00000000Haemostatic changes in DHF involve three factors: vasculopathy, thrombocytopenia and coagulopathy. All patients demonstrate an increase in vascular fragility (positive tourniquet test) and moderate to marked thrombocytopenia. About 80 per cent of patients with DSS and 17 per cent of non-shock cases have an abnormal coagulogram as evidenced by concomitant thrombocytopenia, prolonged partial thromboplastin time (PTT), decreased fibrinogen levels, and increased fibrinogen degradation products (FDP), suggesting disseminated intravascular clotting (DIC)(3). In the case of prolonged uncontrolled shock, DIC may cause important clinical bleeding and may play an important part in the development of lethal shock. About one third of shock cases, mostly those with refractory shock, present with bleeding, mainly from the gastro-intestinal tract. Gastro-intestinal haemorrhage is a fairly constant finding at autopsy in the majority of patients who die.

00000000 Early and effective replacement of plasma loss with plasma, plasma expander and/or fluid and electrolyte solution, results in a favourable outcome in most cases. With adequate volume replacement, DSS is rapidly reversible. Early recognition of shock and rapid volume replacement will usually prevent clinical DIC. Prognosis depends upon early monitoring of patients for a drop in platelet count and rise in haematocrit values are essential for early recognition and prevention of shock. The critical period in severe cases is the transition from the febrile to the afebrile phase, which usually occurs after approximately the third day.

2.2 Treatment Regimen

00000000 The management of DHF during the febrile phase is similar to that of DF, but antipyretics should be used with caution. Salicylates should be avoided since they may cause bleeding and acidosis.

00000000 Oral electrolyte solution (as used in diarrhoea) or fruit juice is recommended during the febrile phase.

00000000 A rise in haematocrit value of more than 20 per cent from baseline indicates significant plasma loss and a need for parenteral fluid therapy. In mild and moderate cases (Grades I and II), volume replacement can be given in an out-patient department rehydration unit for a period of 12 - 24 hours.

00000000 Patients who are restless and who have cool extremities, acute abdominal pain and oliguria should be admitted to hospital. Patients with any signs of bleeding and persistently high haematocrit values, despite being given volume replacement, should be promptly admitted to hospital.