Department of Pediatrics

Clinical Practice Guidelines

Document Code:
QS QPS 0809 PS-001-05
Clinical Practice Guidelines Effective Date: Page:
January 1, 2010 Page 1 of 4
Dated:
New Supersedes:
January 1, 2010

Clinical Practice Guidelines on Dengue Fever Syndrome and Dengue Hemorrhagic Fever

I. 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
Leukopenia
And
Supportive serology
( A reciprocal HI antibody titer > or = 1280, a comparable
ELISA assay titer or a (+) IgM antibody test on a late acute
Or convalescent phase serum specimen)
Confirmed: a case confirmed by laboratory criteria

II. Case Definition for Dengue Hemorrhagic Fever (DHF)

The following must all be present:
a. Fever, or a history of acute fever lasting 2-7 days, occasionally biphasic
b. Hemorrhagic tendencies, evidenced by at least one of the following:
• (+) tourniquet test
• Petechiae, ecchymosis, purpura
• Bleeding from the mucosa, GIT, injection sites or other
locations
• Hematemesis or melena
3
c. Thrombocytopenia ( 100,000 cells/mm or less)
d. Evidence of plasma leakage due to increased vascular permeability, manifested by
at least one of the following:
d.1. a rise in the hematocrit equal or greater than 20 above average for age, sex
and population
d.2. a drop in hematocrit following volume-replacement treatment equal to or
greater than 20% of baseline
d.3. signs of plasma leakage such as pleural effusion, ascites, and
hypoproteinemia

III. Case Definition for Dengue Hemorrhagic Shock Syndrome (DSS)

All of the four criteria for DHF must be present, plus evidence of circulatory failure
manifested by:
Rapid and weak pulse, and
Narrow pulse pressure [ < 20 mmHg (2.7kPa)] of manifested by:
Hypotension for age, and
 Department of Pediatrics
Clinical Practice Guidelines
Document Code:
QS QPS 0809 PS-001-05
Clinical Practice Guidelines Effective Date: Page:
January 1, 2010 Page 2 of 4
Dated:
New Supersedes:
January 1, 2010

Cold, clammy skin and restlessness

IV. Grading Severity of DHF/DSS

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
Grade 2
Spontaneous bleeding in addition to manifestations of grade I patients, usually in
the form of skin or other hemorrhages (mucocutaneous, GIT)
Grade 3
Circulatory failure manifested manifested by a rapid, weak pulse and narrowing
of pulse pressure or hypotension, with the presence of cold, clammy skin and
restlessness
Grade 4
Profound shock with undetectable blood pressure or pulse
Grades 3 and 4 DHF constitute DSS

V. Diagnosis:
1. When DF/DHF is suspected, a CBC and actual platelet count should be done
2. Due to a low sensitivity, CBC and actual platelet count should be done at least on a
daily basis to determine hemoconcentration and thrombocytopenia.
3. Between Partial thromboplastin time (PTT) and prothrombin time (PT), PTT is a
better predictor of bleeding than PT but they should not be routinely done.
4. There are commercially available rapid diagnostic tests for patients suspected of
dengue but should not be done routinely
• Dengue IgM and IgG ELISA
• Dengue Dot Blot ELISA
• Dengue Immunochromatography test (ICT)
• Dengue Dipstick ELISA
These tests give the best results when done starting on Day 5 of illness but do not
distinguish DF from DHF.

VI. Criteria for Admission

The presence of any of the following is an indication for admission for suspected or
confirmed dengue patients:
1. Shock: narrowing of the pulse pressure ≤ 20mmHg, rapid weak pulse, cold clammy
skin, restlessness or irritability.
2. Spontaneous bleeding: mucosal bleeding (gum or nose bleeding), hematemesis,
coffee-ground vomitus, melena, menometrorrhagia
 Department of Pediatrics
Clinical Practice Guidelines
Document Code:
QS QPS 0809 PS-001-05
Clinical Practice Guidelines Effective Date: Page:
January 1, 2010 Page 3 of 4
Dated:
New Supersedes:
January 1, 2010

3. Any of the following danger signs: inability to drink or feed, vomits everything,
convulsions, lethargy or unconsciousness, no urine output for 6-8 hours
4. Signs of increased vascular permeability as manifested by increasing hematocrit,
serious effusion or hypoproteinuemia
5. Abdominal pain

VII. Management
A. Among patients without shock, intravenous fluids (IVF) recommended for use are:
1. Isotonic solutions [D5LRS, D5NSS, D50.9%NaCl] are appropriate for patients without
shock.
2. Maintenance IVF should be given using Holiday Segar Method and fluid rate may be
increased to cover for mild dehydration as needed:
Body Wt (kg) Fluid per day
0-10 100ml/kg
11-20 1,000 + 50ml/kg for each kg > 10kg
>20 1,500 + 20ml/kg for each kg > 20kg

3. Clinical parameters should be monitored closely and correlated with the hematocrit. It
is important to avoid fluid overload.
B. Appropriate IV fluids for patients with shock (DF Grade III and IV/DSS):
1. Isotonic crystalloid (LRS, NSS, 0.9% NaCl) is the fluid of choice for initial fluid
resuscitation in patients with shock. Avoid glucose containing solutions to prevent
osmotic dieresis.
2. IVF fluid volume to be infused 20 ml/kg bolus. If there is no improvement, this may be
repeated 2 to 3 times. An inotropic agent should be considered.
3. If 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.
4. Constantly monitor the ff parameters: level of consciousness, work of breathing, RR.
CRT, temperature of extremities, pulse rate, quality of pulse, urine output, and BP. If
improvement is not satisfactory, refer to a specialist.
5. Other aspects of management should be instituted. O2 should be started at 2-3
L/min.
Stepwise Fluid Therapy of DHF
Grade I: fever, anorexia, constitutional signs and symptoms
- Home treatment with ORS 500-1500/24 hours
- If hospitalized, infuse with maintenance fluid only
Grade II: spontaneous petechiae, hemoconcentration, no circulatory failure
- Do serial hematocrit and platelet count every 8-12 hours, baseline PT/PTT
- Maintenance therapy plus deficit therapy
- For deficit therapy: to treat hemoconcentration (initial hct > 40 in children and >
 Department of Pediatrics
Clinical Practice Guidelines
Document Code:
QS QPS 0809 PS-001-05
Clinical Practice Guidelines Effective Date: Page:
January 1, 2010 Page 4 of 4
Dated:
New Supersedes:
January 1, 2010

45 in adolescent/adult), infuse D5 lactated or acetated Ringer’s, D5NR, or

D5NSS at 20-30 cc/kg in 4-6 hours.
- If no initial hemoconcentration resume maintenance fluid and interrupt with
D5LR/D5NR if hematocrit is >10% from baseline or previous level
Grade III: circulatory failure, GI bleeding, epistaxis, RUQ pain, tenderness,
pleural effusion
- Do serial PT/PTT, TP, A/G ratio, serial CBC/platelet count
- Treat hypovolemia, shock, GI bleeding: maintain 2 IV lines, 1 for maintenance,
and 1 for plasma expanders (colloids), FFP, blood transfusion, etc
- If no GI bleeding but increased hemoconcentration, normal PT/PTT: use plasma
volume expander (colloids) 20-30 cc/kg in 2-4 hours. Repeat plasma volume
expander if still with hemoconcentration and circulatory failure. If not corrected,
give FFP.
- If with bleeding and/or with abnormal PT/PTT, same management as Grade IV
Grade IV: profound shock
- Use specific blood components
- Repeat FFP for GI bleeding and/or pRBC, cryoprecipitate, platelet concentrate
as indicated based on DOH guidelines

VIII. Indications for Blood Transfusions

1. In DHF/DSS patients with significant bleeding (hematochezia, hematemesis), fresh
whole blood is preferred but packed RBC and plasma may be used as an alternative
2. Once DIC sets in, blood component therapy with cryoprecipitate, FFP, and platelet
concentrate is recommended

IX. Criteria for Discharge

Patients may be discharged 72 hours after defervescence in those diagnosed with DHF or
72 hours after termination of shock for DSS patients.
(Department)
(Chapter)
Document Code:

Effective Date: Page:

Page 5 of 5