Treatment of Severe Dengue
For severe dengue, administer an initial fluid bolus of 20 mL/kg isotonic crystalloid over 5-10 minutes with immediate reassessment, escalating to colloid solutions if shock persists, while avoiding aspirin/NSAIDs and monitoring closely for fluid overload. 1
Initial Fluid Resuscitation
Crystalloid therapy forms the foundation of severe dengue management:
- Administer 20 mL/kg of isotonic crystalloid (lactated Ringer's or normal saline) as the initial bolus over 5-10 minutes for dengue shock syndrome 2, 1
- Reassess immediately after the bolus for signs of improvement: capillary refill time, peripheral pulse quality, blood pressure, 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
Colloid solutions provide faster shock resolution in severe cases:
- Moderate-quality evidence demonstrates colloids achieve faster resolution of shock compared to crystalloids alone (RR 1.09,95% CI 1.00-1.19) 2, 1
- Consider colloid solutions (dextran, gelafundin, or albumin) when shock persists despite adequate crystalloid resuscitation 1
- Colloids reduce the total volume of initial bolus needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 2
Critical Monitoring Parameters
Watch for these specific indicators of adequate resuscitation:
- Normal capillary refill time (<2 seconds), absence of skin mottling, warm and dry extremities 1
- Well-felt peripheral pulses, return to baseline mental status 1
- Adequate urine output (>0.5 mL/kg/hour in adults) 3
- Stable vital signs: age-appropriate heart rate and blood pressure 1
Monitor daily complete blood count to track:
- Platelet counts and hematocrit levels, particularly watching for high hematocrit with rapidly falling platelets 1, 3
- Rising hematocrit indicates plasma leakage and impending shock 3
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
- Consider invasive monitoring in resource-rich settings to guide therapy 1
Symptomatic Management
No specific antiviral therapy exists; treatment is supportive:
- Use acetaminophen at standard doses for fever and pain relief 3
- Absolutely avoid aspirin and NSAIDs due to increased bleeding risk 1, 3
- Blood transfusion may be necessary for significant bleeding 1, 3
Critical Pitfalls to Avoid
Fluid overload represents the most dangerous complication of aggressive resuscitation:
- Stop aggressive fluid resuscitation immediately when signs of fluid overload appear: hepatomegaly, rales on lung examination, respiratory distress 1
- Switch to inotropic support rather than continuing fluids once overload develops 1
- Overhydration particularly dangerous during recovery phase when plasma leakage reverses 1
Do not use restrictive fluid strategies in established dengue shock syndrome:
- Moderate-quality evidence shows no survival benefit from colloid restriction 1
- Restrictive fluids in severe malaria showed harm with increased need for rescue fluid (17.6% versus 0.0%; P<0.005) 2
Avoid routine bolus IV fluids in patients with severe febrile illness who are NOT in shock:
- This increases risk of fluid overload and respiratory complications without improving outcomes 2, 1
- High IV fluid volumes (>2000 mL/day) in non-shock patients associated with increased risk of progression to severe dengue (HR 1.77,95% CI 1.05-2.97) 4
Recognize the critical phase (days 3-7 of illness):
- Plasma leakage can rapidly progress to shock during this window 1, 3
- Failure to recognize this phase and delay fluid resuscitation worsens outcomes 1
Warning Signs Requiring Hospitalization
Admit patients immediately if any of these develop: