WARNING SIGNS
• CHANGE IN MENTAL STATUS/SEIZURES
• URINE OUTPUT (FREQUENCY, VOLUME, TIME OF LAST VOIDING)
• CO-EXISTING CONDITIONS – PREGNANCY, DIABETES MELLITUS,
CARDIOVASCULAR DISEASE, SICKLE CELL DISEASE
• OCCUPATIONAL HISTORY
• OTHER KEY FEATURES IN HISTORY TO EXCLUDE DIFFERENTIALS
PHYSICAL EXAM• ASSESSMENT OF MENTAL STATUS – ALERT VS LETHARGIC
• ASSESSMENT OF HYDRATION STATUS – DRY VS MOIST MUCOSA
• HEMODYNAMIC STATUS - PULSE, BP, CAPILLLARY REFILL
• ASSESSING FOR RASH, BLEEDING MANIFESTATIONS
• ASSESSING FOR PLEURAL EFFUSION
• ASSESSING FOR ABDOMINAL PAIN, ASCITES, HEPATOMEGALY
• TOURNIQUET TEST
• INVESTIGATIONS : CBC, NS1,PCR, IGM (PER PROTOCOL) FOR ALL
SEVERE CASES, CASES WITH WARNING SIGNS OR RETURN CASES
INVESTIGATIONS :CBC, NS1,PCR, IGM (PER PROTOCOL)
FOR ALL SEVERE CASES, CASES WITH WARNING SIGNS OR RETURN CASES
PT, PTT, LFT’S, UAND E’S, GRP & XMATCH
APPROACH TO THE MANAGEMENT
DISEASE NOTIFICATION
• IN DENGUE-ENDEMIC COUNTRIES, CASES OF SUSPECTED, PROBABLE
AND CONFIRMED DENGUE SHOULD BE NOTIFIED
• PUBLIC HEALTH MEASURES
– SUSPECTED CASES
• CLINICAL CRITERIA OF DENGUE
• LIVES IN OR HAS TRAVELLED TO A DENGUE-ENDEMIC AREA
• FEVER FOR THREE DAYS OR MORE
• LOW OR DECREASING WHITE CELL COUNTS
• THROMBOCYTOPAENIA ± POSITIVE TOURNIQUET TEST
APPROACH TO THE MANAGEMENT
Groups A• may be sent
home• tolerate
adequate volumes of oral fluids and passes urine at least once every 6 hours
• no warning signs
Groups B• stabilise
• refer if doesn’t settle
• with warning signs, co-morbidities
• with social risk
Groups C• Emergency
intervention and refer to tertiary centrewhere possible.
• severe dengue (in critical phase)
Management Decisions
SPECIAL RISK- SOCIAL
• LIVES ALONE
• NO TRANSPORTATION
• NO ACCESS TO HEALTH CENTRE
• LIVES AFAR OFF
• INDIGENT
GROUP A ACTION PLAN
• Encourage intake of ORS, fruit juice and other fluids
• Paracetamol and tepid sponge for fever
• OBSERVE Drinking, Ensure stable
• Advise to come back if with
no clinical improvement
severe abdominal pain
persistent vomiting
cold and clammy extremities,
lethargy or irritability or restlessness,
bleeding
not passing urine for more than 4–6 hours.
monitor: temperature pattern, volume of fluid intake and losses, urine output, warning signs, signs of plasma
leakage and bleeding, rising haematocrit, and white blood cell and platelet counts every 48 hours if
possible
ADVICE ON DISCHARGE
• CLOSE OBSERVATION FOR WARNING SIGNS
• IMMEDIATE RETURN IF WARNING SIGNS OCCUR
• ABSOLUTE AVOIDANCE OF NSAIDS
• CONTINUED REST
• USE OF NETS AND MOSQUITO REPELLANT
• DRINK FLUIDS
• SHOULD HAVE SOMEONE TO MONITOR PROGRESS
• GIVE ALERT CARD/FLYER/INSTRUCTIONS
FOLLOW UP WILL MAKE A DIFFERENCE
• CALL TO ASK ABOUT RESOLUTION OF SYMPTOMS OR NEW
SYMPTOMS
• CALL TO ASK ABOUT WARNING SIGNS
• VISIT BY CHA/HEALTH TEAM
• HAVE THE PATIENT RETURN IN 48 HOURS
• REPEAT CBC :- LOOK FOR INCREASE HAEMATOCRIT, DECREASE
PLATELETS, DECREASE WHITE CELLS
APPROACH TO THE MANAGEMENT
• REFERRAL CENTRES RECEIVING SEVERELY ILL DENGUE PATIENTS
MUST BE ABLE TO
• GIVE PROMPT ATTENTION
• BEDS SHOULD BE AVAILABLE TO THOSE PATIENTS WHO MEET
THE ADMISSION CRITERIA
• THERE SHOULD BE A DESIGNATED AREA TO COHORT DENGUE
PATIENTS
• HIGH-DEPENDENCY UNIT FOR THOSE WITH SHOCK/SEVERE
DISEASE.
• STAFFED BY DOCTORS AND NURSES
GROUP B (WITHOUT WARNING SIGNS)ACTION PLAN
• Encourage oral fluids
• If not tolerated, start intravenous fluid therapy of 0.9% saline or Ringer’s lactate with or without dextrose at maintenance rate
Patients may be able to take oral fluids after a few hours of
intravenous fluid therapy.
• Give the minimum volume required to maintain good
perfusion and urine output.
• Intravenous fluids are usually needed only for 24–48
hours.
• Close monitoring
CLOSE MONITORING IS CRITICAL
GENERAL STATUSNEUROLOGICAL STATUS
RESPIRATORY STATUSVITAL SIGNS
URINE OUTPUT
GROUP B (WITH WARNING SIGNS)ACTION PLAN
• reference hematocrit before fluid therapy
• isotonic solutions Lactated Ringers/Normal Saline
5–7 ml/kg/hour for 1–2 hours,
then reduce to 3–5 ml/kg/hr for 2–4 hours,
then reduce to 2–3 ml/kg/hr or less
according to the clinical response
reassess:• haematocrit remains the same or rises only minimally → 2–3 ml/kg/hr for
another 2–4 hours
• worsening vital signs and rising haematocrit rising → 5–10 ml/kg/hour for 1–2
hours
GROUP B (WITH WARNING SIGNS)ACTION PLAN
Give minimum intravenous fluid volume: maintain good perfusion and urine output of about 0.5 ml/kg/hr• Intravenous fluids are usually needed for only 24–48 hours.
• Reduce intravenous fluids gradually when the rate of plasma
leakage decreases towards the end of the critical phase.
monitor: • vital signs and peripheral perfusion (1–4 hourly until the patient is out
of the critical phase)• urine output (4–6 hourly)• hematocrit (before and after fluid replacement, then 6–12 hourly) • blood glucose • organ functions (renal profile, liver profile, coagulation profile)
APPROACH TO THE MANAGEMENT
CRITERIA FOR TRANSFER:
• EARLY PRESENTATION WITH SHOCK (ON DAYS 2 OR 3 OF
ILLNESS);
• SEVERE PLASMA LEAKAGE AND/OR SHOCK;
• UNDETECTABLE PULSE AND BLOOD PRESSURE;
• SEVERE BLEEDING;
• FLUID OVERLOAD;
• ORGAN IMPAIRMENT (SUCH AS HEPATIC DAMAGE,
CARDIOMYOPATHY, ENCEPHALOPATHY,
• ENCEPHALITIS AND OTHER UNUSUAL COMPLICATIONS).
GROUP C ACTION PLAN
• admit to a hospital with access to intensive care facilities and blood transfusion
• plasma losses should be replaced immediately and rapidly with isotonic crystalloid solution or, in the case of hypotensive shock, colloid solutions
• blood transfusion: with suspected/severe bleeding
• judicious intravenous fluid resuscitation: sole intervention required
GROUP C ACTION PLAN
Goals of fluid resuscitation:• improving central and peripheral circulation
(decreasing tachycardia, improving BP, warm and pink
extremities, and capillary refill time <2 seconds)
• improving end-organ perfusion
– i.e. stable conscious level (more alert or less restless),
urine output ≥ 0.5 ml/kg/hour,
decreasing metabolic acidosis.
TREATMENT OF HEMORRHAGIC COMPLICATIONS
Patients at risk of major bleeding are those who:
• prolonged/refractory shock;
• hypotensive shock and renal or liver failure
and/or severe and persistent metabolic acidosis
• given non-steroidal anti-inflammatory agents
• pre-existing peptic ulcer disease
• anticoagulant therapy
• any form of trauma
TREATMENT OF HEMORRHAGIC COMPLICATIONS
• Blood transfusion is life-saving and should be given as soon
as severe bleeding is suspected or recognized
• Do not wait for the haematocrit to drop too low before
deciding on blood transfusion
• There is a Risk of fluid overload. Give what is needed
LAB INVESTIGATION IN HOSPITAL
• CBC AND HAEMATOCRIT
• PT, PTT
• UREA AND ELECTROLYTES’S
• GLUCOSE
• LIVER FUNCTION TESTS ALT/AST
• SERUM AMYLASE ( DEPENDING ON PRESENTATION
• GROUP AND CROSS MATCH
• CXRAY, ECHOCARDIOGRAM
• ABDOMINAL ULTRASOUND
TREATMENT OF HEMORRHAGIC COMPLICATIONS
•blood transfusion if with bleeding• 5-10 ml/kg of PRBC or 10-20 ml/kg FreshWBlood• repeat if with further blood loss or no rise in hematocrit
after transfusion
• Transfuse platelets if <10,000/mm3 • (Consult Haematologist)
• Massive bleeding not managed by FWB/PRBC• may exacerbate fluid overload
MANAGEMENT OF COMPLICATIONS
• Fluid OverloadCauses:
– excessive and/or too rapid intravenous fluids;
– incorrect use of hypotonic rather than isotonic crystalloid solutions;
– inappropriate use of large volumes of intravenous fluids in patients with
unrecognized severe bleeding;
– inappropriate transfusion of FFP, platelet concentrates and Cryo
– continuation of IVF after plasma leakage has resolved
– co-morbid conditions such as congenital or ischaemic heart disease,
chronic lung and renal diseases
MANAGEMENT OF COMPLICATIONS
Clinical Features:
– respiratory distress, difficulty
in breathing;
– rapid breathing;
– chest wall in-drawing;
– wheezing (rather than
crepitations);
– large pleural effusions;
– tense ascites;
Other investigations:
• CXR
• ECG
• ABG
MANAGEMENT OF COMPLICATIONS
• Oxygen therapy• Stop IVF
• When to discontinue IVF:
– stable blood pressure, pulse and peripheral perfusion;
– haematocrit decreases in the presence of a good pulse volume;
– afebrile for more than 24–48 days (without the use of antipyretics);
– resolving bowel/abdominal symptoms;
– improving urine output
• If necessary, give oral or intravenous furosemide 0.1–0.5 mg/kg/dose once or
twice daily, or continuous infusion of furosemide 0.1 mg/kg/hour.
MANAGEMENT OF COMPLICATIONS
• If the patient has stable haemodynamic status but is still within the critical phase,
reduce the intravenous fluid accordingly. Avoid diuretics during the plasma
leakage phase
• Patients who remain in shock with low or normal haematocrit levels but show signs
of fluid overload may have occult haemorrhage.
• Careful fresh whole blood transfusion
• repeated small boluses of a colloid solution
OTHER CONSIDERATIONS
• NOTIFY PUBLIC HEALTH.. CLASS ONE DISEASE
• REPELLANT USE 5-7.5% DEET CHILDREN, 15% DEET ADULTS
• BED NETS
• CLOSE MONITORING
• SERIAL LABS
• MANAGE SYMPTOMATICALLY
• MITIGATE RISK. IDENTIFY THOSE AT GREATER RISK
CO MORBIDITIES INCREASE RISK FOR SEVERE DENGUE
• SICKLE CELL DISEASE.. RISK OF MISDIAGNOSIS
• HTN.. NOTE EFFECTS OF MEDS. RISK OF CARDIOVASCULAR DISEASE
• DM… GLUCOSE HIGH/LOW, RISK OF ACIDOSIS, CARDIOVASCULAR
DISEASE
• OBESE… FLUIDS SHOULD BE DEPENDENT ON IDEAL BODY WEIGHT
• RENAL FAILURE .. RISK OF OVERLOAD
• HEART DISEASE.. RISK OF OVERLOAD
• COAGULOPATHY… ON ANTICOAGULANTS, LIVER DISEASE
OBSTETRIC MANAGEMENT
• FOR PATIENTS WITH A PLATELET COUNT OF <50,000 PER MM3 WHO ARE
IN LABOUR AND WILL UNDERGO A CAESAREAN SECTION, PLATELET
CONCENTRATE SHOULD BE GIVEN AS CLOSE TO SURGERY AS POSSIBLE
• THE TIMING AND ROUTE OF DELIVERY OF THE BABY WILL DEPEND ON
THE OBSTETRIC CONDITION.
• IF A CAESAREAN SECTION IS NEEDED, GENERAL ANESTHESIA IS
RECOMMENDED. SPINAL AND EPIDURAL ANESTHESIA ARE NOT
RECOMMENDED BECAUSE THEY REQUIRE PUNCTURE
• UTERINE BLEEDING CAN BE A MAJOR COMPLICATION DURING DELIVERY IF
THE PREGNANT WOMAN HAS DENGUE, PARTICULARLY IF SURGICAL
PROCEDURES THAT CAN BE ASSOCIATED WITH SEVERE BLEEDING ARE
PERFORMED.
OBSTETRIC MANAGEMENT
• NOTIFY THE PAEDIATRIC SERVICE OF EVERY BABY BORN TO A MOTHER
WITH DENGUE AT THE TIME OF DELIVERY, AS THE CHILD MAY BECOME
ILL UP TO 12 DAYS AFTER BIRTH.
• BREASTFEEDING SHOULD BE CONTINUOUS AND ENCOURAGED.
• NEWBORNS OF MOTHERS WITH DENGUE (OR A MOTHER WHO HAD
THE INFECTION UP TO ONE WEEK BEFORE DELIVERY) WHO DEVELOP
THROMBOCYTOPENIA, FEVER, HEPATOMEGALY, OR VARYING DEGREES
OF CIRCULATORY FAILURE DURING THE FIRST WEEK OF LIFE MAY BE
MISDIAGNOSED WITH NEONATAL SEPSIS.
• TO PREVENT THIS, THE EPIDEMIOLOGICAL LINK MUST BE CONSIDERED
MOTHER TO CHILD TRANSMISSION
• NEWBORNS WHO DEVELOP SEVERE SYMPTOMS MAY CLINICALLY
RESEMBLE SEPSIS SUCH AS WITH HYPOTHERMIA INSTEAD OF FEVER,
PLEURAL EFFUSION, GASTROINTESTINAL BLEEDING, CIRCULATORY
FAILURE, INTRACRANIAL HEMORRHAGE, AND DEATH
• TREATMENT OF THESE SEVERE CASES CONSISTS OF ADMINISTRATION
OF BALANCED ELECTROLYTE SOLUTIONS (RINGER’S ACETATE, ETC.)
FOR THE PURPOSE OF MAINTAINING MAP WITHIN NORMAL RANGES
FOR AGE AND SEX
SPECIAL NOTE ON THE PAEDIATRIC PATIENT
• MORTALITY IS HIGHER IN THE < 1 YEAR GROUP
• SYMPTOMS IN YOUNGER CHILDREN MAY NOT FIT THE CASE
DEFINITION
• MAY BE OLIGOSYMPTOMATIC, OR MANIFEST AS A NONSPECIFIC
FEBRILE SYNDROME ,UPPER RESPIRATORY TRACT MANIFESTATIONS ,
DIARRHEA, OR SEIZURES
PAEDIATRIC SIGNS
• PLASMA LEAKAGE FROM THE INTRAVASCULAR COMPARTMENT
INITIALLY MANIFESTS AS PALPEBRAL AND PERIPHERAL OEDEMA
• HEPATOMEGALY AND SPLENOMEGALY ARE UP TO SEVEN TIMES MORE
FREQUENT IN CHILDREN UNDER ONE YEAR OF AGE THAN IN OLDER
CHILDREN
• SHOCK MAY MANIFEST AS HYPOTHERMIA, RESTLESSNESS OR
LETHARGY, COLD EXTREMITIES, AND TACHYCARDIA
PAEDIATRIC DENGUE SIGNS
• VITAL SIGNS IN THE PAEDIATRIC PATIENT ARE AGE DEPENDENT
• HAVE A REFERENCE CHART ON HAND TO IDENTIFY CLINICAL SIGNS
OF HEMODYNAMIC INSTABILITY
• CAREFULLY EVALUATE FOR WARNING SIGNS EVEN WHEN
NONSPECIFIC SYMPTOMS ARE PRESENT ESPECIALLY IN THE YOUNGER
AGE GROUP. FEVER IS USUALLY PRESENT IN ALL CASES
DISCHARGE CRITERIA
CLINICAL:–
• NO FEVER FOR 48 HOURS
• IMPROVEMENT IN CLINICAL STATUS:- GENERAL BEING, APPETITE, URINE
OUTPUT, HAEMODYNAMIC STATUS, NO RESPIRATORY DISTRESS.
LAB:-
• HAEMATOCRIT NORMALIZING WITHOUT IV FLUIDS
• PLATELET COUNTS INCREASING
CRITERIA FOR DISCHARGE