Ministry of Health of Vietnam: What are the warning signs of Dengue fever? What is the treatment for dengue fever with warning signs?
Ministry of Health of Vietnam: What is Dengue fever?
Pursuant to the Guidelines for the Diagnosis and Treatment of Dengue Fever issued with Decision 2760/QD-BYT in 2023, the concept of Dengue fever is described as follows:
Dengue Fever is an infectious disease caused by the Dengue virus. The Dengue virus has four serotypes: DEN-1, DEN-2, DEN-3, and DEN-4. The virus is transmitted from infected individuals to healthy individuals through mosquito bites. The Aedes aegypti mosquito is the main vector for disease transmission.
The disease can occur throughout the year, with an increase in cases during the rainy season. It affects both children and adults. The characteristic symptoms of Dengue fever include fever, hemorrhage, and plasma leakage, which can lead to hypovolemic shock, coagulation disorders, organ failure, and if not diagnosed and treated early, can result in death.
Ministry of Health of Vietnam: What are the warning signs of Dengue fever? What is the treatment for dengue fever with warning signs? (Image from the Internet)
Ministry of Health of Vietnam: What are the warning signs of Dengue fever? What is the progression of Dengue fever?
Pursuant to the Guidelines for the Diagnosis and Treatment of Dengue Fever issued with Decision 2760/QD-BYT in 2023, there are instructions on the signs and progression of Dengue fever as follows:
(1) Febrile phase:
Clinical signs:
- Sudden and continuous high fever.
- Headache, loss of appetite, nausea.
- Flushed skin.
- Muscle pain, joint pain, pain behind the eyes.
- Positive tourniquet test.
- Often accompanied by under-the-skin hemorrhage, bleeding gums, or nosebleeds.
(2) Critical phase: usually occurs on days 3-7 of the illness.
Clinical signs:
- The patient may still have fever or a decreased fever.
- Possible manifestations include:
+ Severe abdominal pain: severe and continuous abdominal pain, especially in the liver area.
+ Restlessness, irritability, lethargy.
+ Enlarged liver > 2cm below the rib margin, may be painful.
+ Nausea and vomiting.
+ Signs of plasma leakage due to increased vascular permeability (usually lasting for 24-48 hours).
++ Pleural effusion, interstitial edema (can cause respiratory distress), ascites, periorbital edema.
++ Excessive plasma leakage can lead to shock with manifestations of restlessness, agitation, cold extremities, rapid weak pulse, low blood pressure (maximum systolic and diastolic blood pressure difference ≤ 20mmHg or hypotension, unmeasurable blood pressure, weak pulse, cold skin, cyanosis (severe shock), decreased urine output.
+ Hemorrhage.
++ Subcutaneous hemorrhage: scattered petechiae or hemorrhagic spots usually on the front of the lower legs and inner arms, abdomen, thighs, flanks, or purplish patches.
++ Mucosal hemorrhage such as bleeding gums, nosebleeds, vomiting blood, black or bloody stools, vaginal bleeding, or blood in urine.
++ Severe hemorrhage: severe nosebleeds (requiring packing or applying pressure), severe vaginal bleeding, bleeding in muscles and soft tissues, gastrointestinal and internal organ bleeding (lungs, brain, liver, spleen, kidneys), often accompanied by shock, decreased platelet count, tissue hypoxia, and metabolic acidosis, which can lead to multiple organ failure and severe disseminated intravascular coagulation. Severe hemorrhage can also occur in patients taking anti-inflammatory drugs such as acetylsalicylic acid (aspirin), ibuprofen, or corticosteroids, or in patients with a history of peptic ulcer disease, liver inflammation.
+ Some severe cases may have manifestations of organ failure such as severe liver injury/liver failure, kidney, heart, lung, brain. These severe manifestations can occur in patients with or without shock due to plasma leakage.
++ Severe liver injury/liver failure, liver enzymes AST, ALT ≥ 1000U/L.
++ Acute kidney injury/renal failure.
++ Neurological impairment (Dengue hemorrhagic fever with encephalopathy).
++ Myocarditis, heart failure, or other organ dysfunction.
(3) Recovery phase: usually occurs on days 7-10 of the illness.
Clinical signs:
- The patient is fever-free, overall condition improves, has an increased appetite, stable blood pressure, and increased urine output.
- There may be a rash or itching on the skin during recovery.
- The patient may have a slow or irregular heartbeat, and respiratory distress due to fluid overload may occur.
Ministry of Health of Vietnam: What is the treatment for dengue fever with warning signs?
Pursuant to the Diagnosis and Treatment Guidelines for Dengue Fever, issued with Decision 2760/QD-BYT in 2023, the treatment for dengue fever is as follows:
For pediatric patients (<16 years old):
Treatment for dengue fever with warning signs: The patient should be admitted to the hospital for treatment.
- Symptomatic treatment: Fever reduction.
- Early fluid replacement via oral route if the patient is able to tolerate it.
- Monitoring of pulse, blood pressure, warning signs, fluid intake, urine output, and hematocrit (Hct) every 4-6 hours.
- Intravenous fluid administration is indicated when at least one of the following signs is present:
+ Lethargy.
+ Inability to drink.
+ Frequent vomiting.
+ Severe abdominal pain.
+ Signs of dehydration.
+ Elevated Hct.
- The fluids used for intravenous administration include Ringer lactate, Ringer acetate, and 0.9% NaCl.
- Intravenous fluid administration protocol:
+ Administer Ringer lactate, Ringer acetate, or 0.9% NaCl at a rate of 6-7ml/kg/hour for 1-3 hours, then reduce the rate to 5ml/kg/hour for 2-4 hours. Monitor clinical signs and Hct every 2-4 hours.
+ If the pulse and blood pressure are stable, Hct decreases, and urine output is ≥ 0.5-1ml/kg/hour, reduce the rate of Ringer lactate, Ringer acetate, or 0.9% NaCl to 3ml/kg/hour for 2-4 hours. If the clinical condition continues to improve, fluid administration may be stopped after 24-48 hours.
+ If the pulse is fast, blood pressure drops or remains low, and Hct increases: treat shock, hemorrhage, hypoglycemia, and hypocalcemia if present, and continue fluid administration as follows:
++ If the total fluid administered is > 60ml/kg, switch to high molecular weight intravenous colloid at a rate of 10-20ml/kg/hour for 1 hour. Then continue fluid administration according to the shock treatment protocol for dengue fever.
++ If the total fluid administered is ≤ 60ml/kg, increase the rate of Ringer lactate, Ringer acetate, or 0.9% NaCl to 10-20ml/kg/hour for 1 hour. Then continue fluid administration according to the shock treatment protocol for dengue fever.
Note:
- If shock is accompanied by cold, clammy extremities, capillary refill time ≥ 3 seconds, lethargy, restlessness, or agitation; normal blood pressure or pulse pressure = 25 mmHg: treat as shock due to dengue fever.
- If shock is accompanied by cool extremities, tachycardia, and normal blood pressure: administer Ringer lactate, Ringer acetate, or 0.9% NaCl at a rate of 10ml/kg/hour for 1 hour, then reassess.
+ If there is clinical improvement, warm extremities, and a slower pulse rate, with normal blood pressure: continue Ringer lactate, Ringer acetate, or 0.9% NaCl at a rate of 6-7ml/kg/hour for 1-3 hours, then 5ml/kg/hour for 2-4 hours, and proceed with the shock treatment protocol.
+ If there is shock, administer Ringer lactate, Ringer acetate, or 0.9% NaCl at a rate of 20ml/kg/hour for 1 hour, and proceed with the shock treatment protocol.
- The duration of fluid administration is usually not more than 24-48 hours.
For adult patients (≥ 16 years old):
- Treatment for dengue fever with warning signs: The patient should be admitted to the hospital for treatment.
+ Symptomatic treatment: Fever reduction.
+ Early fluid replacement via oral route if the patient is able to tolerate it.
+ Monitoring of pulse, blood pressure, warning signs, fluid intake, urine output, and Hct every 4-6 hours.
+ Intravenous fluid administration should be considered when the patient experiences frequent vomiting, inability to drink, high Hct, or signs of dehydration.
+ Intravenous fluid administration protocol:
Administer Ringer lactate, Ringer acetate, or 0.9% NaCl at a rate of 6ml/kg/hour for 1-2 hours, then reduce the rate to 3ml/kg/hour for 2-4 hours. Monitor clinical signs and Hct every 2-4 hours. During the monitoring process:
If the pulse and blood pressure are stable, Hct decreases, and urine output is ≥ 0.5-1ml/kg/hour, reduce the rate of Ringer lactate, Ringer acetate, or 0.9% NaCl to 1-2ml/kg/hour. If the clinical condition continues to improve, fluid administration may be stopped after 24-48 hours.
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