Sedation in Dengue Fever Syndrome
If intubation or invasive procedures are required in patients with dengue shock syndrome, ketamine with atropine premedication is the recommended sedation agent to maintain cardiovascular stability. 1, 2
When Sedation May Be Indicated in Dengue
Sedation becomes relevant in dengue patients primarily in two clinical scenarios:
- For intubation and mechanical ventilation when patients develop respiratory distress, persistent hypoxemia despite oxygen therapy, or require invasive hemodynamic monitoring 1, 2
- For invasive procedures in uncooperative, coagulopathic patients where sedation and immobilization are needed for safe placement of monitoring lines 1
Specific Sedation Recommendations
Ketamine as First-Line Agent
Ketamine with atropine premedication should be used for sedation and intubation in dengue shock syndrome patients. 1, 2
The rationale for ketamine includes:
- Maintains cardiovascular stability through central NMDA receptor blockade while preserving an intact adrenal axis 1
- Reduces systemic inflammation by blocking nuclear factor-kappa B transcription and reducing interleukin-6 production 1
- Can be continued as an infusion for ongoing sedation during mechanical ventilation 1
Agents to Avoid
Avoid propofol, thiopental, benzodiazepines, and inhalational agents as these carry significant risks of worsening hypotension through direct myocardial depression, vasodilation, and blunting of endogenous catecholamine release 1
Etomidate is not recommended despite maintaining cardiovascular stability, as even a single dose for intubation is independently associated with increased mortality in pediatric and adult septic shock, likely due to adrenal corticosteroid biosynthesis inhibition 1
Clinical Context for Sedation Need
Sedation becomes necessary when dengue progresses to severe manifestations:
- Dengue shock syndrome with persistent tissue hypoperfusion despite fluid resuscitation may require vasopressors and mechanical ventilation 2, 3
- Respiratory support indications include respiratory distress, persistent hypoxemia, or need for invasive monitoring in unstable patients 2, 4
- Up to 40% of cardiac output may be required to support work of breathing, which can be unloaded by mechanical ventilation to divert flow to vital organs 1
Important Caveats
- Sedation facilitates temperature control and reduces oxygen consumption, which may be beneficial in dengue patients 1
- Volume loading is often necessary when initiating mechanical ventilation, as positive pressure ventilation may impair cardiac output, particularly with hypovolemia 1
- Continuous monitoring with pulse oximetry and blood/end-tidal CO2 levels should be maintained throughout sedation 2
- The decision to intubate should be considered early in any dengue shock patient not rapidly stabilized with fluid resuscitation and peripherally administered inotropes 1