New revised WHO Dengue case classification

by severity
A) Dengue without warning signs: Group A
(Send home).

B) Dengue with warning signs: Group B

(Referred for in-hospital care).

C) Severe dengue: Group C

(Require emergency management).


 Dengue case classification by severity
Dengue ± warning signs Severe dengue

with 1. Severe plasma leakage

Without warning signs 2. Severe haemorrage
3. Severe organ impairment


Criteria for dengue ±warning signs Criteria for severe dengue

Probable Dengue Warning Signs* 1. Severe Plasma Leakage

Live in/travel to dengue Seveere abdominal pain or leading to :
endemic area. Fever and 2 tenderness Shock (DSS)
of the following criteria Persistent vomiting >3 times/ day Fluid accumulation with
Nausea, vomiting Persistent diarrhoea >3 times/ day respiratory distress
Rash Clinical fluid accumulation 2. Severe Bleeding
Aches and pains Mucosal bleed as evaluated by clinician
Tourniquet test positive Lethargy, restlessness
Leucopenia Liver enlargement >2cm 3. Severe Organ Involvement
Laboratory : Increase in Hct. Liver: AST or ALT>=1000
Any Warning singn
concurrent with rapid decrease CNS: Impaired consciousness
Laboratory Confirmed dengue Heart and other organs
in platelet count
(important when no sign of 4. Metabolic & electrolytes
plasma leakage) Requiring strict observation
and medical intervention abnormalities
 Clinical Management
Dengue case classification
Dengue Viral Infection
Symptomatic Asymptomatic

Mild DF : Group -A Moderate DF : Group - B Servere DF: Group -C

DF with high risk / DF with warning signs & symptoms

co-morbid conditions with / without minor bleeding


A. Undifferentiated DF Infants A. DF with warning sign A. DF with significant
B. Fever without complication Old age and symptoms Haemorrhage
like bleeding, hypotension Diabetes Recurrent vomiting B. (i) DHF with significant
and organ involvement Hypertension Abdominal pain/tenderness haemorrhage with or without
C. Without evidence of Pregnancy General weakness/lethargy/ shock
capillary leakage Coronary Artery Disease restless (ii) DHF III & IV (DSS) with
Haemoglobinopathies Minor bleeding shock with or without
Immunocompromized Mild pleural effusion/ascites significant haemorrhage
Home Management patient Hepatomegaly C. Severe organ involvement
Patient on steroids, Increased Hct. (Expanded Dengue Syndroms)
anticoagulants or B. DHF Gr I & II with / without D. Metabolic and electrolyte
immunosuppresants minor bleeds abnormalities

Close Monitoring and Hospitalization Tertiary level care

Clinical Presentation of Dengue
Dengue fever
Dengue haemorrhagic fever
Dengue shock syndrome
Expanded dengue syndrome

Dengue fever

Headache
Myalgia
Arthralgia / bone pain (break-bone fever)
Rash
GIT manifestations: Nausea, vomiting, diarrhea (seen in
recent outbreaks)
Haemorrhagic manifestations (mild, unusual hemorrhage)
Leukopenia (WBC <5,000 cells/mm3)
Platelet count ≤150,000 cells/mm3
Rising Hct. 5-10%

Diagnosis:

Tourniquet test positive + WBC ≤ 5,000 cells/cu.mm

(positive predictive value = 83%)


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 fever from other non Dengue
febrile illness.

How to do a Tourniquet Test

Take the patient's blood pressure and record it, for example, 100/70.

Inflate the cuff to a point midway between SBP and DBP and
maintain for 5 minutes. (100+70)/2= 85 mm Hg

The pressure is released for at least one minute and the skin below
the cuff is examine for petechiae. See image at right

A finding of 10 or more petechiae in one square inch area

considered positive. In DHF, the test usually gives a definite positive
result when there is 20 petechiae per 1 inch with a sensitivity of
more than 90%

Positive tourniquet test with greater

than 10 petechiae per one square inch


Dengue Haemorrhagic Fever

Clinical:
High, continuous fever 2-7 days.
Haemorrhagic manifestations; tourniquet test positive,
petechiae, epistaxis, haematemesis etc.
Liver enlargement ±
Shock ±

Laboratory:
Evidence of plasma leakage; rising Hct. >20%, pleural
effusion, ascites, hypoalbuminemia (serum albumin <3.5
gm% or <4gm% in obese patients)
Platelet count <100,000 cells/mm3.

Evidence of Plasma Leakage (key differentiating point

between Dengue and Dengue Haemorrhagic Fever)

Rise in Hct. : 20% (eg. In children 35 42 and in

adults 40 48)
Circulatory failure: Cold/cold clammy skin, CRFT>2 Sec,
tachycardia, weak pulse, narrow pulse pressure <20,
hypotension.
Fluid accumulation – Ascites/ Pleural effusions
Albumin <3.5 gm/dl


Natural Course of DF Natural Course of DHF

Febrile Phase: Febrile Phase:

High fever for 2-7 days High fever for 2-7 days

Critical phase :
Can start from Day 3
(Leakage Phase)
Lasts only 24-48 hrs
No critical phase in DF
Usually on D5/D6,
but earliest on D3

Convalescent phase : Convalescent phase :

2-5 days longer in adults 2-5 days longer in adults


Dengue Shock Syndrome
Clinical Signs of Dengue Shock Syndrome:

Cool extremities, delayed capillary refill time

Lethargy or restlessness (which may be a sign of reduced
brain perfusion)
Tachypnoea or Kussmaul’s breathing
Tachycardia, weak pulse
Narrow pulse pressure: Pulse pressure ≤20 mmHg with
increased diastolic pressure, e.g. 100/80 mmHg
Hypotension by age, defined as systolic pressure <80
mmHg for those aged <5 years or 80 to 90 mmHg for older
children and adults

Expanded Dengue Syndrome

Unusual manifestations with severe organ involvement
such as liver, kidneys, brain or heart associated with
Dengue infection reported in DHF and also in DF who do
not have evidence of plasma leakage.

These unusual manifestations may be associated with

co-infections, co-morbidities or complications of
prolonged shock.


Investigations
1 to 5 days of fever : CBC, NS1 antigen, SGOT and SGPT
(Not mandatory but helpful)
After day7 : IgM and IgG Antibodies (Day 5-7 window
period)
Follow up testing may be done on 1st afebrile day, but
should be done daily when DHF is suspected
Haematocrit:
-A regular haematocrit is more important for management
than the thrombocytopenia
-In severe dengue especially with shock hourly
haematocrit is crucial for management


Clinical and Laboratory Criteria for Patients
Who Can Be Treated at Home
Able to tolerate orally well, good urine output and no
history of bleeding

Absence of warning signs

Physical examination:
-Haemodynamically stable
-No tachypnoea or acidotic breathing.
-No tender liver or abdominal tenderness
-No bleeding manifestation
-No sign of third space fluid accumulation
-No alterations in mental state

Investigation:
-Stable serial Hct.

No other criteria for admission (i.e- co-morbidities,

pregnancy, social factors)


Management Plan for Group-A Patient

These patients will be advised for

home management

Advised for adequate bed rest

Adequate fluid intake (around 2500 ml or 8-10

glasses for average-sized adults or accordingly in
children, around 50ml/kg)-e.g. milk, fruit juice
(caution with diabetic patients), oral rehydration
solution (ORS) or barley/rice water/coconut water

Take paracetamol (not more than 3 grams per day

for adults; 10-15 mg/kg/dose, not more than 3 to
4 times in 24 hours in children) .

Tepid sponging

These patients will be advised to avoid

Acetylsalicylic acid (aspirin), Mefenamic acid,
Ibuprofen or other NSAIDs, Steroids, Antibiotics

These patients should be immediately taken to

the nearest hospital in 1st afebrile day with
worsening of the situation or if any warning sign
is observed

Observe urine output. If no urine output for 4–6

hours go immediately to nearby hospital


 Fluid Management Plan for Group-B Patients
Guide to rate of fluid intake in Critical
Phase-without shock
10
9
Amount of fluids (ml / kg/ h)

8
7 ml/ kg/ h (200ml/h)
7
6
5 ml/ kg/ h (120ml/h) 5 ml/ kg/ h
5
3 ml/ kg/ h (80ml/h) 3 ml/ kg/ h
4
3
1.5 ml/ kg/ h (40ml/h) 1.5 ml/kg/h
2
1
0
6 12 18 24 30 36 42 48
Time (Hours)
Rate of IV fluid for children
(Fluids for adults are mentioned within brackets)

Starting fluid on the basis of Hct. :

Hct. <20: 1.5 mL/kg/hour for children and 40 mL/hour for adults
Hct. 20-25: 3 mL/kg/hour for children and 80 mL/hour for adults
Hct. >25: 7 to 10 mL/kg/hour (for children) and 100 to 500 mL/hour
for adults

Drop Calculation : (ml/h÷4 = drops/min)

40ml/hour = 10 drops/min
80ml/hour = 20 drops/min
100ml/hour = 25 drops/min
200ml /hr = 50 drops/min


Figure 1 : IV Fluid Therapy for Compensated Shock

Pulse Pressure≤20 mm of Hg/Hypotension (<90/60 mm of Hg)/Fainting

Do immediately: Hct., Blood sugar + give oxygen

IV(5% DNS/NS 10ml/kg/hr (in child) x 1-2 hrs (500ml/hr in adults)

Check Vital signs:

Improved Not Improved
(BP, Pulse, U/O, Skin temperature)

Reduce the rate of IVF CHECK ABCS

To 7->5->3->1.5ml/kg/hr (in child)

(in adults 250->150->100->80->40-
Hct. / vital signs Hct./ vital signs deteriorated
>Keep vein open) and then deteriorated / sign of obvious blood loss
stop at 24+hr / concealed haemorrhage
suspected
Colloid/Dextran-40 in NS
/Plasmasol-10ml/kg/h Packed cell volume/Fresh whole blood
(500ml/hr in adults as bolus) =5/ 10ml/kg (OR 1 unit in adults)
in 1-2 hrs
Improved
Hct. / vital signs Hct.<10
deteriorated points Reduce the rate of IVF
Hct. >10 points or below baseline
To 7->5->3->1.5ml/kg/hr (in child)
(in adults 250->150->100->80->40-
Packed cell volume/Fresh whole blood Improved >Keep vein open) and then
=5/ 10ml/kg (or 1 unit in adults)
in 1-2 hrs stop at 24+hr

Not Improved
Improved

Check ABCS again and plan for Dialysis

(Peritoneal/Haemodialysis) organ
support


Figure 2 : Flow Diagram for Profound Shock (Decompensated Shock)

Profound Shock (No B.P, No Palpable Pulse)

Profound Shock
Do immediately: Hct., Blood sugar (DTX) and NS 10-20ml/kg IV overload states
bolus ( in adults 500ml) in 15-30 min, free flow +oxygen
Start Colloid-10ml/kg IV
(IVF: NS, DAR, DLR) followed by IV frusemide
Check ABCS and correct
Repeat 2nd Bolus of IVF
Not Improved Give NHCO3 1-2mEq/kg
(OR 50-100ml in adults)
Change IVF to
5% DNS/NS: 10ml/kg/hr for 1-2 hr (in Child)
Hct. / vital signs Hct. / vital signs deteriorated
(in adults 500 ml/hr)(125 drop/min) deteriorated / sign of obvious blood loss
/ concealed haemorrhage
suspected
Improved Not Improved Colloid: Dextran-40 in NS
/Plasmasol/ Voluven- 10ml/kg/h Packed Cell Volume : 5ml/kg/ hr
Or
(500ml/hr in adults as bolus) Fresh Whole Blood : 10 ml/kg/hr
( or 1 unit in adults)
Reduce the rate of IVF

Improved
To 7->5->3->1.5ml/kg/hr (in child)
(in adults 250->150->100->80->40- Hct. >10 points Hct. >10 points
or below
>Keep vein open) and then baseline Reduce the rate of IVF
stop at 24+hr
To 7->5->3->1.5ml/kg/hr (in child)
Packed Cell Volume : 5ml/kg/ hr (in adults 250->150->100->80->40-
Or >Keep vein open) and then
Fresh Whole Blood : 10 ml/kg/hr
( or 1 unit in adults) stop at 24+hr

Not Improved

Check ABCS again and plan for Dialysis

(Peritoneal/ Haemodialysis) organ
support


Figure 3 : Flow Diagram for the Management of Fluid Overload
Signs of Fluid Overload:
Puffy eyelids, Distended abdomen
Dyspnea / Tachypnea
Positive Lung Signs : Crepitation, Wheezing, Rhonchi

Give Oxygen
Insert urinary catheter
Check ABCS and corret (Table 2)
Check Hct
NCPAP

Reabsorption Phase
(High + wide pulse pressure) Critical / early convalescence phase
>36hrs after shock/ >60hrs after Shock or signs of fluid overload
onset of leakage

Dextran 40 rate 10ml/kg/hr (in child)

Discontinue IV fluid / KVO (in adults 500ml/hr)
Frusemide 1mg/kg/dose IV (in child) Frusemide 1mg/kg/dose IV (in child)
(40gm in adults) (in Adults 40mg) given midway to Dextran

Hct. <10 points Hct. >10 points

Improved or below baseline /vital signs
With good urine output >1 /vital signs improved deteriorated
ml/kg/hr (>50ml/hr in adults)
Fresh Whole Blood: 10 ml/kg/hr
(or 1 unit in adults)

Not Improved
Stop iv fluid and follow up vital With no urine output, still
signs +amount of urine output dyspnea/tachypnea
Repeat Frusemide if signs/
symptoms of fluid overload
persist
Check ABCS again, consider
mechanical ventilation
Pleural and/ or Peritoneal tapping
Plan for dialysis
(Peritoneal/ Haemodialysis)


 IV Fluid in Dengue
Two types of iv fluids are used in Dengue
1. Crystalloid (first choice)
2. Colloid

Indications of iv fluid in Dengue

When the patient cannot have adequate oral fluid intake
or vomiting
When Hct continues to rise 10-20% despite oral rehydration
Impending shock/Shock

Types of Crystalloid uses in Dengue:

1) 0.9% NaCl (isotonic normal saline solution) (0.9% NS)

(Preferable)

2) 0.45% half strength normal saline solution (0.45% NS)

(For children <6 months)

3) 5% dextrose in Ringer's lactate solution (5% DRL)

4) 5% dextrose in acetated Ringer's solution (5% DRA)

5) Hartman solution (Preferable)


Types of Colloid uses in Dengue:
1) Dextran-based: Dextran 40, Dextran 70
2) Starch based (6% HES):
Voluven, Plasmasol (6% hydroxyl ethyl ester with normal
saline)
Volulyte (6% hydroxyl ethyl ester with balanced electrolyte)
3) Gelatin
4) Human Albumin
5) Plasma
6) Haemaccel
7) Blood and blood components

Indications of Colloid in Dengue

Patients with massive plasma leakage
Patients with shock with rising Hct.
Those not responding to the minimum volume of crystalloid
Those with pulse pressure < 10 mm Hg, who need urgent
restore BP


Indications for Platelet Concentrate
It has been observed that there is very limited role of platelet transfusion. In
most of the situation fresh whole blood transfusion is suffice. However it may
be required in some special situation. The indication of which may be as
follows:

1. Very Severe Thrombocytopania who need urgent surgery

2. Clinical judgement of the treating physician

Indications for blood transfusion

Overt bleeding (more than 10% or 6-8ml/kg)
Significant drop of Hct. < 40 (<45 for males) after fluid
resuscitation
Hypotensive shock + low/normal Hct.
Persistent or worsening metabolic acidosis
Refractory shock after fluid 40-60 ml/kg


Dengue with Organopathy (Expanded Dengue Syndrome):
Management Issue
Severe Dengue can be complicated with Myocarditis, Encephalopathy/
Encephalitis/Acute liver failure, AKI, ARDS and sometimes with multiorgan
failure (MOF)
These complicated patient should be managed by Medicine
Specialist/Pediatricians for comprehensive care

In myocarditis with raised Troponin I and ECG changes

(Bradycardia, Tachycardia, ST-T changes) injudicious use of
antiplatelet, anticoagulant or intervention (e.g. pacemaker and
others) should be avoided (20% fluid is to be reduced)

In encephalitis, judicious use of steroids can be given.

(Dexamethasone: 0.15 mg / kg 6-8 hourly for 3-5 days)

In hepatic encephalopathy in dengue, the management should

be done as per protocol of Hepatic Encephalopathy

For AKI, ARDS or multiorgan failure, appropriate supportive

care should be provided

Hepatic Encephalopathy:
- O2 Therapy Monitoring:
- Fluid: 20% fluid reduction (Hepatic Encephalopathy)
- Colloid - Blood suger
- Frusemide in fluid overload - Correction of electrolytes
- Lactulose - Bleeding episodes
- H2 receptor blocker - I/O chart
- Rifaximin - Any convulsion
- FFP

Note : Expanded Dengue Syndrome cases should be managed

- In tertiary care setting.
- Here management of EDS is highlighted above.
- For detailed management further reading is recommended


 Pregnancy and Dengue Management:
- Medical termination is to be avoided
- MR should not allow
- Hospital delivery advised
- Blood should be available
- Multi-disciplinary approach
- Avoid elective C/S & induction of labour
- No episiotomy
- No instrumental delivery
- In Preterm labour advice delay in delivery
- Injection steroid I/V to be given for Premature delivery
- Active management in third stage of labour
- Misoprostol / Tranexamic acid can be (1 gm in 10 ml solution
administered slowly over 10 minutes)
- All Dengue patients or suspected Dengue patients with pregnancy must
get admitted to hospital for close monitoring

In case of child:
- Shock is to be managed by Normal Saline
- After shock managed, 5% DNS is to used for maintenance
- Below 1 year age: Baby saline ( 0.45% NaCl) is to be used


 PEARLS
No Do’s Do Not
1 Administration of Paracetamol for Send patients with non-severe
high fever and myalgia. dengue at home without follow-up and
inadequate instructions

2 Clinical assessment of the Administer of NSAIDs

haemodynamic status before and (eg. Aspirin or Ibuprofen)
after each fluid bolus

3 Give intravenous fluids for repeated Miss clinical assessment of patient

vomiting or rapidly rising with respect to fluid therapy
haematocrit

4 Use the appropriate isotonic Use intravenous fluids to

intravenous fluids for severe dengue any patient with mild dengue (those
in appropriate time and dose who can take orally)

5 Avoid intramuscular injections Give intramuscular injections to

dengue patients

6 Tight glycaemic control Avoid monitoring blood glucose

7 Give appropriate Colloid, Packed Red Give excessive fluid, blood and
Cell or Fresh Whole Blood if indicated blood products

Overall Preparation of this Pocket Guideline by:

Bangladesh Society of Medicine (BSM)

National Guideline link:

https://dghs.gov.bd/images/docs/Guideline/NationalGuidelineforDengue2018.pdf