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The most important thing to do about management is counseling the patient about dengue fever. We have to tell them that its not dangerous and if treated accordingly the mortality is very low. We should make patient and his attendants tension free.
Now we will discuss management plans for different types of dengue fever
****AYMPTOMATIC DENGUE FEVER: we don’t have to do anything in this case as the patient already has immuntity against it.

****UNDIFFERENTIATED FEVER: in this case too no treatment is offered and patient gets fine on its own usually.

· PANADOL (ACETAMINOPHEN) 2 tablets after every 6 hours. We ask the patient not to take any other NSAID for 2 reasons.
First of all NSAIDS are known to have anti platelet action and so as in dengue fever the platelets decrease so we avoid any drug with anti platelet actions. Secondly NSAIDS are known to cause gastric ulcers or to aggravate them. So we avoid them so that if they create such problem in a patient with decreased platelet count we may have to deal with internal GI bleed which can be dangerous.
· IV FLUIDS. As the patient has nausea and vomiting so dehydration would be a common finding. We give IV fluids as ringer lactate or dextrose to the patient
· ANTI EMETICS. To decrease the symptoms of nausea and vomiting anti emetics like metoclopramide are suggested
· NO PLATELETS. No platelet infusion is required in dengue patients. Its indicated in only 0.1 percent of the cases with proper indication. Its seen that it may cause anaphylactic shock in the patient and should be avoided at all costs. Instead patient may be given whole blood if any signs of bleeding or very low platelet count may be seen.

The reason for emphasizing that the patient must present on 4th day of disease to doctor so as to differentiate dengue hemorrhagic fever from classic fever is the fact that the management plan of both are opposite. So if we continue to treat a case of hemorrhagic fever in same way as that of classic fever we would end up getting a disaster. Lets see how to manage a case of dengue hemorrhagic fever
· COUNSELLING. Tell the patient that crucial phase starts from 4th day and as a clinician we must identify it as well.
· SIGNS OF LEAK. Signs of capillary leakage must be looked for. Patient with persistent vomiting, RHC pain must be identified and managed accordingly
· ACETAMINOPHEN (PANADOL) 2 tablets 6 hourly for fever reduction if fever is still present. No NSAIDs for same reason as written above in management of dengue classical fever
· RESTRICTION OF FLUIDS. We must tell patient to take less fluids because fluid is leaking into extra vascular compartment so we will overload extra vascular compartment and later when the capillary leak would end after 48 hours same fluid would come back to intravascular compartment overloading it and ending into congestive heart failure etc. So we suggest giving diuretics to decrease overload problem after the passage of crucial phase.(But in case of dengue classical fever more fluids must be given as patient has dehydration with no capillary leakage)
· IV DEXTRAN 40. We do not give ringer lactate or dextrose to these patients as we do not want to over load their extravascular compartment due to capillary leakage. So we give patient IV dextran 40 (10ml/kg body weight in half hour). Dextran 40 makes extravascular fluid to come into intravascular compartment and hence protects our patient to go into intravascular overload after 48 hours of crucial phase.
· NO PLATELETS. Again for same reasons as described in management of dengue classical fever platelet transfusion is contraindicated. They are only given in patients with absolute indication but such patients are 1 in 1000. Whole blood transfusion for platelets and clotting factors is a better option.
It’s a very serious condition which is managed as a case of shock under strict supervision of neurosurgeons and physicians and mortality rate is high. Still timely and correct management can make most of the cases recover. The management plan of dengue shock syndrome is above the level of discussion we are having here.

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