Outline the management of a patient with dengue haemorrhagic fever.

Initial Assessment and Classification

Upon presentation, a thorough clinical assessment is paramount. This includes:

• History: Detailed history regarding fever, bleeding manifestations (epistaxis, gum bleeding, melena, menorrhagia), abdominal pain, vomiting, and any co-morbidities.
• Physical Examination: Assessing for signs of plasma leakage (pleural effusion, ascites), bleeding manifestations (petechiae, purpura, ecchymosis), and shock (hypotension, tachycardia, altered mental status).
• Laboratory Investigations: Complete blood count (CBC) with platelet count, hematocrit, dengue NS1 antigen, IgM and IgG antibodies, liver function tests (LFTs), coagulation profile (PT/INR, aPTT), and serum albumin.

Patients are classified according to the 2009 WHO classification for dengue severity into:

• Dengue without warning signs: Fever with non-specific symptoms.
• Dengue with warning signs: Abdominal pain, persistent vomiting, fluid accumulation (pleural effusion, ascites), mucosal bleeding, lethargy/restlessness, liver enlargement.
• Severe Dengue: Plasma leakage leading to shock, severe bleeding, organ impairment (liver, heart, brain).

Fluid Management

Fluid management is the cornerstone of DHF treatment. The goal is to maintain adequate circulatory volume and prevent hypovolemic shock.

• Crystalloids: Isotonic crystalloids (Normal Saline or Ringer's Lactate) are the preferred initial fluid for resuscitation.
• Fluid Resuscitation:
  • Shock (Systolic BP <90 mmHg): Rapid bolus of 20 ml/kg of crystalloid over 15-30 minutes, repeated as needed, monitoring response.
  • Pre-shock (Warning Signs): Cautious fluid administration, typically 5-7 ml/kg/hour, adjusted based on hematocrit and clinical response.
• Monitoring: Frequent monitoring of vital signs (BP, pulse, respiratory rate), hematocrit, platelet count, and urine output is crucial. A rising hematocrit indicates worsening plasma leakage.

Monitoring Parameters

Close monitoring is essential to detect deterioration and guide further management.

Parameter	Frequency	Significance
Hematocrit	6-12 hourly	Rising hematocrit indicates plasma leakage
Platelet Count	Daily	Falling platelet count increases bleeding risk
Blood Pressure	Hourly	Indicates circulatory status
Urine Output	Hourly	Reflects renal perfusion
Serum Albumin	Daily	Indicates severity of plasma leakage

Management of Bleeding

Bleeding manifestations require specific management:

• Minor Bleeding (Petechiae, Epistaxis): Supportive care, monitoring.
• Major Bleeding (Gastrointestinal, Intracranial):
  • Platelet Transfusion: If platelet count <20,000/µL or in the presence of active bleeding.
  • Fresh Frozen Plasma (FFP): To correct coagulopathy.
  • Tranexamic Acid: May be considered in specific cases of significant bleeding, but use with caution.

Management of Shock

Shock requires aggressive resuscitation:

• Continued Crystalloid Boluses: As needed, guided by hematocrit and vital signs.
• Colloids: May be considered if crystalloids fail to maintain adequate perfusion, but use cautiously due to risk of pulmonary edema.
• Vasopressors: Reserved for refractory shock, after adequate fluid resuscitation.

Supportive Care

Supportive care is vital for optimal recovery:

• Nutritional Support: Maintain adequate hydration and nutrition.
• Fever Management: Paracetamol for fever, avoid NSAIDs due to increased bleeding risk.
• Prevention of Secondary Infections: Monitor for and treat any secondary bacterial infections.