What is the treatment for dengue shock syndrome (DSS)?

Treatment of Dengue Shock Syndrome

Administer an immediate fluid bolus of 20 mL/kg of isotonic crystalloid over 5-10 minutes, then reassess and escalate to colloid solutions (preferably dextran 70) if shock persists, as colloids restore cardiac index and normalize hematocrit more rapidly than crystalloids alone. 1, 2

Initial Fluid Resuscitation

Crystalloid First-Line Approach:

• Begin with 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% saline) as the initial bolus over 5-10 minutes 1, 3
• Reassess immediately after the bolus for signs of improvement: capillary refill time, skin warmth, peripheral pulses, mental status, and urine output 1
• If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour 1

Escalation to Colloids:

• For severe dengue shock syndrome or when crystalloids fail to restore perfusion, colloid solutions are beneficial 1
• Dextran 70 is the preferred colloid as it provides the most rapid normalization of hematocrit and restoration of cardiac index without adverse effects 2
• Alternative colloids include gelafundin or albumin if dextran is unavailable 1
• Moderate-quality evidence shows colloids provide faster resolution of shock compared to crystalloids alone (RR 1.09,95% CI 1.00-1.19) 4

Critical Monitoring During Resuscitation

Watch for these specific indicators of adequate perfusion:

• Normal capillary refill time (less than 2 seconds) 1
• Absence of skin mottling 1
• Warm and dry extremities with well-felt peripheral pulses 1
• Return to baseline mental status 1
• Adequate urine output (>0.5 mL/kg/hour in adults) 5

Signs of fluid overload requiring immediate cessation of aggressive fluids:

• Hepatomegaly 1
• Rales on lung examination 1
• Respiratory distress 1
• Critical pitfall: Do not continue aggressive fluid resuscitation once these signs appear; switch to inotropic support instead 1

Management of Refractory Shock

When shock persists despite adequate fluid resuscitation (40-60 mL/kg in first hour):

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1
• In resource-rich settings, consider invasive monitoring to guide therapy 1

Timeline and Clinical Context

Shock typically occurs between days 4-6 of illness during the critical phase when plasma leakage is maximal 6

• Most patients (91%) are afebrile at shock onset 6
• Almost one-third have no bleeding manifestations at presentation 6
• With prompt intervention and experienced care, mortality can be as low as 0.5% despite 7% presenting with unrecordable blood pressure 6

Evidence-Based Outcomes

The aggressive protocol approach significantly improves outcomes:

• Pediatric ICU mortality decreased from 16.6% to 6.3% with aggressive management protocols 7
• Aggressive shock management with judicious fluid removal when indicated decreases mortality in the severest forms 7
• Do not use restrictive fluid strategies in established dengue shock syndrome—moderate-quality evidence shows no survival benefit from colloid restriction 1

Key Risk Factors Requiring Heightened Vigilance

Patients at highest risk for progression to shock:

• Bleeding manifestations (adjusted OR 5.1) 8
• Secondary dengue infection (adjusted OR 21.8) 8
• Hemoconcentration >22% from baseline hematocrit (adjusted OR 15.5) 8

Common Pitfalls to Avoid

• Never delay fluid resuscitation in patients showing signs of shock 1, 5
• Never use aspirin or NSAIDs due to increased bleeding risk 1, 5, 3
• Never administer excessive fluid boluses in patients without shock, as this leads to fluid overload and respiratory complications 1
• Never fail to recognize the critical phase (typically days 3-7) when plasma leakage can rapidly progress to shock 1
• Only 2% develop severe bleeding requiring transfusion, so prophylactic platelet transfusion is not indicated 6, 9