Dengue fever · House

Red Flags

Severe dengue criteria — severe plasma leakage with shock or fluid accumulation/respiratory distress; severe bleeding; severe organ involvement (AST/ALT ≥1000, encephalopathy) — ICU admission, careful crystalloid^[1]
Warning signs (abdominal pain, persistent vomiting, mucosal bleeding, lethargy/restlessness, tender hepatomegaly, rapid Hct rise + falling platelets) — admit and start IV fluids per protocol^[1]
Pregnant women, infants, elderly, comorbidities (DM, CKD, sickle cell) with dengue — lower threshold for admission regardless of warning signs^[1]
Critical phase (typically days 4–6 after fever onset) when platelets fall and Hct rises — most fluid leakage and shock occur here; close monitoring^[1]

First-line treatment

Interventions

Oral rehydration (Group A — uncomplicated)^[1]
Adequate oral fluids (water, ORS, soup, fruit juice) with daily review until 24–48 h after defervescence; outpatient management feasible
IV crystalloid for warning-sign dengue (Group B)^[1]
Isotonic crystalloid (RL or NS) — start 5–7 mL/kg/h × 1–2 h, reduce to 3–5 mL/kg/h × 2–4 h, then 2–3 mL/kg/h. Reassess Hct and clinical signs every hour. Reduce as Hct stabilises
Compensated shock (Group C — severe dengue)^[1]
Crystalloid bolus 5–10 mL/kg over 1 h. If no improvement, repeat. If Hct continues rising despite repeated crystalloid → shift to colloid (gelatin, dextran, albumin). If Hct falls → consider blood transfusion
Hypotensive shock (decompensated) — fluid resuscitation^[1]
Rapid bolus 20 mL/kg over 15 minutes; if not improving, consider colloid or blood. ICU level care
Platelet transfusion ONLY for clinically significant bleeding^[1]
Routine prophylactic platelet transfusion is NOT recommended even with platelet counts <20 ×10⁹/L. Transfuse for active major bleeding or pre-procedural

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Paracetamol^[1]	Analgesic / antipyretic	500–1000 mg PO QDS PRN, max 4 g/day	10–15 mg/kg/dose q4–6h, max 60 mg/kg/day	Avoid NSAIDs, aspirin, steroids — bleeding and Reye's risks

Paracetamol^[1]

Analgesic / antipyretic

Adult: 500–1000 mg PO QDS PRN, max 4 g/day
Paediatric: 10–15 mg/kg/dose q4–6h, max 60 mg/kg/day

Avoid NSAIDs, aspirin, steroids — bleeding and Reye's risks

Safety-net

Take only paracetamol for fever; avoid ibuprofen, diclofenac, mefenamic acid, and aspirin — they raise bleeding risk^[1]
Drink oral fluids regularly even if you don't feel thirsty; weigh yourself daily; pass urine ≥6 times in 24 hours^[1]
Return same-day for severe abdominal pain, persistent vomiting, bleeding from gums or nose, lethargy, restlessness, breathing difficulty, or cold extremities^[1]

Referral criteria

Severe dengue (shock, severe bleeding, severe organ involvement)ICU/HDU; haematology if severe bleeding^[1]
Warning-sign dengue (abdominal pain, vomiting, lethargy, mucosal bleeding, Hct rise)Hospital admission for IV fluids and monitoring^[1]
Pregnancy with dengueJoint obstetric and ID care^[1]
Dengue with comorbidity (DM, CKD, sickle cell, immunosuppression)Hospital admission for monitoring even if no warning signs^[1]

Clinical summary

Risk-stratified management of dengue across uncomplicated, warning-sign, and severe dengue per WHO/NVBDCP classification, with judicious crystalloid resuscitation.

References

1.ICMR / NVBDCP National Guidelines for Clinical Management of Dengue; WHO Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control (2022)