What is the recommended approach for fluid management in patients with dengue?

Fluid Management in Dengue

Crystalloid solutions are the recommended first-line fluid therapy for dengue patients, with careful monitoring and adjustment based on clinical response. 1, 2

Initial Assessment and Classification

• Assess for warning signs of severe dengue including high hematocrit with rapidly falling platelet count, severe abdominal pain, persistent vomiting, lethargy, and mucosal bleeding 3
• Monitor for signs of shock: tachycardia, hypotension, poor capillary refill, and altered mental status 3
• Classify patients based on severity to determine appropriate fluid management strategy 3

Fluid Management Approach by Severity

Non-Severe Dengue (Without Shock)

• Oral rehydration is the first-line treatment for patients without shock 3
• Avoid routine use of bolus intravenous fluids in patients with severe febrile illness who are not in shock 3
• Monitor clinical indicators of adequate tissue perfusion including capillary refill time, skin appearance, extremity temperature, peripheral pulses, mental status, and urine output 3

Dengue with Warning Signs

• American Heart Association recommends an initial bolus of 20 ml/kg of isotonic crystalloid solution 1
• After initial bolus, perform clinical reassessment to determine response and adjust therapy accordingly 1
• Crystalloids (such as normal saline or Ringer's lactate) are preferred over colloids for initial resuscitation 1, 4

Dengue Shock Syndrome (DSS)

• Administer an initial fluid bolus of 20 ml/kg of isotonic crystalloid solution 3, 4
• Evidence shows that the majority of patients with DSS can be successfully treated with isotonic crystalloid solutions 5
• If patients are not responsive despite adequate crystalloid resuscitation, consider switching to colloid solutions 2, 4
• Among colloids, 6% hydroxyethyl starch may be preferable to dextran 70 due to fewer adverse reactions with similar efficacy 4

Monitoring During Fluid Management

• Closely monitor for signs of fluid overload: pulmonary edema, distension of jugular veins, and peripheral edema 1
• Maintain strict fluid balance records (intake and output) 1
• Monitor electrolytes, BUN, and creatinine every 12-24 hours 1
• Target urine output of >0.5 ml/kg/hour 1
• Be vigilant during the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 3

Special Considerations

• Higher infused fluid volumes are associated with increased risk of respiratory distress (hazard ratio 1.18 per 10 ml/kg increase) 6
• Elevated venous lactate levels at admission predict patients at risk for recurrent shock 7
• After stabilizing hemodynamics and clinical improvement, carefully reduce and discontinue fluids to avoid congestion and complications 2
• For patients with persistent tissue hypoperfusion despite adequate fluid resuscitation, consider vasopressors such as norepinephrine 2

Pitfalls to Avoid

• Excessive fluid administration can lead to fluid overload, respiratory distress, and poor outcomes 6
• Total IV fluid volume administered during ICU admission is associated with respiratory distress (OR: 1.03,95% CI 1.01-1.06) 7
• Avoid solutions with high osmotic renal load, particularly in patients with renal impairment 1
• Do not delay switching to colloids in patients who fail to respond to initial crystalloid therapy 2, 4