1.

CASE DEFINITION FOR DENGUE FEVER PROBABLE: An acute febrile illness with 2 or more of the following: Headache Retro-orbital pain Arthralgia Rash Hemorrhagic manifestations Leucopenia Supportive serology

CONFIRMED: A case confirmed by laboratory data 2. CASE DEFINITION FOR DENGUE HEMORRHAGIC FEVER The following must be present: Fever, or history of acute fever, lasting 2-7 days, occasionally biphasic Hemorrhagic tendencies, evidenced by at least one of the following: o (+) tourniquet test o Petechiae, ecchymosis, purpura o Bleeding from the mucosa, GIT injection sites or other locations o Hematemesis or melena Thrombocytopenia (100,000 cells/mm3 or less) Evidence of plasma leakage due to increased vascular permeability, manifested by at least one of the following: o A rise in the hematocrit equal to or greater than 20 above average for age, sex and population o A drop in hematocrit following volume-replacement equal to or greater than 20% of baseline o Signs of plasma leakage such as pleural effusion, ascites and hypoproteinemia

3. CASE DEFINITION FOR DENGUE SHOCK SYNDROME All of the four criteria for DHF must be present, plus evidence of circulatory failure manifested by: o Rapid and weak pulse

o Narrow pulse pressure [<20 mmHg (2.7kPa) o Hypotension for age o Cold, clammy skin and restlessness

GRADING OF SEVERITY OF DHF/DSS o Grade 1: Fever accompanied by nonspecific constitutional symptoms such as anorexia, vomiting, abdominal pain; the only hemorrhagic manifestations is a (+) tourniquet test and/or easy bruising o Grade 2: Spontaneous bleeding in addition to manifestations of grade 1 patients, usually in the form of skin or other hemorrhages (mucocutaneous, GIT) o Grade 3: Circulatory failure manifested by a rapid, weak pulse and narrowing of pulse pressure or hypotension, with the presence of cold, clammy skin and restlessness o Grade 4: Profound shock with undetectable blood pressure or pulse o Grades 3 and 4 DHF constitute DSS.

DIAGNOSIS
WHEN SHOULD DF/DHF BE CONSIDERED IN A PATIENT? RECOMMENDATION: o DF/DHF should be considered in any individual with fever of 2-7 days duration together with any 2 of the following findings: Positive tourniquet test Restlessness Spontaneous petechiae Flushing Hemoconcentration Thrombocytopenia Abdominal pain Headache Retro-orbital pain Myalgia Anorexia Epistaxis

Congested oropharynx Injected conjunctivae

WHAT IS THE VALUE OF THE CBC AND ACTUAL PLATELET COUNT IN THE DIAGNOSIS OF DF/DHF? RECOMMENDATION: o When DF/DHF is suspected, a CBC and actual platelet count should be done. o Due to low sensitivity, CBC and actual platelet count should be done at least on a daily basis to determine hemoconcentration and thrombocytopenia.

WHAT IS THE VALUE OF PROTHROMBIN TIME (PT) AND PARTIAL THROMBOPLASTIN TIME (PTT) AS PREDICTORS OF BLEEDING? RECOMMENDATION: o PTT is a better predictor of bleeding than PT, They should not be routinely done.

WHAT SEROLOGICAL TESTS OTHER THAN HEMAGGLUTINATION INHIBITION TEST (HAI) CAN BE REQUESTED IN PATIENTS SUSPECTED OF DF/DHF? RECOMMENDATIONS: o Commercially available rapid diagnostic tests for patients suspected of dengue may be requested but should not be routinely done. Dengue IgM and IgG ELISA Dengue Dot Blot ELISA Dengue Immunochromatography test (ICT) Dengue Dipstick ELISA o These tests give the best results when done starting on Day 5 of illness but do not distinguish DF from DHF.

WHAT IS THE VALUE OF NONSTRUCTURAL 1 (NS 1) ANTIGEN TEST IN THE DIAGNOSIS OF DF/DHF? RECOMMENDATION: o NS 1 antigen test is useful for the rapid, early diagnosis of dengue infection using acute phase samples collected between day 1 to day 4 from onset of illness but does not distinguish DF from DHF.

MANAGEMENT
WHAT ARE THE CRITERIA FOR ADMISSION FOR SUSPECTED OR CONFIRMED DENGUE PATIENTS? RECOMMENDATION: o The presence of any of the following is an indication for admission for suspected or confirmed dengue patients: Shock: narrowing of the pulse pressure 20mmHg, rapid weak pulse, cold clammy skin, restlessness or irritability Spontaneous bleeding: mucosal bleeding (gum or nose bleeding), hematemesis, coffee-ground vomitus, melena, menometrorrhagia Any of the following danger signs: inability to drink or feed, vomits everything, convulsions, lethargy or unconsciousness, no urine output for 6-8 hours Signs of increased vascular permeability as manifested by increasing hematocrit, serous effusion or hypoproteinemia Abdominal pain

RECOMMENDATION OF OTHERS: The WHO Guidelines on DHF diagnosis, treatment, prevention and control (1997) recommends the following indications for hospitalization for bolus IVF therapy for significant dehydration (>10% of normal body weight) has occurred and rapid volume expansion is needed. Signs of significant dehydration include: Tachycardia Increased capillary refill time (>2 s) Cool, mottled or pale skin

Diminished peripheral pulses Changes in mental status Oliguria Sudden rise in hematocrit or continuously elevated hematocrit despite administration of fluids Narrowing of pulse pressure [<20mmHg (2.7kPa)] Hypotension

A local guideline by the Philippine Pediatric Society on the Diagnosis and Treatment of DHF/DSS (1998) give the following as their criteria for admission: When diagnostic criteria or DHF/DSS have been met Dengue suspects: fever > 2 days with any of the following: Increasing hematocrit Decreasing platelet count and/or prolonged bleeding time Altered sensorium Marked anorexia and persistent vomiting resulting in dehydration A more recent local guideline by Department of Health Revised National Consensus on the Case Management of Dengue Fever and Dengue Hemorrhagic Fever (2001) states the following criteria for hospitalization: Continuous bleeding Persistent abdominal pain Persistent vomiting Listlessness Changes in mental status Restlessness Weak, rapid pulse; cold clammy skin Circum-oral cyanosis Difficulty of breathing Seizures Hypotension or narrowing of pulse pressure <20mmHg HOW CAN THE PRESENCE OF PLEURAL EFFUSION BE ESTABLISHED IN DHF AND HOW IS IT MANAGED? RECOMMENDATION: o The presence of pleural effusion can be established with physical examination. Chest X-ray should not be done routinely. o Chest drainage should be avoided.

IN PATIENTS WITH DF/DHF WHO ARE NOT ADMITTED, WHAT ORAL FLUIDS ARE TO BE GIVEN? HOW MUCH AND HOW SHOULD IT BE GIVEN? RECOMMENDATION: o Oral rehydration solution should be given as follows based on weight, using the currently recommended ORS >3-10kg 100ml/kg/day >10-20kg 75ml/kg/day >20-30kg 50-60ml/kg/day >30-60kg 40-50ml/kg/day o Sports drinks should not be used in children.

AMONG PATIENTS WITHOUT SHOCK, AND ARE ADMITTED, WHAT IVF IS APPROPRIATE? RECOMMENDATIONS: o Isotonic solutions [D5LRS, D5NSS, D5 0.9% NaCl] are appropriate for patients without shock. o Maintenance IVF should be given using the Holiday-Segar Method and fluid rate may be increased to cover for mild dehydration as needed. 0-10kg 100ml/kg 11-20kg 1000+5ml/kg for each kg >10kg >20kg 1500+20ml/kg for each kg >20kg o Clinical parameters should be monitored closely and correlated with the hematocrit.

AMONG PATIENTS ADMITTED TO THE HOSPITAL WITH SHOCK, WHAT WILL BE THE APPROPRIATE IV FLUID? RECOMMENDATIONS: o An isotonic crystalloid [LRS, 0.9% NaCl] is the IVF of choice in the initial fluid resuscitation in patients in shock. Avoid glucose containing solutions to prevent osmotic dieresis. o IVF fluid volume to be infused 20ml/kg bolus. If there is no noted improvement, this may be repeated 2-3 times. And an inotropic agent should be considered.

o If the patient is consistently stable, with normal BP, good pulses, increased urine output >2ml/kg/hr; or with stable vital signs with decreased breath sounds, gradually decrease IVF rate. Avoid fluid overload. o Constantly monitor the following parameters: level of consciousness, work of breathing, respiratory rate, capillary refill time, temperature of extremities, pulse rate, quality of pulse, urine output and blood pressure. If improvement is not satisfactory, refer to a specialist. o Other aspects of management should be instituted. Oxygen should be started at 2-3L/min. ALGORITHM (see table) WHAT ARE THE INDICATIONS FOR BLOOD TRANSFUSION IN DHF? RECOMMENDATION: o In DHF/DSS patients with significant bleeding, which includes hematemesis and hematochezia, fresh whole blood/whole blood is preferred but packed red blood cells and plasma may be used as alternative. o Once Disseminated Intravascular Coagulopathy (DIC) sets in, blood component therapy with cryoprecipitate, fresh frozen plasma (FFP), and platelet concentrates is recommended.

WHAT IS THE ROLE OF PREVENTIVE TRANSFUSION IN DHF? RECOMMENDATION: o Preventive transfusion has no role in the treatment of DHF.

IS IT BENEFICIAL TO USE STEROIDS IN THE MANAGEMENT OF DENGUE SHOCK SYNDROME? RECOMMENDATION: o Steroids are not recommended because their use has not been shown to have any benefit in DSS.

IS VITAMIN C OF ANY BENEFIT IN THE MANAGEMENT OF DENGUE INFECTION? RECOMMENDATION: o Vitamin C is not recommended.

IS THERE A ROLE OF ANTIHISTAMINES IN THE MANAGEMENT OF PATIENTS WITH DENGUE HEMORRHAGIC FEVER? RECOMMENDATION: o Antihistamines have no documented role in the management of DF/DHF.

WHAT IS THE ROLE OF CARBAZACHROME SODIUM SULFONATE (AC-17)IN CHILDREN WITH DHF/DSS? RECOMMENDATION: o Carbazachrome sodium sulfonate has no role in the treatment of children with DF/DHF.

WHAT IS THE ROLE OF VITAMIN K IN DHF/DSS? RECOMMENDATION: o Vitamin K has no role in the treatment of DHF/DSS.

WHAT IS THE ROLE OF ALBUMIN IN THE TREATMENT OF DHF/DSS? RECOMMENDATION: o We found no systemic review or published RCTs on the effects of albumin in the treatment of DHF/DSS.

WHEN IS IT SAFE TO DISCHARGE PATIENTS WITH DHF/DSS? RECOMMENDATION: o Patients may be discharged 72 hours after defervescence in those diagnosed with DHF or 72 hours after termination of shock for DSS patients.

PREVENTION
o Insect repellents with N, N-diethyl-1-3-methylbenzamide (DEET) as active ingredient in 10%-30% concentration is effective and safe in preventing mosquito bites in children >2 months old. There are limited data on efficacy and safety of non-DEET-containing repellents. o The use of household insecticides containing propoxur, organophosphates, and pyrethrium are most effective only indoors for a short period of time in preventing mosquito bites in children. However, caution should be practiced because of many side effects on the CNS, liver, kidneys and lungs. o Screening of windows and doors decreases the risk of being bitten by mosquitoes reducing the risk of DF/DHF. o The use of mosquito nets reduces the risk of dengue infections. Impregnated mosquito nets are effective but safety in children has not been established. o Defogging/space spraying when done properly and larviciding, decrease the adult mosquito population. Defogging is recommended only during a dengue epidemic. Larviciding is effective under certain conditions. o The practices of covering and regular emptying and cleaning of water storage once or twice a week reduce the risk of acquiring Dengue Fever/Dengue Hemorrhagic Fever and must therefore be done.

Western Visayas Medical Center Department of Pediatrics

Evidence-Based Guidelines

On Dengue Fever / Dengue Hemorrhagic Fever

Reference:
Evidence-Based Guidelines On Dengue Fever / Dengue Hemorrhagic Fever Philippine Pediatric Society, Inc.