A 28-year-old woman from Delhi presents on day 4 of fever with severe abdominal pain, persistent vomiting, and a platelet count of 65,000/µL. Her haematocrit has risen from 38% to 44% since admission. She is alert, BP 110/72 mmHg, and urine output is 0.8 mL/kg/hr. NS-1 antigen and IgM dengue are positive. What is the most appropriate immediate next step in management?

Explanation

## Clinical Context: Dengue Haemorrhagic Fever (DHF) Grade II This patient meets criteria for **DHF Grade II** — positive tourniquet test equivalent (rising haematocrit >20%), thrombocytopenia, and signs of plasma leakage (abdominal pain, vomiting, haemoconcentration). She is **not in shock** (BP normal, urine output adequate). ### Management Hierarchy in DHF Without Shock **Key Point:** The cornerstone of DHF management is **judicious fluid resuscitation**, NOT transfusion or antibiotics. Platelet transfusion is reserved for active bleeding or counts <20,000/µL with bleeding risk. **High-Yield:** Dengue management follows a **fluid-first, transfusion-last** approach: | Grade | Plasma Leakage | Management | |-------|---|---| | I | Mild (no shock) | Oral rehydration, close monitoring | | II | Moderate (no shock) | IV crystalloid bolus; reassess q1–2h | | III | Shock (SBP <90 or pulse pressure <20) | IV bolus + vasopressors if needed | | IV | Profound shock | ICU, aggressive resuscitation | ### Why Bolus Normal Saline Is Correct 1. **Plasma leakage is ongoing** — haematocrit rise (38% → 44%) and clinical signs (pain, vomiting) indicate active extravasation. 2. **Fluid responsiveness is the first-line intervention** — a 15–30 mL/kg bolus over 15–30 minutes restores intravascular volume and improves perfusion. 3. **Reassessment is mandatory** — repeat vitals, urine output, and haematocrit after bolus to guide further management (repeat bolus vs. colloid vs. ICU escalation). 4. **She is NOT in shock** — BP and urine output are adequate; ICU admission is premature without deterioration. **Clinical Pearl:** Rising haematocrit in dengue is a **red flag for plasma leakage**, not a reason to withhold fluids. Fluid deficit must be corrected before shock develops. ### Why Other Options Are Incorrect - **IVIG:** Not indicated in uncomplicated DHF; reserved for dengue with atypical manifestations (e.g., encephalitis, myocarditis) or severe thrombocytopenia with bleeding. - **Platelet transfusion:** Platelet count of 65,000/µL is NOT an indication for transfusion in the absence of active bleeding. Transfusion risks volume overload and paradoxical worsening of plasma leakage. - **Prophylactic antibiotics:** Dengue is viral; secondary bacterial infection is rare in uncomplicated cases. Antibiotics are reserved for clinical evidence of superinfection. **Mnemonic: DHF Fluid Strategy — "REASSESS"** - **R**esuscitate with crystalloid bolus first - **E**valuate response (vitals, urine, Hct) after 15–30 min - **A**djust further fluids based on reassessment - **S**hock developing? → Colloid, vasopressors, ICU - **S**table? → Maintenance fluids + close monitoring - **E**scape plasma leakage phase (day 5–7)? → Gradual fluid withdrawal - **S**upport until recovery [cite:Harrison 21e Ch 189]