What are the indications and choice of colloids, such as 5% albumin, in pediatric dengue patients with severe plasma leakage, shock, or significant hypovolemia?

Use of Colloids in Pediatric Dengue: Indications and Choice

For pediatric dengue patients with severe plasma leakage, colloid solutions such as 5% albumin should be used when patients have severe dengue shock syndrome (pulse pressure <10 mmHg) or when they fail to respond to initial crystalloid resuscitation. 1, 2

Initial Fluid Management Approach

• Isotonic crystalloid solutions (such as normal saline) should be the first-choice fluid for initial resuscitation in pediatric dengue patients with hypovolemia 2
• Initial fluid bolus should be 10-20 mL/kg with subsequent patient reassessment 2, 1
• Fluid administration should be guided by clinical indicators of adequate tissue perfusion, including normal capillary refill time, absence of skin mottling, warm extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output 2, 1

Indications for Colloid Use

• Severe dengue shock syndrome with pulse pressure <10 mmHg 2, 1
• Patients who fail to respond to initial crystalloid resuscitation with persistent shock 3, 4
• Patients requiring large volumes of fluid resuscitation where continued crystalloid administration may lead to fluid overload 2, 3
• Patients with massive plasma leakage and in whom a large volume of crystalloids has already been given 3, 5

Choice of Colloid Solutions

• 5% albumin is an appropriate colloid choice for pediatric dengue patients with severe shock, though it is more expensive than synthetic colloids 6, 3
• Synthetic colloids such as 6% hydroxyethyl starch may be preferable to dextran due to fewer adverse reactions while maintaining similar efficacy 4, 7
• When using albumin (Plasbumin-25), it should be administered intravenously, either undiluted or diluted in 0.9% sodium chloride or 5% dextrose in water 6
• The rate of administration should not exceed 2 mL per minute to avoid precipitating circulatory embarrassment and pulmonary edema 6

Monitoring During Colloid Administration

• Frequent monitoring of vital signs and hematocrit levels is essential during colloid administration 3, 1
• A rise in hematocrit of 20% along with a continuing drop in platelet count is an important indicator for the onset of shock 3, 8
• Watch for signs of fluid overload, particularly during the recovery phase when capillary permeability begins to normalize 1, 3

Special Considerations for Different Shock Severities

• For moderate dengue shock syndrome (pulse pressure >10 and <20 mmHg), crystalloid solutions remain the first-line fluid and have similar outcomes to colloids 2, 4
• For severe dengue shock syndrome (pulse pressure <10 mmHg), colloid solutions provide better initial plasma volume support 2, 9
• The pulse pressure at presentation is the most significant factor determining clinical response to fluid resuscitation 9, 4

Common Pitfalls to Avoid

• Delaying fluid resuscitation in patients with dengue shock syndrome can lead to increased morbidity and mortality 1, 3
• Administering excessive fluid boluses in patients without shock can lead to fluid overload and respiratory complications 1, 2
• Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 8
• Using aspirin or NSAIDs, which can worsen bleeding tendencies 1, 8

Cost Considerations

• Colloid solutions are significantly more expensive than crystalloid solutions: 1 L of albumin costs around 140 Euro, 1 L of HES costs 25 Euro, and 1 L of isotonic saline costs 1.5 Euro 2
• The cost differential should be considered when deciding between colloids and crystalloids, especially in resource-limited settings 2, 5