What is the primary approach to managing perinephric fat stranding in patients with dengue?

Management of Perinephric Fat Stranding in Dengue Fever

The primary approach to managing perinephric fat stranding in patients with dengue is careful fluid management with crystalloids, while monitoring for signs of plasma leakage and shock, as perinephric fat stranding represents a manifestation of capillary leakage that characterizes severe dengue. 1

Understanding Perinephric Fat Stranding in Dengue

Perinephric fat stranding in dengue patients represents:

• A manifestation of the increased capillary permeability that occurs during the critical phase of dengue infection
• Part of the polyserositis (fluid accumulation in body cavities) that can occur in severe dengue cases
• A warning sign that requires careful monitoring and appropriate fluid management

Management Algorithm

1. Assessment and Monitoring

• Evaluate for other warning signs: abdominal pain, persistent vomiting, mucosal bleeding, lethargy, hepatomegaly, and increased hematocrit with rapid decrease in platelet count 1
• Monitor vital signs frequently, particularly blood pressure and pulse
• Track hematocrit trends - a rise of 20% along with dropping platelet counts indicates progression to shock 2
• Assess urine output (target >0.5 ml/kg/hour in adults, >1 ml/kg/hour in children) 1

2. Fluid Management

• Initial approach: Crystalloids as first-line treatment (5-10 ml/kg/hour) 1
• For patients with signs of shock:
  • Administer crystalloid bolus (20 ml/kg) rapidly 1
  • Reassess clinical status after each bolus
  • May require 2-3 boluses in profound shock 2
• If inadequate response to crystalloids or evidence of severe plasma leakage:
  • Consider colloids (6% hydroxyethyl starch preferred over dextran due to fewer adverse reactions) 1, 3

3. Monitoring Response to Treatment

• Frequent vital sign assessment
• Serial hematocrit measurements
• Strict fluid balance monitoring
• Urine output monitoring
• Assessment of respiratory status for signs of fluid overload

4. Special Considerations

• Position patient semi-recumbent (head elevated 30-45°) to improve ventilation 1
• Avoid drainage of fluid collections (including perinephric) as it can lead to hemorrhage and circulatory collapse 2
• Use acetaminophen/paracetamol for fever and pain; avoid NSAIDs and aspirin due to bleeding risk 1
• More cautious fluid management in:
  • Infants (higher risk of fluid overload) 1
  • Patients with comorbidities (cardiac or renal disease) 1, 4
  • Elderly patients (≥60 years) 4

Pitfalls and Caveats

1. Fluid Overload Risk: After stabilizing hemodynamics, be vigilant about reducing fluid rates to prevent pulmonary edema and other complications of fluid overload 5

2. Comorbidity Considerations: Patients with diabetes, cardiac disorders, and asthma are at higher risk for severe organ involvement and require more intensive monitoring 4

3. Balance Between Under and Over-Resuscitation: The key challenge in managing dengue with perinephric fat stranding is providing adequate fluid to prevent shock while avoiding fluid overload

4. Avoid Invasive Procedures: Drainage of fluid collections should be avoided unless absolutely necessary, as it can precipitate hemorrhage 2

5. Transition Management: After the critical phase, careful reduction of fluids is essential to prevent iatrogenic fluid overload 5

By following this structured approach with careful monitoring and judicious fluid management, mortality from dengue can be reduced to less than 0.5% even in hospitalized patients 1.