Dengue in children: Issues in critical care settings

Abstract

Dengue infection is an important tropical infection that can be responsible for serious illness and intensive care admission in children. Dengue virus belongs to Flavivirus genus and is transmitted by Aedes aegypti and Aedes al- bopictus mosquito. New World Health Organisation classification for the disease into dengue with/ without warning signs and severe dengue better identifies patients requiring in-hospital treatment and classifies atypical cases with severe end organ system involvement (liver, brain, heart, etc.) without shock or bleeding diathesis. Point of care tests for Non-Structural Protein 1 antigen and IgM based immuno-assay are important adjuncts to early diagnosis in emergency wards. Capillary leak and bleeding are central mechanism of manifestations of severe dengue. Severe capillary leakage creates intravascular hypovolemia which needs correction with aggressive but not over-jealous fluid therapy with timely tapering of high fluid rates, to maintain a fine balance of adequate resuscitation and preventing fluid overload at the same time. Indication for use of colloids upfront especially in patients with evidence of severe plasma leakage needs further evaluation. Transfusion of fresh whole blood or fresh packed red cells is important in patients with suspected severe bleeding. In view of recent evidence, prophylactic transfusion of platelets is going out of favour and platelets should be transfused for severe bleeding irrespective of platelet counts. Echocardiography and central venous pressure based fluid status evaluation act as precious adjuncts to for better assessment of intravascular volume. Atypical manifestation like neurological manifestations, renal failure, abdominal compartment syndrome, hemophagocytic lymphohistiocytosis need further documentation for better management of critically ill patients. Outcomes worldwide are improving with structured protocol based management.