What is the treatment for dengue shock syndrome?

Treatment of Dengue Shock Syndrome

The treatment of dengue shock syndrome (DSS) should begin with aggressive fluid resuscitation using crystalloid solutions at 20 mL/kg boluses over 5-10 minutes, with reassessment after each bolus to guide further management. 1

Initial Fluid Resuscitation

First-line Fluid Therapy

• Start with isotonic crystalloid solutions (normal saline or Ringer's lactate) at 20 mL/kg boluses over 5-10 minutes 1
• Reassess the patient after each bolus for:
  • Improvement in hemodynamic parameters
  • Signs of adequate tissue perfusion
  • Signs of fluid overload

Clinical Indicators of Adequate Tissue Perfusion 1

• Normal capillary refill time
• Absence of skin mottling
• Warm and dry extremities
• Well-felt peripheral pulses
• Return to baseline mental status
• Urine output >0.5 mL/kg/hr (adults) or >1 mL/kg/hr (children)

Volume Requirements

• Initial volume resuscitation commonly requires 40-60 mL/kg but may be as much as 200 mL/kg in severe cases 1
• The majority of patients with DSS can be successfully treated with isotonic crystalloid solutions 2

Second-line Therapy for Refractory Shock

Colloid Solutions

• Consider colloid solutions (6% hydroxyethyl starch or albumin) if shock persists despite 40-60 mL/kg of crystalloids 1, 3
• Hydroxyethyl starch may be preferable to dextran due to fewer adverse reactions 3

Inotropic Support

• If shock persists despite adequate fluid replacement, initiate inotropic support 1
• Options include:
  • Dopamine
  • Epinephrine (adrenaline)
  • Norepinephrine (for excessive peripheral vasodilation)

Monitoring and Ongoing Management

Essential Monitoring Parameters

• Vital signs (heart rate, blood pressure, respiratory rate)
• Capillary refill time
• Urine output
• Hematocrit (serial measurements)
• Signs of fluid overload:
  • Hepatomegaly
  • Rales/crackles
  • Increased work of breathing
  • Peripheral edema

Managing Fluid Overload

• If signs of fluid overload develop, stop fluid resuscitation and consider:
  • Diuretics
  • Peritoneal dialysis or CRRT (continuous renal replacement therapy) for severe cases 1
• Ranjit et al. reported improved outcomes when implementing aggressive fluid resuscitation followed by fluid removal using diuretics and/or peritoneal dialysis if oliguria ensued 1

Positioning

• Place patients in a semi-recumbent position (head of bed elevated 30-45°) to improve ventilation 4

Management of Complications

Bleeding Management

• Significant bleeding should be managed with transfusion of blood products as needed 4
• Maintain hemoglobin >10 g/dL in patients with septic shock to achieve ScvO2 >70% 1
• Avoid prophylactic platelet transfusions 4

Respiratory Support

• Apply oxygen to achieve oxygen saturation >90% 1
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy 1

Pitfalls and Caveats

1. Fluid Overload: Aggressive fluid resuscitation can lead to fluid overload. Monitor closely for signs of pulmonary edema, hepatomegaly, and increasing respiratory distress.

2. Delayed Recognition of Shock: Early recognition and treatment are critical. Hypotension is a late sign in children, and shock should be recognized and treated before it develops.

3. Inadequate Monitoring: Frequent reassessment is essential. The patient's response to fluid therapy should guide subsequent management.

4. Inappropriate Colloid Use: While colloids may be beneficial in severe cases, they should not be used as first-line therapy due to higher costs and potential for adverse reactions.

5. Neglecting Acid-Base Status: Monitor and correct acid-base disturbances as they may complicate management.

The evidence shows that with proper management, the case fatality rate in severe dengue can be reduced to less than 0.5% 4. A protocol of aggressive shock management with judicious fluid removal when needed has been shown to decrease mortality rates in severe forms of DSS 5.