What is the management approach for a patient with severe dengue hemorrhagic fever presenting with shock, leukocytosis, polyserositis, and acute kidney injury?

Management of Severe Dengue Shock Syndrome with Leukocytosis, Polyserositis, and Organ Injury

Immediate aggressive fluid resuscitation with crystalloids is the cornerstone of management for dengue shock syndrome, followed by colloids if needed, with careful monitoring for fluid overload and secondary complications. 1

Initial Resuscitation Phase

• First-line fluid therapy:

  • Begin with crystalloid fluid bolus of 20 ml/kg as rapidly as possible 1
  • May need to repeat bolus 2-3 times in profound shock 1
  • Normal saline is preferred over lactated Ringer's solution 1

• Monitoring during resuscitation:

  • Vital signs every 15-30 minutes during rapid fluid administration 1
  • Monitor hematocrit trends - a rise of 20% along with dropping platelets indicates worsening shock 2
  • Assess cardiac index and blood pressure response 3

• Escalation to colloids:

  • If inadequate response to crystalloids, switch to colloids 4
  • Dextran 70 may provide the most rapid normalization of hematocrit and restoration of cardiac index 3
  • About 20% of DHF patients require colloids in addition to crystalloids 5

Management of Specific Complications

Polyserositis (Pleural effusion and ascites)

• Avoid drainage if possible as it can lead to severe hemorrhages and sudden circulatory collapse 2
• Continue careful fluid management with monitoring for signs of fluid overload

Acute Kidney Injury (AKI)

• Lower fluid volumes than standard protocol 1
• Consider hemodialysis in severe cases 6
• Monitor BUN, creatinine, and urine output closely
• Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) to maintenance fluids once renal function is assured 1

Acute Lung Injury (ALI)

• Provide oxygen therapy to all patients in shock 2
• Monitor for signs of fluid overload including dyspnea and pulmonary edema 1
• Consider vasopressors (norepinephrine) if fluid restriction is needed due to pulmonary edema 4

Leukocytosis (WBC 35,000)

• Investigate for secondary bacterial infection, particularly endocarditis 6
• Consider empiric antibiotics if bacterial infection is suspected
• Blood cultures should be obtained before starting antibiotics

Ongoing Monitoring and Management

• Fluid management after initial resuscitation:

  • Adjust to 5-10 ml/kg/hour based on clinical response 1
  • Carefully monitor for fluid overload (dyspnea, enlarging liver, gallop rhythm) 1
  • Begin reducing fluids once hemodynamically stable 4

• Laboratory monitoring:

  • Serial hematocrit and platelet counts
  • Liver function tests (elevated transaminases common) 1, 6
  • Coagulation studies (PT, PTT) to assess for DIC 2
  • Electrolytes to monitor and correct imbalances

• Blood product support:

  • Consider blood, fresh frozen plasma, and platelet transfusions if DIC develops 2

Vigilance for Complications

• Secondary bacterial infections:

  • Patients with prolonged fever (>5 days) and AKI are at high risk for concurrent bacteremia 6
  • Monitor for neutrophil leukocytosis as a sign of bacterial infection

• Thrombotic complications:

  • Be alert for deep vein thrombosis or other thrombotic events 6
  • Consider anticoagulation if thrombosis is detected

Criteria for Improvement

• No fever for 48 hours without antipyretics
• Improving clinical status
• Increasing platelet count
• Stable hematocrit
• No respiratory distress
• Good urine output 1

The management of dengue shock syndrome with multiple organ involvement requires a careful balance between adequate fluid resuscitation and prevention of fluid overload. The high leukocyte count suggests possible secondary bacterial infection, which should be investigated and treated appropriately while continuing supportive care for the dengue-related complications.