An approach to inpatient management of dengue infection with plasma leakage in the absence of shock (WHO DHF Grades I and II)*^¶

WHO: World Health Organization; DHF: dengue hemorrhagic fever; DSS: dengue shock syndrome.
* Inpatient management is warranted for patients high-risk patients (infants, pregnant women, elderly, obese, diabetes, renal failure, neurologic signs), patients with significant bleeding, patients with leukopenia (white blood cell count ≤5,000 cells/mcL), patients with thrombocytopenia (platelet count ≤100,00 cells/mcL), and patients with warning signs of severe dengue (as defined in Box B above).
¶ The WHO has established a grading for severity of DHF. DHF Grade I refers to fever and hemorrhagic manifestation (positive tourniquet test) and evidence of plasma leakage. DHF Grade II refers to Grade I plus spontaneous bleeding. DHF Grade III refers to Grade I or Grade II plus circulatory failure, and DHF Grade IV refers to Grade III plus profound shock with undetectable blood pressure and pulse. DSS consists of DHF Grade III and DHF Grade IV. Shock refers to normal systolic pressure but rising diastolic pressure with narrowing pulse pressure.
Δ The baseline hematocrit may be the patient’s hematocrit obtained prior to acute illness, the initial hematocrit obtained in the absence of evidence of plasma leakage, shock, severe dehydration, or hemorrhage, or age and sex matched normal values. In the absence of shock, the rate of fluid repletion depends on the degree of hemoconcentration, adjusted to the body weight. If the hematocrit increases by less than 20% and the patient can drink, no intravenous fluid is needed; in case of poor oral intake, we administer half-maintenance intravenous fluid (1.5 mL/kg/hour for children and 40 mL/hour for adults). If the hematocrit increases by 20 to 25%, we administer maintenance intravenous fluids (3 mL/kg/hour for children and 80 mL/hour for adults). If the hematocrit rises by more than 25%, we administer intravenous fluids at 7 to 10 mL/kg/hour (for children) and 100 to 500 mL/hour (for adults).
◊ Criteria for clinical stability include: blood pressure rising or normalized, heart rate decreasing, pulse pressure widening, respiratory rate decreasing, skin warm with turgor intact.
§ Criteria for clinical instability include: blood pressure decreasing, heart rate increasing, pulse pressure narrowing, respiratory rate increasing, skin cool and clammy with diminshed turgor.
¥ No other colloid formulations (such as albumin) should be used for management of dengue. If 10% dextran-40 in normal saline is not available, crystalloid should be used.
‡ The patient's clinical status (including vital signs, urine output, and hematocrit) should be evaluated prior to each infusion rate adjustment.