Dengue Triage & Fluid Wizard

Abdominal pain or tenderness; persistent vomiting; clinical fluid accumulation; mucosal bleed; lethargy or restlessness; liver enlargement greater than 2 cm; and rising haematocrit with a concurrent rapid fall in platelet count. Any one means in-hospital observation.

DEAG Punjab uses the M+5% formula — maintenance (100 ml/kg for the first 10 kg, 50 ml/kg for the next 10 kg, 20 ml/kg for the remainder) plus 5% of body weight as 50 ml/kg. Critically, the weight used is capped at 50 kg, so the total quota can never exceed 4600 ml for any patient, adult or paediatric. The quota covers the whole 48-hour critical phase, or 24 hours if the patient presents in shock, and includes oral intake and any boluses.

DEAG states that irrespective of real weight, an adult heavier than 50 kg still has the same circulatory volume as a 50 kg adult. Using actual weight for a 90 kg patient would produce roughly 8,300 ml instead of 4,600 — and fluid overload is a leading cause of death in dengue. The guideline is explicit: M+5% should not exceed 4600 ml in any patient.

DEAG specifies an initial bolus of 10 ml/kg ideal body weight in compensated shock and 20 ml/kg in decompensated shock, titrated carefully to clinical response to avoid over-replacement. Crystalloids first — about 60% of dengue shock can be managed with crystalloids alone.

Best is weight for height on a growth chart at the 50th centile. In an emergency: under 1 year, (age in months + 9) ÷ 2; under 7 years, (age × 2) + 8; over 7 years, age × 3; or the APLS formula (age + 4) × 2. The weight used for calculation is the current weight or ideal body weight, whichever is lower.

DEAG lists: afebrile 48 hours without antipyretics; stable condition and vitals (pulse under 90, pulse pressure over 30 mmHg); no or minimal bleeding in 24 hours; no dyspnoea from effusion or ascites; recovered organ function (ALT/AST under twice normal, creatinine under 1.5 mg/dl); stable haematocrit for 24 hours; and a rising platelet trend above 40,000.

Not on its own. The WHO laboratory warning sign is a rising haematocrit together with a rapidly falling platelet count — trend and combination, not an isolated number. Platelets appear in DEAG as a discharge criterion (rising trend, above 40,000), not as an admission threshold.

Around defervescence — as the fever settles, which is exactly when families assume the patient is improving. This is the critical phase, and it is when deterioration is most often missed.

No. Paracetamol only, at intervals of not less than six hours, with tepid sponging. Aspirin, ibuprofen and other NSAIDs may aggravate gastritis and bleeding, and aspirin carries a risk of Reye's syndrome. Ask what the patient has already taken — self-medication before presentation is common in Pakistan.