What is the recommended fluid management for patients with dengue?

Fluid Management in Dengue

For patients with dengue shock syndrome, an initial fluid bolus of 20 mL/kg of isotonic crystalloid solution should be administered, with careful reassessment after each bolus. 1, 2

Classification and Assessment

• Dengue patients should be classified based on severity to guide appropriate fluid management, with special attention to warning signs including persistent vomiting, abdominal pain, clinical fluid accumulation, mucosal bleeding, lethargy, liver enlargement, and rising hematocrit with falling platelet count 2, 3
• Daily complete blood count monitoring is essential, particularly to track platelet counts and hematocrit levels in patients at risk of progression to shock 2
• The critical phase of dengue typically occurs around days 3-7 of illness when plasma leakage can rapidly progress to shock, requiring vigilant monitoring 2, 3

Fluid Management Algorithm

For Patients Without Shock

• Oral rehydration with fluids containing electrolytes is the first-line treatment for patients without signs of shock 2, 3
• Avoid routine use of bolus intravenous fluids in patients with "severe febrile illness" who are not in shock 1, 2
• Monitor for warning signs that may indicate progression to more severe disease 2

For Patients With Dengue Shock Syndrome

• Administer an initial fluid bolus of 20 mL/kg of isotonic crystalloid solution (such as normal 0.9% saline or Ringer's lactate) 1, 2
• Reassess the patient after each fluid bolus to determine response and need for additional fluids 1, 2
• For moderate dengue shock syndrome, crystalloid solutions are recommended as first-line therapy 2, 4
• For severe dengue shock syndrome or patients not responding to initial crystalloid therapy, consider colloid solutions 2, 5
• If using colloids, medium-molecular-weight preparations like 6% hydroxyethyl starch may be preferable to dextran due to fewer adverse reactions 6

Monitoring During Fluid Resuscitation

• Watch for clinical indicators of adequate tissue perfusion, including normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output 2
• Monitor for signs of fluid overload, especially during the recovery phase 2, 7
• Assess hematocrit levels regularly, as rising values indicate ongoing plasma leakage 2, 3

Management of Complications

• For patients with persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or norepinephrine may be required 2, 5
• Blood transfusion may be necessary in cases of significant bleeding 2
• After stabilizing hemodynamics and clinical improvement, carefully reduce and discontinue fluids to avoid congestion and other complications 5

Common Pitfalls to Avoid

• Avoid administering excessive fluid boluses in patients without shock, which can lead to fluid overload and respiratory complications 2, 7
• Strictly avoid aspirin and other non-steroidal anti-inflammatory drugs due to increased bleeding risk 2, 3, 8
• Avoid delaying fluid resuscitation in patients with dengue shock syndrome 2
• Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 2
• Be cautious with intravenous fluid therapy in patients with significant vascular leakage, as it may aggravate serosal fluid accumulation and result in respiratory distress 7