Immediate Fluid Resuscitation for Dengue Shock Syndrome
This 12-year-old patient with dengue shock syndrome and documented hypotension (BP 60/40 mmHg) requires immediate aggressive fluid resuscitation with 20 mL/kg boluses of isotonic crystalloid (D5LR or Ringer's lactate) administered rapidly over 5-10 minutes, which translates to 750 mL given at maximum infusion rate, followed by immediate reassessment and repeat boluses up to 40-60 mL/kg in the first hour if shock persists. 1, 2, 3
Current Clinical Status Assessment
Your patient is in dengue shock syndrome (DSS) Grade IV based on:
- Documented hypotension with BP 60/40 mmHg (profound shock) 1
- Current BP 80/60 mmHg indicates persistent hypotension for a 12-year-old 1
- Weight: 37.5 kg 1
The current rate of 113 microdrops/minute (approximately 113 mL/hour or 3 mL/kg/hour) is grossly inadequate for active shock resuscitation. 1
Immediate Action Required
First Hour Resuscitation Protocol
Administer 750 mL (20 mL/kg) D5LR as rapid bolus over 5-10 minutes:
- Using gravity flow or pressure bag, infuse as rapidly as possible 1
- This requires approximately 75-150 mL/minute, not 113 mL/hour 1
- Do not use the 9-hour alternating schedule during active shock 1
After first bolus, immediately reassess for:
- Blood pressure normalization (target MAP appropriate for age) 1, 2
- Capillary refill <2 seconds 1, 2, 3
- Warm extremities, strong peripheral pulses 1, 2, 3
- Improved mental status 1, 2, 3
- Urine output >0.5 mL/kg/hour 1, 2
If shock persists after first bolus:
- Repeat 20 mL/kg boluses (750 mL each) 1
- Can administer up to 40-60 mL/kg total (1,500-2,250 mL) in first hour 1
- Reassess after each bolus 1, 3
Monitoring During Resuscitation
Watch for signs of adequate resuscitation:
- Normal capillary refill time 1, 2, 3
- Absence of skin mottling 1, 2
- Warm and dry extremities 1, 2, 3
- Well-felt peripheral pulses 1, 2, 3
- Return to baseline mental status 1, 2, 3
- Adequate urine output 1, 2, 3
Watch for signs of fluid overload (stop boluses if present):
- Hepatomegaly (new or worsening) 1, 2, 3
- Rales on lung examination 1, 2, 3
- Increased work of breathing 1
- Respiratory distress 1, 2, 3
Escalation if Fluid-Refractory Shock
If hypotension persists despite 40-60 mL/kg crystalloid:
Consider colloid therapy:
- Moderate-quality evidence shows colloids achieve faster shock resolution (RR 1.09,95% CI 1.00-1.19) 2, 3
- Colloids require less total volume (mean 31.7 mL/kg vs 40.63 mL/kg for crystalloids) 2, 3
- Options include 6% hydroxyethyl starch (preferred over dextran due to fewer adverse reactions) 4
Initiate vasopressor support if shock persists:
- For cold shock with hypotension: epinephrine as first-line 1, 2, 3
- For warm shock with hypotension: norepinephrine as first-line 1, 2, 3
- Target ScvO2 >70% 1, 2, 3
- Can begin peripheral inotropic support while establishing central access 1
Maintenance Fluid After Shock Resolution
Only after shock resolves and patient stabilizes:
- Reduce to maintenance rate: 5-7 mL/kg/hour initially 1
- For 37.5 kg patient: approximately 188-263 mL/hour 1
- Continue monitoring hematocrit every 4-6 hours 3, 5
- Adjust based on clinical response and hematocrit trends 1, 3
Critical Pitfalls to Avoid
Do not continue the current slow infusion rate during active shock - this patient requires immediate aggressive resuscitation, not maintenance fluids. 1
Do not delay fluid resuscitation - dengue shock can rapidly progress to cardiovascular collapse and death within hours without adequate resuscitation. 1, 3
Do not continue aggressive fluid boluses once signs of fluid overload appear - switch to inotropic support instead. 1, 2, 3
Do not rely solely on blood pressure - children compensate with vasoconstriction and tachycardia, so hypotension represents late, severe shock requiring immediate intervention. 1
Do not use restrictive fluid strategies in established dengue shock syndrome - moderate-quality evidence shows no survival benefit and may worsen outcomes. 2, 3