Preface

Dengue fever is the fastest emerging Arboviral infection which is spread

by Aedes mosquitoes and has major public health consequences. Up to
2.5 billion people in the tropics and subtropics globally live under the
threat of dengue fever and its severe forms—dengue haemorrhagic fever
(DHF) or dengue shock syndrome (DSS). It is estimated that 50-100 million
cases of dengue fever occur worldwide annually and half a million people
suffering from DHF require hospitalization each year, a very large
proportion of whom (approximately 90%) are children less than five years
old. About 2.5% of those affected with dengue die of the disease.
However, evidence shows that good clinical management may reduce the
case fatality to <1%.

Dengue in Pakistan is not new and the first outbreak was detected in
Karachi back in 1994. Since then the disease has become endemic in
almost all geographical areas of Pakistan. The first major outbreak
happened in 2011 in Punjab province with over 500,000 suspected cases
with over 21,000 lab confirmed cases and around 300 deaths reported.
In 2013, Dengue outbreak in Malakand region of Khyber Pakhtunkhwa
saw a total 11,838 cases with 34 deaths. In 2017 Dengue outbreak in
Peshawar, the capital of Khyber Pakhtunkhwa province, 125,000
suspected cases with 23,541 lab confirmed cases and 67 deaths, with CFR
of 0.28% were recorded.

During the 2017 Peshawar Dengue outbreak, it was noted that the
Dengue case management for hospitalized patients was highly
individualized among the major hospitals. A large number of suspected
cases were presented each day in the hospital but due to lack of effective
triage mechanism in the hospital, it was difficult for the physicians and
paramedic staff to handle the caseload and were overworked. No proper
monitoring of admitted cases led to complications. Therefore, there was
a need for simple, clear and user friendly guidelines about natural course
of DHF/DSS, OPD triaging, indications for admission, in-patients
monitoring, IV fluid management, indications for blood transfusion and
discharge criteria in order to reduce the morbidity, mortality and case
fatality rate (CFR). In order to achieve these, an expert mission from the
WHO collaborating center on Dengue Case Management in Thailand was
invited to visit Peshawar, which visited all the major hospitals, consulted
with the Public Health department and concerned Hospitals, reviewed
literature and case studies and provided recommendations and 2 days
training to selected health care providers.

This handbook is a modification and contextualization of the guidelines

provided by the Dengue expert mission from WHO collaborating centre
on Dengue Case Management and is intended to provide guidance to
physicians and all categories of doctors to carry out appropriate
treatment of patients with Dengue Fever/Dengue Haemorrhagic Fever
and would help to bring down complications and the case fatality rate to
a minimum in the future. Aspects of managing severe cases of dengue
are also described for practitioners at higher levels of health care. This
handbook will be made available to health-care practitioners at all levels
and is meant to provide recommendations in light of best practices based
on best evidence available.
List of Abbreviations

AFI Acute Febrile Illness

ALT Alanine Aminotransferase
BP Blood Pressure
CBC Complete Blood Count
CR Creatinine
CRT Capillary Refill Time
CVC Central Venous Catheter
DBP Diastolic Blood Pressure
DF Dengue Fever
DOA Date of Admission
DSS Dengue Shock Syndrome
EDS Extended Dengue Syndrome
FBC Full Blood Count
GCS Glasgow Coma Scale
GI Gastrointestinal
HCT Haematocrit
HDU High Dependency Unit
Haemolysis, Elevated Liver Enzymes , Low
HELLP
Platelets
HR Heart Rate
IBW Ideal Body Weight
ICU Intensive Care Unit
IgG Immunoglobulin G
IgM immunoglobulin M
LFT Liver function Test
M Maintenance
MRNO Medical Record Number
NG Tube Naso-Gastric Tube
NS Normal Saline
NS1 Non-structural Protein – 1
PP Pulse Pressure
PR Pulse Rate
RBS Random Blood Sugar
RBS Random Blood Sugar
RDT Rapid Diagnostic Test
RL Ringer Lactate
RR Respiration Rate
Reverse transcriptase Polymerase chain
RT-PCR
reaction
SBP Systolic blood pressure
TDI Total Duration of Illness
TLC Total Leukocyte Count
TT Tourniquet Test
UOP Urinary Output
USG Ultrasonography
USS Ultrasound Scan
WCC White cell count
WHO World Health Organization
CONTENTS
Introduction……………………………………………………………………………………………………..4
Surveillance Case Definition For Dengue Infection……………………………………………5
Classification /categorization of Dengue Patients ................................................6
Dengue Fever (DF) .................................................................................................7
Dengue Haemorrhagic fever (DHF) ...................................................................... 7
Dengue Shock Syndrome (DSS) ............................................................................ 8
Extended Dengue Syndrome (EDS) ...................................................................... 8
History of Presenting Illness ..................................................................................9
Phase of the disease based on history and associated complications? ...............9
Febrile Phase and its complications ......................................................................9
Critical Phase and its complications ................................................................... 10
Recovery Phase and its complications ............................................................... 10
High Risk Patients ............................................................................................... 11
Examination ........................................................................................................ 12
Evaluate and document each of the following parameters ............................... 12
Warning Signs ................................................................................................... 13
Plasma Leakage .................................................................................................. 14
Signs of plasma leakage ...................................................................................... 14
How to identify the leak phase by using clinical parameters? ........................... 15
Clinical signs of dehydration include .................................................................. 16
How to do a Tourniquet Test.............................................................................. 17
Pulse Pressure..................................................................................................... 17
Ideal Body Weight Calculation ........................................................................... 18
Differential Diagnosis to consider ...................................................................... 19
Laboratory tests for a patient with Suspected Dengue ..................................... 19
Rapid Diagnostic Tests (RDT) .............................................................................. 19
NS1 Ag Test ......................................................................................................... 20
Anti-Dengue IgG/IgM.......................................................................................... 21
How to identify the leak phase by using the laboratory
parameters?.......................................................................................................23
Heamoconcentration .......................................................................................... 24
Heamatocrit Reading .......................................................................................... 25
Shock................................................................................................................... 27
Severe Dengue/ Dengue Shock Syndrome (DSS) ............................................... 27
Presumptive /Probable/Suspected/Confirmed Diagnosis ................................. 28
Dengue clinical management groups ................................................................. 29
Grading of Dengue Fever according to WHO criteria......................................... 29
Group A ............................................................................................................... 29
Group-B............................................................................................................... 30
Group-C............................................................................................................... 30
A: Compensated Shock ....................................................................................... 31
B: Hypotensive Shock ......................................................................................... 31
Out Patient Management (Group A ................................................................... 32
Schedule for laboratory monitoring and follow up visits ................................... 32
Instructions regarding monitoring of Out patients ............................................ 34
Evaluation of patients on outpatient follow-up visit ......................................... 37
Symptoms that should be not be ignored ......................................................... 37
Warning signs that should be checked for are ................................................... 37
Clinical parameters to be checked and documented ......................................... 38
Inpatient Management....................................................................................... 38
For group B Patients ........................................................................................... 38
For group C patients ........................................................................................... 39
Fluid Management during Febrile Phase............................................................ 41
Critical Phase (Leak Phase) ................................................................................. 41
Signs and symptoms of fluid overload ............................................................... 45
Fluid requirement based on IBW........................................................................ 45
Management of fluid overload ........................................................................... 45
Management of convalescence phase ............................................................... 46
Platelet transfusion ............................................................................................ 47
Use of Frusemide…………………………………………………………………………………………..48
Use of Tranexamic acid………………………………………………………………………………….48
Use of Antibiotics .............................................................................................. 48
Discharge criteria ................................................................................................ 48
Special Circumstances during management ...................................................... 49
Rare Complications ............................................................................................. 50
Dengue Management DO’s and DON’Ts ............................................................ 51
Don’t ................................................................................................................... 51
Do’s ..................................................................................................................... 51
Outbreak Preparedness Plan for Hospitals ........................................................ 52
Quality Assurance parameters for Managers .................................................... 55
Clinical & Laboratory monitoring chart for Outpatient Management ............... 56
Clinical Monitoring Chart .................................................................................... 58
Laboratory Monitoring Chart ............................................................................. 60
Fluid Replacement Chart during critical phase/shock phase ............................. 62
Triage Pathway……………………………………………………………………………………………….63
Dengue case reporting form.………………………………………………………………………….64
Staff requirement ............................................................................................... 65
Bibliography ........................................................................................................ 66
INTRODUCTION

Dengue infection has a variety of clinical presentations and has a risk of

increased morbidity if not managed properly and may result in adverse
outcomes if not managed timely. These guidelines are developed in
accordance with the regional resources, best practices and with the aim
to create uniformity in care by knowing the clinical course of the disease,
case definitions, differential diagnosis, identify complication in each
phase of the disease and how to recognize the warning signs, plasma
leakage and early shock and to apply correct treatment accordingly to
dengue patients. At the same time tools are provided for the managers
to monitor the care of patients in the health care facilities and to prepare
for Dengue outbreaks management in the hospitals. These guidelines will
provide an insight into the following areas of concern in order to enable
the treating physicians provide the best care required by a dengue
patient.

❖ What to know about Dengue?

❖ What to ask from a suspected Dengue patient?
❖ What to examine in a Dengue infected patient?
❖ What to order e.g. from the lab?
❖ Where to send/refer?
❖ What to tell the patient and family?
❖ Where to report?
❖ How to recognise different categories?
❖ How to manage as outpatient and inpatient?
❖ Common mistakes and common concerns.
❖ How to prepare for Dengue outbreak response?

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SURVEILLANCE CASE DEFINITION FOR DENGUE INFECTION

The diagnostic criteria for dengue fever are divided into 3 categories;

1. Suspected case of Dengue Fever

2. Probable case of Dengue Fever
3. Confirmed case of Dengue Fever

Following is the criteria for each segment.

LIVES IN OR TRAVEL TO ENDEMIC AREA +

1. Suspected Case – Presence of 3 or more Clinical Criteria

Clinical Criteria:

Acute high-grade Fever of 2 to 8 days duration (essential criterion) AND

any two of the following:

• Headache
• Retro orbital pain
• Myalgia
• Arthralgia/ severe backache/ bone pains
• Rash
• Bleeding manifestations (epistaxis, hematemesis, bloody stools,
menorrhagia, hemoptysis)
• Abdominal pain

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 • Decreased urinary output despite adequate fluid intake

2. Probable Case – Suspected Case with both Supportive Lab Evidence

Supportive Lab Evidence:
• Thrombocytopenia ≤ 100,000/mm3
• Leukopenia ≤ 4000/mm3

3. Confirmed Case – suspect OR Probable case with any one of the three
Confirmatory Evidence

• Confirmatory Detection of viral antigen (NS1 antigen in blood)

OR
• Detection of IgM
OR
• Detection of virus by PCR
OR
• evidence of viral infection would therefore, be based on:
Demonstration of ≥ 4 fold rise in IgG antibody titer in paired acute
and convalescent serum
•

CLASSIFICATION /CATEGORIZATION OF DENGUE PATIENTS

A majority of the patients who get infected with dengue virus are never
recognized due to asymptomatic infection that could be as high as 80-
90%.

The Incubation period is 3-14 days.

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Patients who develop symptomatic disease can be categorised/classified
into those with undifferentiated fever, classic Dengue Fever (DF), Dengue
Haemorrhagic fever (DHF), Dengue shock syndrome (DSS) and those with
organ failures/Extended Dengue Syndrome(EDS) based on severity of the
disease.

DENGUE FEVER (DF)

Dengue fever sometimes called
“Break bone fever” is a severe, flu-like
illness that affects infants, young
children and adults. The clinical
features of Dengue fever vary
according to the age of the patient.
Infants and young children may have
a non-specific febrile illness with rash.
Older children and adults may have
either a mild febrile syndrome or the
classical incapacitating disease with
abrupt onset and high fever, severe
headache, pain behind the eyes,
muscle and joint pains, and rash.
DENGUE HAEMORRHAGIC FEVER
(DHF)
Dengue haemorrhagic fever is
different from Dengue Fever in that
the patient has typical
pathophysiologic hall marks of selective plasma leakage into the body
IMPORTANT TO KNOW
ABOUT DENGUE
• There are 4 distinct, but
closely related serotypes
of the virus that cause
dengue (DEN-1, DEN-2,
DEN-3 and DEN-4).
• Recovery from infection
by one serotype provides
lifelong immunity against
that particular serotype.
• Cross-immunity to the
other serotypes after
recovery is only partial
and temporary.
• Subsequent infections by
other serotypes increases
the risk of developing
severe dengue.

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cavities and other extravascular compartments and a tendency to bleed.
The term “Dengue haemorrhagic fever” per se does not mean that all
these patients will be bleeding, its actually the leaking of plasma from the
intravascular compartment to the extravascular compartment due to
endothelial dysfunction. Actual bleeding is found in a smaller fraction of
these patients.

DENGUE SHOCK SYNDROME (DSS)

DSS may develop in the Dengue Haemorrhagic fever patients who have
massive plasma leakage compromising the hemodynamic status in
absence of proper intervention. In simple terms DSS is the severe form of
DHF.

EXTENDED DENGUE SYNDROME (EDS)

EDS or Dengue with organ damage/failure usually occurs in patients who

have undetected DSS which results in prolonged shock, sometimes
irreversible shock and organ damage. Other causes of EDS are dengue
infections in hosts with co-morbidities or coinfections with other
microbial agents.

For any patient who is presenting to any health facility, based on

evaluations from history, physical examination +/- CBC and HCT, the
clinicians should be able to determine:

1. Diagnosis of Dengue Fever (suspected, probable or confirmed)

2. The phase of illness (febrile/critical/convalescent or recovery)
3. The hydration level and hemodynamic status of the patient

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 4. Whether the patient requires admission or should be managed
as outpatient.

HISTORY OF PRESENTING ILLNESS

1. Fever history
2. Does the patient have a consistent exposure history? Sick
contacts, travel etc.
3. Reported signs and symptoms
4. Have you ruled out other diseases that the patient might have
been exposed to at the same time, for example, malaria, typhoid,
influenza, measles etc.?
5. What was the day and time of the first fever of this illness?
6. What was the day and time of the last fever that the patient
reported during the current illness in the last 1 week?
7. Is this a high risk patient?
8. What is the phase of disease?

WHAT IS THE PHASE OF THE DISEASE BASED ON HISTORY?

Based on the presentation day after the onset of fever that should be
documented as Total Days or Duration of Illness (TDI), if the
presentation is after 8 days of onset of symptoms the chances of DHF
are negligible.

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FEBRILE PHASE

• Does the patient still have

COMPLICATIONS OF FEBRILE PHASE
fever? If yes, then the
disease is in the febrile • Dehydration
phase • Febrile seizures
• How many days has the • Neurologic manifestations
patient had fever? If fever
has been present for at
least 3 days, the patient could be nearing defervescence (the day
and time when the body temperature drops and remains below
38.0°C)

CRITICAL PHASE

If the patient is afebrile at

presentation after an initial COMPLICATIONS OF CRITICAL PHASE
fever of 2-5 days, ask what was
the day and time of the last • Prolonged shock
fever? If the patient is within • Organ impairment
24–48 hours of defervescence, • Bleeding/Haemorrhage
then the disease can progress
to the critical phase as the chances of leaks usually occurs during this
phase called Dengue Haemorrhagic Fever (DHF) or Dengue Shock
Syndrome (DSS).

This is the most emphasized/critical time in terms of monitoring and

patient management as the critical phase can be missed if clinical and
laboratory monitoring does not follow standard guidelines leading to
adverse outcomes for the patient.

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RECOVERY PHASE

If the patient is without fever

COMPLICATIONS IN RECOVERY PHASE
for more than 48 hours, and is
hemodynamically stable and • Fluid overload
maintains diuresis, then the • Worsening effusions
disease is in the recovery • Acute pulmonary oedema
phase.

HIGH RISK GROUPS

• Infants • Cardiac Disease
• Pregnant women • Diabetes Mellitus
• Poor social status • Liver cirrhosis
• Elderly • Bleeding Disorders
• Obese • Malignancy/
• Renal Failure Immunosuppressive therapies

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EXAMINATION

1. What is the patient’s mental

status?
2. What is the patient’s EVALUATE EACH OF THE
hemodynamic status? FOLLOWING PARAMETERS
3. What is the patient’s
hydration status? • Level of consciousness. GCS
4. Are there warning signs for • Capillary refill
severe disease? • Skin temperature, colour, and
5. Are there signs or symptoms moisture level (normal, dry or
of plasma leakage or
clammy)
bleeding?
6. Are the patient's signs and • Peripheral pulse volume
symptoms consistent with • Heart rate
dengue, given the day post • Blood pressure
onset that the patient • Tourniquet test
presents?
• Respiratory rate
7. Are the patient's clinical
• Urine output
manifestations consistent
with dengue versus or other
AFIs?

12
 WARNING SIGNS

❖ Severe abdominal pain or tenderness

❖ Persistent vomiting more than three times in a day
❖ Bleeding manifestations: petechiae, epistaxis, gum bleeding, coffee
ground vomiting, hematemesis, melena, mucosal bleed
❖ Liver enlargement >2cm
❖ Clinical fluid accumulation (right pleural space, abdominal cavity)
❖ Lethargy; restlessness; behavioural changes; Giddiness
❖ Increase in Heamatocrit (HCT) concurrent with rapid decrease in
platelet count
❖ Pale, cold clammy hands and feet
❖ Decrease urine output/anuria

After obtaining the patient's exposure and fever history, perform a

physical exam. Begin by assessing the patient’s mental state. Dengue
patients typically retain a normal mental status compared to patients
with bacterial sepsis. Dengue patients should have their mental status
evaluated nonetheless and the findings documented.

If the patient complains of dizziness, fainting, or syncope assess the

hemodynamic status.

13
Hemodynamic status: It is important to frequently reassess the
hemodynamic status of a patient with dengue, especially during
defervescence and the critical phase. Assess hemodynamic status by
evaluating parameters listed below. If the documented blood pressure
(BP) measurement does not match the expectations set by the clinical
examination (for example, a patient has a capillary refill of 4 seconds and
the recorded BP is 120/80), take the blood pressure again.

PLASMA LEAKAGE

It is important to assess if a patient has evidence of plasma leakage early

and reassess regularly as it can become clinically significant at the time of
defervescence.

As a patient with dengue begins to leak plasma into the pleural and
abdominal cavities, the heart rate increases to compensate for the
reduced blood volume, as this happens, the Diastolic blood pressure
(DBP) increases without substantial change in Systolic blood pressure
(SBP), leading to a narrowing Pulse Pressure (PP).

If treatment is not provided, the heart rate will continue to increase while
the PP narrows, until the SBP falls. At this point, the patient is said to be
in decompensated hypovolemic shock.

SIGNS OF PLASMA LEAKAGE:

• Ascites or pleural effusion as determined by examination or an

imaging method.
• Oedema, facial puffiness, leg/arm swelling are not suggestive of
leaking but only suggest fluid overload and should not be confused.

14
HOW TO IDENTIFY THE LEAK PHASE BY USING CLINICAL
PARAMETERS?

15
CLINICAL SIGNS OF DEHYDRATION INCLUDE :

• Fast pulse rate

• Poor skin turgor
• Delayed capillary refill
• Dry mucous membranes
• Sunken fontanelle in infants
• Dry eyes or no tears

16
TOURNIQUET TEST

The tourniquet test is part of the new WHO case definition for dengue.
The test is a marker of capillary fragility and it can be used as a triage tool
to differentiate patients with dengue from those, for example, acute
gastroenteritis. Even if a tourniquet test was previously done, it should
be repeated if:

• It was previously negative

• There is no bleeding manifestation

HOW TO PERFORM TOURNIQUET TEST:

1. Take the patient's blood

pressure and record it, for
example, 100/70 mmHg.
2. Inflate the cuff to a point midway
between Systolic BP and
Diastolic BP and maintain for 5
minutes. (100 + 70) ÷ 2 = 85
mm Hg
3. Deflate the cuff and wait 2
minutes.
4. Count patechiae below antecubital fossa. See the image
5. A positive test is 10 or more petechiae per 1 square inch.

PULSE PRESSURE (PP)

17
• Pulse pressure is the difference between the systolic and diastolic
blood pressure. It is measured in millimetres of mercury (mmHg).
• For early detection of compensated shock this is a simple clinical
parameter where pulse pressure will become narrower and a pulse
pressure of 20mmHg or less is used as a cut off mark to label a patient
as having compensated shock during clinical monitoring
• For example: If resting blood pressure is 120/80 mm Hg, then
the pulse pressure is 120 minus 80 that is 40 mmHg. (120-80=40)

IDEAL BODY WEIGHT (IBW)

• Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet.

▪ Example: IBW of a 5.8 feet tall male with actual weight of 92 kg
= 50+2.3(8)=50+18.4=68.4 kg

18
• Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet
▪ Example: IBW of a 5.8 feet tall female with actual weight of 92 kg
= 45.5+2.3(8)=45.5+18.4=63.9 kg

DIFFERENTIAL DIAGNOSIS TO CONSIDER

• Malaria • Typhoid
• Chikungunya • Other viral haemorrhagic fevers
• Influenza • Rickettsial fevers
• Measles • West Nile virus infection
• COVID-19 • Autoimmune disorders

LABORATORY TESTS FOR PATIENT WITH SUSPECTED DENGUE :

All the patients who are presenting to any health facility and labelled as
a suspected /probable/confirmed Dengue should have the clinical and
laboratory form filled after performing the clinical and laboratory
evaluations. (Form annexed). All the patients should have a baseline
complete blood count that should include haematocrit and platelet
count.

Other tests like Blood Sugar, Blood Urea , Serum Creatinine, Serum
ALT/AST etc are need based and should be decided on patient to patient
basis.

RAPID DIAGNOSTIC TESTS (RDT)

19
Dengue specific testing is indicated at all regions in patients presenting
with ACUTE FEBRILE ILLNESS having Dengue as a differential diagnosis
where the disease activity is not confirmed yet and the samples should
be submitted to the national/provincial reference laboratories for further
confirmation and genotyping.

In areas where the disease activity (Dengue cases) is already confirmed

and patients are fulfilling the criteria for Group A, B or C Dengue testing
is not indicated in routine and should be encouraged only in severe cases.
A negative test should not hinder the clinical case management due to
the variable sensitivities of commercially available rapid diagnostic kits.

NS1 AG TEST:

For early confirmation of Dengue, this is the quickest option and is

reported in 5-10 minutes using rapid diagnostic kits. It is positive during
the febrile phase with a sensitivity of 40-70% depending on the viremia
and kit quality. Newer kits introduced recently have an improved
sensitivity but their validity is yet to be confirmed. The percentage of
positivity decreases rapidly as the days of fever passes on and the test
usually become negative after 5-7days of onset of illness. The positivity is
high in primary infection compared to patients presenting with a
secondary infection.

False positivity due to cross reaction with other flaviviruses, malaria

parasite, leptospira and immune disorders such as rheumatoid and lupus
is another concern for using NS1 rapid diagnostic kits.

NS1 AG test does not guide the clinical management, it only confirms
dengue infection.

20
A negative NS1 (due to the low sensitivity of NS1) does not mean that
the patient do not have Dengue, and if patient fulfils other criteria for
suspected dengue, the patient should be managed accordingly.

ANTI-DENGUE IGM/IGG:

It usually becomes positive on 5th day so it is not used for the early
diagnosis, and is used to confirm dengue but can become positive as late
as 7-14 days after the initial infection. If only IgM is positive it suggests
acute primary infection. The IgM will remain positive up to 1-2 months.
If only IgG is positive this suggest past dengue infection because IgG can
persist for many years. If both IgG and IgM are positive, this suggests
secondary dengue infection or a late testing. During secondary dengue
infection (when the host has previously been infected by dengue),
antibody titres rise rapidly. IgG antibodies are detectable in higher levels
while IgM antibody levels are significantly lower, hence the ratio of
IgM/IgG is commonly used to differentiate between primary and
secondary dengue infections.

• Primary infection - antibody response in patients never exposed

to a flavivirus (neither by infection or vaccine)
• Anti-Dengue IgM
o detectable in 50% by days 3-5
o detectable in 80% by day 5
o detectable in 90% by day 10
o peak at about 2 weeks

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 o decline to undetectable levels over 2-3 months
• Anti-Dengue IgG
o usually detectable in low levels by end of first week of
illness
o can still be detected after months and may be
detectable for life
o Secondary infection - antibody response in patients
who have had previous exposure to dengue or other
related flavivirus
o anti-dengue IgG levels rise rapidly to high levels
o can be seen early in disease course
o last for months to life
• IgM levels are much lower than in primary infection

Dengue NS1, Anti Dengue IgM and IgG by Elisa compared to RDT do not
add too much to the management of Dengue patients.

For epidemiological investigations during outbreaks, blood samples

should be submitted to the national/provincial reference labs for
genotyping by PCR.

22
HOW TO IDENTIFY THE LEAK PHASE BY USING THE LABORATORY
PARAMETERS?

23
It is important to assess and document oral intake and output of
fluid:

• How much has the patient drunk in the last 12–24 hours?
• How much has the patient vomited in the last 12–24 hours?
• Has there been diarrhoea?
• When did the patient last urinate?
• What is the frequency and volume of urination in the last 12–24
hours?

HEMOCONCENTRATION IS DEFINED IN ONE OF THE TWO WAYS:

❖ An increasing HCT compared to the patient's baseline HCT (taken

early in the clinical course) by 20% or more. Can use the population
mean HCT for age and sex if no baseline HCT is available.
❖ A drop in HCT compared to the patient's baseline HCT by 20% or
more in a patient with stable vital signs following volume
replacement. If the patient's vital signs are unstable, evaluate for
occult bleeding.

Note: The population mean HCT might vary depending on the nutritional
status of the population and the prevalence of other diseases, such as
malaria, parasitic infections, and hemoglobinopathies.

Even patients with non-severe dengue can have minor bleeding including
petechiae, purpura, epistaxis, and gingival bleeding. Mild bleeding can be
due to increased capillary fragility as a result of thrombocytopenia or
platelet dysfunction, and cytokines that disrupt vascular integrity.

24
Normally, platelets release factors that help maintain integrity of
the endothelial adherens junctions.

Patients with severe dengue might present with severe bleeding that
could be occult as well as gastrointestinal (GI), pulmonary, intracranial or
vaginal bleeding. Massive GI bleeding has been associated with
prolonged shock and metabolic acidosis.

Occult bleeding can be detected by:

• Monitoring the patient’s hemodynamic status

• Obtaining frequent HCT levels

25
 • Ultrasound chest/abdomen that can show fluid collection in
free spaces and retroperitoneal space
• Performing a stool for occult blood

DSS
DHF

DF

Compensated Shock
Circulatory failure manifested by narrow pulse pressure

Decompensated Shock
Systolic BP less than 90mmHg or more than 20% reduction
in Systolic BP

26
Presence of pleural effusion and ascites indicates that the patient is
already in the critical phase. Pleural effusion detected clinically may not
be obvious in a Chest X Ray (CXR)-PA, but may be seen only in a CXR right
lateral decubitus film.

Use of a focused ultra sound scan (USS) will help to identify clinically
undetectable Pleural effusion and Ascites

Gallbladder wall oedema may be seen by USS in both DF and DHF. Though
it may also be the earliest sign of leaking in DHF, if pericholecystic
oedema is not progressing in subsequent USS such patients are likely to
have only DF. If appropriate interventions are not adopted early, the
patient may progress to develop shock.

SHOCK:

It is critical to identify patients in compensated shock and to intervene at

this stage before they develop decompensated shock.

Early signs of shock include:

• Narrowing of pulse pressure (PP) with rising diastolic blood pressure

(DBP)
• Delayed capillary refill (> 2 seconds)
• Tachycardia in absence of fever

SEVERE DENGUE/ DENGUE SHOCK SYNDROME (DSS):

27
Usually this is a late presentation but can occur as early as three days in
rare cases, the causes of severe dengue are categorised as;

1. Severe plasma leakage

2. Severe haemorrhage
3. Severe organ involvement

Patients can present with criteria for one or more categories.

• Severe plasma leakage resulting in one or both of the following:

o Shock
o Fluid accumulation with respiratory distress
• Severe bleeding as evaluated by clinician clinically/ radiologically or
laboratory based
• Severe organ involvement
• Hepatic: AST or ALT level > 1000 U/L. ( among the organ
involvements in dengue patients liver involvement is one of the
commonest and can lead to prolonged hospital stays
• Neurologic: impaired consciousness (central nervous system
disease, neuropathology)
• Myocardial (involving the heart) and other organs

The severe organ involvement may be the first presentation and dengue
should be considered as one of the causes especially during the endemic
situations.

28
DENGUE CLINICAL MANAGEMENT GROUPS:

For management purposes Dengue patients are grouped based on the

clinical characteristics and laboratory parameters into;

GROUP A

• Undifferentiated fever
• Classic Dengue Fever (DF)

GROUP B

• Dengue Haemorrhagic fever (DHF)

GROUP C

• Dengue shock syndrome (DSS)

• Those with organ failures based on severity of the disease also called
Extended Dengue Syndrome(EDS)

Group B and C are actually comprised of DHF patients with different

severity as explained by WHO criteria for grading severity of DHF.

• DHF Grade I: Fever and plasma leakage without spontaneous

bleeding

29
 • DHF Grade II: Fever and plasma leakage plus spontaneous bleeding
• DHF Grade III: Grade I or II plus evidence of shock
• DHF Grade IV : Grade I or II plus evidence of profound shock
• DHF Grade I & II = Group B = DHF
• DHF Grade III & IV = Group C = DSS

GROUP A:

– Presence of 3 or more Clinical Criteria

Clinical Criteria:

Acute high-grade Fever of 2 to 8 days duration (essential criterion) AND

any two of the following:

• Headache
• Retro orbital pain
• Myalgia
• Arthralgia/ severe backache/ bone pains
• Rash
• Bleeding manifestations (epistaxis, hematemesis, bloody stools,
menorrhagia, hemoptysis)
• Abdominal pain
• Decreased urinary output despite adequate fluid intake

30
And No Warning Signs, No Risk Factors, tolerate adequate volume of oral
fluids, hemodynamically stable and stable/normal haematocrit. These
patients will be sent home on the Out Patient Management protocol

GROUP-B:

– Presence of 3 or more Clinical Criteria

Clinical Criteria:

Acute high-grade Fever of 2 to 8 days duration (essential criterion) AND

any two of the following:

• Headache
• Retro orbital pain
• Myalgia
• Arthralgia/ severe backache/ bone pains
• Rash
• Bleeding manifestations (epistaxis, hematemesis, bloody stools,
menorrhagia, hemoptysis)
• Abdominal pain
• Decreased urinary output despite adequate fluid intake

Plus Warning Signs OR Risk Factors, has challenging social circumstances

such as living alone or living far away without a reliable means of
transport.

These patients will be admitted for Inpatient Management in the General

/ designated units for Dengue Patients

GROUP-C:

31
A: COMPENSATED SHOCK

Circulatory failure manifested by narrow pulse pressure

B: HYPOTENSIVE SHOCK

Systolic BP less than 90mmHg or more than 20% reduction in SBP

Patients with any of the following signs and symptoms will be admitted
/ referred for Inpatient Management preferably at HDU/ICU after
resuscitation:

• Severe Plasma leakage with shock and or fluid accumulation with

respiratory distress
• Severe bleeding
• Sever organ impairment

OUT PATIENT MANAGEMENT (GROUP A):

There is no specific treatment of Dengue Infection. The treatment is only

supportive and symptomatic and the management aim is not to miss the
critical phase if it occurs.

During the febrile phase (that may last 2–7 days) and subsequent critical
phase (1–2 days) if any, you should:

• Follow CBCs (Frequency based on baseline)

• Watch for dehydration
• Watch for warning signs, including decreasing platelet count and
increasing haematocrit

32
 • Watch for defervescence (Not always but could be the beginning of
critical phase)

SCHEDULE FOR LABORATORY MONITORING AND FOLLOW UP

VISITS:

All the Group A patients should visit local health facility /local doctor
(GP/BHU/CH/RHC/DHQ etc) between 3-8 days after onset of first fever
and should have evaluation for warning signs and CBC done daily for two
to three days soon after the defervescence (Afebrile /critical phase) and
any warning signs OR rising HCT or drop in WBC or Platelet count should
prompt further referral /admission.

As temperature declines 3 to 8 days after the first symptoms began,

Return IMMEDIATELY to clinic or emergency department if any of the
warning signs appear as explained above.

33
INSTRUCTIONS REGARDING MONITORING OF OUT PATIENTS :

• Beside detailed history and evaluation all the patients who are
categorised as Group A patients and are on outpatient plan for
management should have this monitoring form with them and all
the required data should be documented.
• Every patient should be instructed to bring this form on each
follow up visit.
• This monitoring is usually required up to 8 days from the beginning
of fever

34
 • If the first RBS,ALT,AST is normal they should be repeated on need
basis only
• Dengue NS1,IgG, IgM are not mandatory in endemic situations
(check Dengue test in the booklet for details)

Advise patient or their family to do the following

Control the fever

• Give acetaminophen every ADVISE PATIENT & FAMILY TO DO THE

6 hours (maximum 4 doses
per day). Do not give
ibuprofen, aspirin, or
aspirin- containing drugs.
• Sponge patient’s skin with
tepid water when
temperature is high.
Prevent dehydration
Dehydration occurs when a
patient loses too much fluid
(from high fever, vomiting, or
poor oral intake).
FOLLOWING:
1. Control Fever with Paracetamol
2. Prevent Dehydration by giving
fluids and ORS
3. Prevent spread of dengue within
the house by eliminating source
and using bed nets and repellents
4. Watch for Warning Signs and
return to clinic immediately if any
of the sign appears

• Give plenty of fluids (not just plain water) and watch for signs of
dehydration. Bring patient to clinic or emergency room if any of the
following signs develop:
o Decrease in urination (check number of wet diapers or trips
to the bathroom)

35
 o Few or no tears when child cries
o Dry mouth, tongue or lips
o Sunken eyes
o Listlessness, agitation, or confusion
o Fast heartbeat (>100/min)
o Cold or clammy fingers and toes
o Sunken fontanel in an infant
o Poor oral intake
o Persistent vomiting

Prevent spread of dengue within your house

• Place patient under bed net or have patient use insect repellent
while febrile to avoid infecting mosquitoes that can infect others
within 2 weeks.
• KILL all mosquitoes in house.
• Empty containers that carry water and cover them.
• Put screens on windows and doors to prevent mosquitoes from
coming into house.

Watch for warning signs as temperature declines 3 to 8 days after

symptoms began. Return IMMEDIATELY to clinic or emergency
department if any of the following warning signs appear:

• Severe abdominal pain or persistent vomiting

• Red spots/patches on skin
• Bleeding from nose or gums
• Vomiting blood
• Black, tarry stools
• Drowsiness or irritability

36
 • Pale, cold, or clammy skin
• Difficulty breathing

EVALUATION OF PATIENTS ON OUTPATIENT FOLLOW-UP VISIT:

Most dengue patients will improve and they will not develop
manifestations of DHF or DSS. Patients who do not improve OR are
coming on the routine follow up as advised should be looked for
warning signs or worsening of their illness during defervescence.
Around time of defervescence, petechiae can appear, especially on
lower extremities.

SYMPTOMS THAT SHOULD NOT BE IGNORED ARE :

• Sweating
• Abdominal pain
• Persistent vomiting
• Altered sensorium
• Decreased urine output

WARNING SIGNS THAT SHOULD BE CHECKED FOR ARE:

• Cold peripheries
• Tachycardia
• Rising Diastolic BP
• Narrowing pulse Pressure
• Hypotention or more than 20% change from baseline
• Increasing Respiratory Rate
• Ascites, pleural effusion

37
 • Mucosal bleed
• Lethargy, restlessness
• Liver enlargement > 2 cm
• Drop in Platelets with increase in HCT

CLINICAL PARAMETERS THAT NEED TO BE CHECKED EVERY TIME

A PATIENT WITH DENGUE PRESENTS TO A HEALTH CARE
WORKER/FACILITY AND SHOULD BE DOCUMENTE D:

• Level of consciousness
• Capillary refill
• Skin temperature, colour, and moisture level (normal, dry or
clammy)
• Peripheral pulse volume
• Heart rate
• Blood pressure
• Respiratory rate
• Urine output

INPATIENT MANAGEMENT:

FOR GROUP “B” PATIENTS:

• Obtain baseline complete blood count

• Intake output record of fluids

38
• Monitor vital signs @ 4 hourly minimum and more frequent if
clinical status unstable
• Encourage oral fluid intake and monitor for warning signs of
shock /severe dengue
• If not tolerating oral fluids or the intake is not adequate or the
haematocrit (HCT) is rising( leak phase) give isotonic
crystalloids(Normal Saline OR Ringer Lactate) in stepwise
manner based on ideal body weight
o 5-7 ml/kg/hr for 1-2 hours
o 3-5 ml/kg/hr for 2-4 hours
• If patient remains clinically stable and there is no or minimal
change in HCT, Continue the isotonic crystalloids
o 2-3 ml/kg/hr for 2-4 hours
o Recheck HCT
o Recheck the clinical status
• If patient’s clinical parameters are worsening OR HCT is rising
o Increase isotonic crystalloid to 5-10 ml/kg/hr for 1-2
hours
o Recheck HCT
o Reassess clinical status of patient
• If improving decrease the rate of fluids in a stepwise manner
o 5-10 ml/kg/hr for 1-2 hours
o 3-5 ml/kg/hr for 2-4 hours
o 2-3 ml/kg/hr for 2-4 hours
o Clinical status must be reassessed before each change

39
 • If patient condition is not improving OR patient develops
compensated shock OR hypotensive shock, this patient should
be immediately shifted to monitored beds in HDU/ICU

FOR GROUP “C” PATIENTS:

• Check HCT
o If patient’s HCT is increasing give isotonic crystalloid at
10-20ml/kg bolus over one hour
o Reassess clinical status
• If improved reduce crystalloids to 7-10 ml/kg/hr for 1-2 hours,
if continued improvement continue reducing fluids 1-2 hourly
with regular assessment before every change
• If clinical status has not improved, recheck HCT, if HCT
increasing repeat Isotonic crystalloid bolus as above OR colloid
(10%Dextran-40) bolus at the rate of 20ml/kg over 15 minutes,
repeat HCT if improving taper fluids at the rate of:
o Colloid 10-20 ml/kg over ½-1 hour, reassess
o Colloid 7-10 ml/kg/hr for 1-2 hours, reassess if
improving switch to crystalloids.
o If patient’s HCT is decreasing along with hemodynamic
worsening such as in prolonged shock, check for ABCS
(see table below).

40
SUMMARY OF FLUID MANAGEMENT:

FEBRILE PHASE:

Management of this phase is essentially similar to outpatient

management except for the addition of intravenous fluids in patients
who are unable to take adequate oral fluids, or in patients with
diarrhoea or vomiting.

Type of I.V. fluid should be Normal Saline or Hartmann’s solution (Ringer

Lactate). The total amount of fluid (both I.V. and oral) should be limited
to 2500 ml for 24 hours for an average adult (2 ml/Kg/hr upto a
maximum of 50 Kg of weight).However, if there is vomiting or diarrhoea
this amount should be increased and dehydration should be corrected.

It should be emphasized that over-hydration during this phase will not

prevent patients developing shock in the Critical phase. In fact it may
cause fluid overload during the Critical phase.

CRITICAL PHASE (LEAK PHASE)

The fluid requirement, both oral and intravenous, in critical phase (36-
48 hours) is calculated as M+5% (maintenance + 5% deficit).

Maintenance (M) is calculated as follows:

• For the 1st 10 kg -100 ml/kg

• For the 2nd 10 kg - 50 ml/kg
• From 20 kg and above up to 50 kg - 20 ml/kg
• 5% deficit is calculated as 50 ml/kg up to 50kg

41
Example of fluid calculation for a 65 kg person (maximum body weight
for fluid calculation is 50 kg

• For the 1st 10 kg - 100 ml/kg = 1000 ml

• For the 2nd 10 kg - 50 ml/kg = 500 ml
• From 20 kg and above up to 50 kg -20 ml/kg = 600 ml
• 5% deficit is calculated as 50 ml/kg up to 50 kg = 2500 ml

Therefore the maximum fluid requirement for an average adult for the
entire phase of critical 48 hours is 4600 ml.Extra volume will only be
required occasionally if the patient is excessively vomiting or having
watery diarrhoea. If the body weight is less than 50 kg, calculation should
be done according to the ideal body weight or actual body weight
whichever is less.

Fluid quota is aimed at giving just adequate amount of fluid to maintain

perfusion to vital organs without causing fluid overload. Once the fluid
quota is exceeded chances of fluid overload is high.

All patients will not need the full fluid quota of M+ 5% and some may
need less than this.

CONVALESCENCE PHASE:

NO IV fluid should be administered during the convalescence phase.

42
 Ideal Ideal
Body M+5% Body M+5%
Maintenance Maintenance
Weight (ml) Weight (ml)
(kg) (kg)

5 500 750 35 1800 3550

10 1000 1500 40 1900 3900

15 1250 2000 45 2000 4250

20 1500 2500 50 2100 4600

25 1600 2850 55 2200 4950

30 1700 3200 Avoid more than this limit to

avoid fluid overload

TABLE: FLUID REQUIREMENT BASED ON IBW

43
Example: Usual pattern of fluid replacement during the critical phase
for a patient who progresses during hospital stay, Frequent monitoring
and adjustment is required accordingly.

44
In a patient whose first presentation is in the critical phase with shock the
initial fluid loading starts at a higher volume and gradually trends down
SIGNS AND SYMPTOMS OF FLUID OVERLOAD INCLUDE
• Puffy eyelids • Distended abdomen
(ascites)
• Tachypnoea/dyspnoea/ • Pulmonary oedema
shortness of breath
according the response but should not exceed the total as explained earlier

MANAGEMENT OF FLUID OVERLOAD:

Fluid overload is usually caused by over hydration due to multiple

reasons. Whenever fluid overload is observed, quickly review the total
fluid intake, check for ABCS and correct them.

If the patient is still in shock or in the critical phase, or plasma leakage

and no signs of reabsorption, a hyper-oncotic colloid bolus (Dextran-40)
in amount of 10ml/kg/hr or 500ml/hr in adults should be given before
giving frusemide. In shock cases, the blood pressures is usually restored
within 10-30 minutes of infusion, then administer 1mg/kg or 40 mg in
adults of frusemide IV and continue the Dextran-40 to complete its dose.
The IV fluid can be reduced to 1mg/kg/hr or 40ml/hr and can be adjusted
in order to obtain a urine output of 0.5ml/kg/hr. if HCT is rising again the

45
dose of Dextran can be repeated, frusemide can be repeated if required
after every 30-60 minutes. If the patient is in the convalescence phase
with stable vitals and fluid overloaded frusemide may be used without
dextran.

Important points to consider:

• In order to maintain a proper hourly output record preferably

these patients should be catheterised
• Frusemide should be given during dextran infusion because the
colloid will increase the intravascular volume and frusemide will
deplete it, as during the leaking phase if frusemide is given alone
it will deplete the intravascular compartment and the patient may
progress to acute renal failure.
• If no urine output in response to the diuretics, check for renal
failure and a higher dose can be given along with the colloid as
above, but if no response and the patient is in the leaking phase
and the ascites is progressive, a quick peritoneal dialysis should be
arranged to remove as much ascetic fluid as possible, as the fluid
compresses the vena cava and hampers the venous returns
(persistent shock and renal failure is commonly seen in these
cases). This intervention will dramatically reduce the intra-
abdominal pressure and spontaneous return of the normal
hemodynamic conditions if timing is not too long.
• If no sophisticated techniques available simple pleural and /or
peritoneal tapping may be indicated and lifesaving in cases with
severe respiratory distress and failure of the colloid challenge and
the possible complication like haemorrhage should be explained to
the family.

46
MANAGEMENT OF CONVALESCENCE PHASE :

This is common for both the DF and DHF patients and can be recognised
by the improvement in the clinical parameters and hemodynamic status
with good peripheral perfusion, stable vital signs and a normalising HCT
or could be below normal.

• The IV fluid should be discontinued

• Hypervolemia may occur and may require diuretic therapy if any
signs of respiratory distress are present as discussed in the fluid
overload management
• Hypokalemia may be found and should be corrected with
supplements
• Convalescent rash which is confluent petechial and at times itchy
on the extremities is a sign of relief for the doctor.

ROLE OF PLATELET TRANSFUSION:

Prophylactic transfusion with platelets does not produce sustained

changes in the coagulation status and platelet count in patients with
DHF. It does not change or reduce the bleeding outcome in DHF either.
On the other hand, platelet transfusions can lead to fluid overload
resulting in pulmonary oedema causing respiratory embarrassment and
allergic reactions including anaphylaxis.

Prophylactic transfusion of platelets is not recommended at any

counts

However, platelet transfusions may be required in a patient with

thrombocytopenia who is to undergo an urgent surgery, has active

47
bleeding which continues in spite of repeated blood transfusions, DIC or
inpatients with intracranial haemorrhage.

USE OF FRUSEMIDE

Intravenous frusemide (10-40mg) could be used in the following

circumstances:

• In fluid overloaded patients who are haemodynamically stable

• In fluid overloaded patients who are haemodynamically
unstable in the midway of a colloid infusion or a blood
transfusion during the critical phase

USE OF TRANEXAMIC ACID

Bleeding per vagina, either menstrual, intermenstrual or

premenopausal or urogenital can be excessive in DHF. Hence those who
have such bleeding may be given Tranexamic acid 500mg - 1 gram eight
hourly.

USE OF ANTIBIOTICS

Antibiotics have no role in Dengue case management. The only scenario

where empiric antibiotics can be used is a patient in sepsis secondary to
organ failure or superadded infections.

48
DISCHARGE CRITERIA:

The following criteria should be fulfilled before discharge from hospital.

• No fever for at least 24 hours without use of antipyretic drugs

• At least two days have lapsed after recovery from shock
• Good general condition with improving appetite
• Normal HCT at baseline value or around 38 - 40 % when baseline
value is not known
• No distress from pleural effusions
• No ascites
• Platelet count has risen above 50,000 /mm3
• No other complications

SPECIAL CIRCUMSTANCES DURING MANAGEMENT:

1. Patient with rising ALT/AST of 1000units or above, manage as pre-

hepatic coma to prevent encephalopathy and add vitamin K and
possibly FFP if the coagulation profile is deranged.
2. Patients in encephalopathy: a majority of these are secondary to
hepatic failure from prolonged shock , other causes are
electrolyte abnormalities, hypoglycaemia that are correctable ,
rarely some cases could be due to intracranial bleeding
3. Diabetic patients: avoid glucose containing crystalloids and switch
to regular insulin during the inpatient management and maintain
the level around 200mg/dl
4. Anticoagulant therapies: discontinue aspirin warfarin etc for 3-5
days during the critical phase and consult cardiologist.

49
 5. Cardiac patients: the fluid management in these patients is more
complex if there is a baseline element of cardiac dysfunctions and
failures. The monitoring frequency will be more and the fluid
replacement should always be done in HDU settings
6. Pregnancy: not to miss HELP and chances of vertical transmission
should be considered.
7. Infants usually have a shorter leak/ critical phase and the usually
seen leukopenia may not be observed, similarly the unusual
presentations like diarrhoeas and convulsion may mask the
diagnosis, the monitoring should be more frequent compared to
the adults
8. Obese patients: the respiratory reserve is less and any fluid
mismanagement will lead to quick deterioration so IBW should be
calculated and fluid replacement should be done as per IBW.

RARE COMPLICATIONS

• Sepsis
• Upper gastrointestinal bleeding
• Bleeding into abdominal cavities
• Myocarditis
• Eye complications
o Uveitis
o Macular edema and blot hemorrhages
o Cotton wool spots
o Retinal vasculitis
o Exudative retinal detachment

50
 • Neurologic complications
o Encephalitis
o Meningitis
o Guillain-Barre syndrome
o Myelitis
o Acute disseminated encephalomyelitis
o Mono or polyneuropathy
o Intracranial hemorrhage
o Myositis and hypokalemic paralysis

DENGUE MANAGEMENT DO’S AND DON’TS

DON’TS:

• DON’T use corticosteroids. They are not indicated and can

increase the risk of GI bleeding, hyperglycaemia, and
immunosuppression.
• DON’T give platelet transfusions for a low platelet count. Platelet
transfusions do not decrease the risk of severe bleeding and may
instead lead to fluid overload and prolonged hospitalization.
• DON’T give half normal (0.45%) saline. Half normal saline should
not be given, even as a maintenance fluid, because it leaks into
third spaces and may lead to worsening of ascites and pleural
effusions.
• DON’T assume that IV fluids are necessary. First check if the
patient can take fluids orally. Use only the minimum amount of IV
fluid to keep the patient well-perfused. Decrease IV fluid rate as
hemodynamic status improves or urine output increases.
• DON’T miss checking ideal body weight.

51
 • DON’T miss to check that the blood collection for laboratory
workup is standardised and the haematology analyser is
calibrated regularly

DO’S

• DO tell outpatients when to return. Teach them about warning

signs and their timing, and the critical period that follows
defervescence.
• DO recognize the critical period. The critical period begins with
defervescence and lasts for 24–48 hours. During this period, some
patients may rapidly deteriorate.
• DO closely monitor fluid intake and output, vital signs, and
hematocrit levels. Intake and output should be measured at least
every shift and vitals at least every 4 hours. Hematocrits should
be measured every 6–12 hours at minimum during the critical
period.
• DO recognize and treat early shock. Early shock (also known as
compensated or normotensive shock) is characterized by
narrowing pulse pressure (systolic minus diastolic BP approaching
20 mmHg), increasing heart rate, and delayed capillary refill or
cool extremities.
• DO administer colloids (such as albumin/10% dextran-40) for
refractory shock. Patients who do not respond to 2–3 boluses of
isotonic saline should be given colloids instead of more saline.
• DO give PRBCs or whole blood for clinically significant bleeding. If
hematocrit is dropping with unstable vital signs or significant
bleeding is apparent, immediately transfuse blood.
• DO check for earlier leak phase by doing ultrasound.
• Do check for COVID-19 as a coinfection will require higher level of
care

52
OUTBREAK PREPAREDNESS PLAN FOR HOSPITALS:

There have been an increasing number of dengue outbreaks in many

parts of the country. Therefore, having a hospital emergency
preparedness plan for dengue outbreaks is vital in early diagnosis and
appropriate clinical management of cases to minimize complications and
deaths.

Such a plan should include the following key elements:

• Outpatient care (with triage and resuscitation areas)

• Assess bed occupancy in each unit (with a view to identifying
additional beds during outbreaks)
• High-dependency care beds
• Staffing and surge capacity needs
• Stock management of essential medicines and supplies
• Laboratory facilities

As the first step, with the available resources, hospitals should develop
and strengthen their capacity to screen and triage suspected dengue
patients at the outpatient departments. Hospital staff including doctors,
nurses and other categories should be trained and assigned appropriate
duties in case of an outbreak. It is essential to conduct regular training for
medical staff based on the current guidelines on clinical management of
dengue fever and dengue haemorrhagic fever. Following essential
medicines, supplies, equipment and services should be available in the
hospitals providing in-ward care for patients with dengue haemorrhagic
fever:

53
MEDICINES:

• Paracetamol tablets
• Oral Rehydration Solution
• I.V. Fluids
o Crystalloids: 0.9% saline
o Colloids: hyper-oncotic (plasma expanders) - 10%
Dextran 40 & 6% starch (Brand: STERIMAIZE)
o 25% or 50% Dextrose
• Parenteral Vitamin K
• IV Calcium Gluconate (10% solution)
• IV KCl (20 mmol concentrated solution)
• IV Sodium bicarbonate (8.4% solution)

SUPPLIES AND EQUIPMENT:

• Thermometers
• Sphygmomanometers with different cuff sizes
• I.V. access sets for Paediatric population and adults
• Oxygen delivery systems
• Micro centrifuge (for bedside haematocrit assessment)
• Microscopes (for platelet count estimation)
• Glucometers (for blood sugar estimation)
• Observation charts
• Weighing scale

LABORATORY SUPPORT:

54
Laboratories should be equipped round the clock for basic tests such as
FBC. More complicated patients will need blood sugar, liver function
tests, renal function tests, serum electrolytes (including serum calcium),
blood gases, coagulation assays, chest x-rays & ultrasonography,
Haematocrit, platelet count, white blood count (WBC) and differential.

BLOOD BANK:

Packed red cells and other blood products should be available on

demand.

55
QUALITY ASSURANCE PARAMETERS FOR MANAGERS
CONCERNED:

56
CLINICAL AND LABORATORY MONITORING CHART FOR ALL
PATIENTS ON OUT PATIENT MANAGEMENT

Name___________________________ Age______

MRNO/OPD NO________ Date___________

57
Instructions:

1. Beside detailed history and evaluation all the patients who are
categorised as Group A patients and are on outpatient plan for
management should have this monitoring form with them and all
the required data should be documented.
2. Every patient should be instructed to bring this form on each
follow up visit.
3. This monitoring is usually required upto 8 days from the beginning
of fever
4. If the first RBS,ALT,AST is normal they should be repeated on need
basis only
5. Dengue NS1,IgG, IgM are not mandatory in endemic situations
(check Dengue laboratory criteria in the booklet for details)

58
 CLINICAL MONITORING CHART

Name__________________MRNO_____________ Date _____________

DOA _____________TDI ______________Weight (IBW) ____________
Sheet #____________

Time Temp HR CRT BP PP RR UOP Bleeding Action

if any

MRNO= Medical record Number, DOA= Day of Admission, TDI= Total Duration of
Illness, HR=Heart Rate per minute, CRT= Capillary Refill Time, BP= Blood Pressure,
PP= Pulse Pressure, RR= Respiratory Rate per minute, UOP= Urine Output/kg/hr

59
Instructions:

• Monitor all the Clinical parameters 03 hourly in Group B

patients and Hourly or more frequently in Group C patients
• Use new/separate sheet if category changes from group B to
group C
• Call for immediate intervention/advice when:
o Pulse rate is more than 100/minute when afebrile OR
more than 120/min when febrile
o Pulse pressure narrowing down to 25mmHg OR less in
supine position
o Capillary Refill time ≥ 2 sec
o Significant Bleeding from any site
o UOP < 0.5 ml/kg/hr
• Don’t miss auscultation of chest, examination of abdomen and
extremities for any fluid accumulation at regular intervals

60
61
 LABORATORY MONITORING CHART

Name____________________MRNO __________ Date ____________

DOA _____________TDI ______________Weight (IBW) ________ Sheet
No ____________Blood Group __________

HCT= Haematocrit, TLC= Total Leucocyte Count, PLT= Platelet Count, ALT=
Alanine Amino transferase, AST (SGOT)=Aspartate Aminotransferase, RBS=
Random Blood Sugar,Cr= Serum creatinine, Ca ++= Serum Calcium, USG= Ultra
Sonography

Instructions:

• Monitor HCT every 6 hourly during the febrile phase of Group B

patients and every 1-3 hourly during the critical phase depending
on the severity, similarly check before and after any Colloid fluid

62
 infusion/ blood transfusion to check the response and not to miss
concealed bleeding.
• Use new/separate sheet if category changes from group B to
group C
• Call for immediate intervention/advice when
o HCT is rising rapidly ≥ 20% of the base line or normal
standard for the age and weight
o PLT ≤ 50000/cumm
o Rising ALT/AST ≥ 1000
o USG showing fluid collections (pericholecyctic fluid
collection and early sign of DHF)
o Rising Creatinine or falling Calcium levels in critical phase
o Hypoglycaemia
• HDU/ ICU patients may need further monitoring like ABGs and
frequent electrolytes etc and that should be done as per
recommended standards.

63
FLUID REPLACEMENT CHART DURING CRITICAL PHASE/SHOCK
PHASE

Instructions:

• The fluid replacement should be adjusted on hourly basis during

the critical phase
• The oral intake should not be missed and should be added to the
total fluid intake to avoid fluid overload

64
TRIAGE PATHWAY

65
66
67
STAFF REQUIREMENT FOR DENGUE GENERAL WARD & HDU/ICU

Reporting form and frequency and what to report should be provided

by the Public Health Department, Director General Health Office.

68
BIBLIOGRAPHY

1. Siripan Kalayanarooj, Clinical Practice Guidelines of Dengue/Dengue

Hemorrhagic Fever management for Asian Economic Community,
Bangkok, 2014
2. WHO TDR, Dengue Guidelines for Diagnosis, Treatment, Prevention
and Control, 3rd Edition, 2009.
3. Comprehensive Guidelines for Prevention and Control of Dengue and
Dengue Haemorrhagic Fever, Revised and Expanded Edition, WHO
SEARO 2011
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