# Presentation: 102543

## VII.  Treatment

## Outpatient Triage

- No hemorrhagic manifestations and patient is well-hydrated: home treatment
- Hemorrhagic manifestations or hydration borderline: outpatient observation center or hospitalization
- Warning signs (even without profound shock) or DSS: hospitalize

## Patient Follow-Up

- Patients treated at home
- Instruction regarding danger signs
- Consider repeat clinical evaluation
- Patients with bleeding manifestations
- Serial hematocrits and platelets at least daily until temperature normal for 1 to 2 days
- All patients
- If blood sample taken in first 5 days after onset, need convalescent sample between days 6 - 30
- All hospitalized patients need samples on admission and at discharge or death

## Treatment of Dengue Fever(Part 1)

- Fluids
- Rest
- Antipyretics (avoid aspirin and non-steroidal anti-inflammatory drugs)
- Monitor blood pressure, hematocrit, platelet count, level of consciousness

## Mosquito Barriers

- Only needed until fever subsides, to prevent *Aedes aegypti* mosquitoes from biting patients and acquiring virus
- Keep patient in screened sickroom or under a mosquito net

## Treatment of Dengue Fever(Part 2)

- Continue monitoring after defervescence
- If any doubt, provide intravenous fluids, guided by serial hematocrits, blood pressure, and urine output
- The volume of fluid needed is similar to the treatment of diarrhea with mild to moderate isotonic dehydration (5%-8% deficit)

## Fluid for Moderate Dehydration(Intravenous)

**weight in lbs****	****     ml/lb/day****	****         weight in kgs****	****  ml/kg/day**

**  ****< 15****	****	****      100****	****	**** < 7****	****	****     220**
**16 - 25****	****        75****	****	****7 - 11****	****	****     165**
**26 - 40****	****        60****	****         12 - 18****	****	****     132**
**41 - 88****	****        40****	****         19 - 40****	****	****       88**

- Adapted from _Guidelines for Treatment of Dengue Fever/_
- _Dengue Haemorrhagic Fever in Small Hospitals_, WHO, 1999.

## Rehydrating Patients Over 40 kg

- Volume required for rehydration is twice the recommended maintenance requirement
- Formula for calculating maintenance volume:   1500 + 20 x (weight in kg - 20)
- For example, maintenance volume for 55 kg patient is:   1500 + 20 x (55-20) = 2200 ml
- For this patient, the rehydration volume would be 2 x 2200, or 4400 ml

- Pan American Health Organization: _Dengue and Dengue_
- _Hemorrhagic Fever: Guidelines for Prevention and Control_.
- PAHO: Washington, D.C., 1994: 67.

## Treatment of Dengue Fever(Part 3)

- Avoid invasive procedures when possible
- Unknown if the use of steroids, intravenous immune globulin, or platelet transfusions to shorten the duration or decrease the severity of thrombocytopenia is effective
- Patients in shock may require treatment in an intensive care unit

## Indications for Hospital Discharge

- Absence of fever for 24 hours (without    anti-fever therapy) and return of appetite
- Visible improvement in clinical picture
- Stable hematocrit
- 3 days after recovery from shock
- Platelets  50,000/mm3
- No respiratory distress from pleural effusions/ascites

- Pan American Health Organization: _Dengue and Dengue_
- _Hemorrhagic Fever: Guidelines for Prevention and Control_.
- PAHO: Washington, D.C., 1994: 69.

## Common Misconceptions aboutDengue Hemorrhagic Fever

- Dengue + bleeding = DHF
- Need 4 WHO criteria, capillary permeability
- DHF kills only by hemorrhage
- Patient dies as a result of shock
- Poor management turns dengue into DHF
- Poorly managed dengue can be more severe, _but_ DHF is a  distinct condition, which even well-treated patients may develop
- Positive tourniquet test = DHF
- Tourniquet test is a nonspecific indicator of capillary         fragility

## More Common Misconceptions about Dengue Hemorrhagic Fever

- DHF is a pediatric disease
- All age groups are involved in the Americas
- DHF is a problem of low income families
- All socioeconomic groups are affected
- Tourists will certainly get DHF with a second infection
- Tourists are at low risk to acquire DHF

## Dengue Vaccine?

- No licensed vaccine at present
- Effective vaccine must be tetravalent
- Field testing of an attenuated tetravalent vaccine currently underway
- Effective, safe and affordable vaccine will not be available in the immediate future