Hydration Management for Dengue with Warning Signs
For patients with dengue and warning signs who are not in shock, ensure adequate oral hydration with a target of more than 2,500 mL daily using oral rehydration solutions, while avoiding routine bolus intravenous fluids which increase risk of fluid overload without improving outcomes. 1, 2
Initial Assessment and Risk Stratification
When a patient presents with dengue and warning signs, immediately assess for the presence of shock versus compensated status:
- Warning signs include: persistent vomiting, severe abdominal pain, lethargy or restlessness, mucosal bleeding, high hematocrit with rapidly falling platelet count, and fluid accumulation 1, 2
- The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock 2
- Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1
Hydration Protocol Based on Clinical Status
For Patients WITH Warning Signs but WITHOUT Shock
Oral rehydration is the cornerstone of management:
- Encourage 5 or more glasses of fluid throughout the day, targeting approximately 2,500-3,000 mL daily 2
- Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 2
- Avoid soft drinks due to high osmolality 2
- Critical pitfall to avoid: Do NOT administer routine bolus intravenous fluids in patients with severe febrile illness who are not in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes 2
For Patients Progressing to Dengue Shock Syndrome
If shock develops (hypotension, narrow pulse pressure, tachycardia, poor capillary refill):
- Administer an initial fluid bolus of 20 mL/kg of isotonic crystalloid over 5-10 minutes 1, 2, 3
- Reassess immediately after the bolus for signs of improvement 1
- If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour 2
- Consider colloid solutions (dextran, gelafundin, or albumin) for severe shock when available, as moderate-quality evidence shows colloids provide faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 2
Monitoring During Fluid Management
Watch for clinical indicators of adequate tissue perfusion:
- Normal capillary refill time 2
- Absence of skin mottling 2
- Warm and dry extremities 2
- Well-felt peripheral pulses 2
- Return to baseline mental status 2
- Adequate urine output (>0.5 mL/kg/hour in adults) 1
Critical signs of fluid overload to monitor:
- Hepatomegaly 2
- Rales on lung examination 2
- Respiratory distress 2
- Do NOT continue aggressive fluid resuscitation once signs of fluid overload appear; switch to inotropic support instead 2
Management of Refractory Shock
If shock persists despite adequate fluid resuscitation:
- For cold shock with hypotension: Titrate epinephrine as first-line vasopressor 2
- For warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 2
- Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 2
Common Pitfalls in Fluid Management
- Avoid overhydration during the recovery phase, which can lead to pulmonary edema, particularly as capillary permeability normalizes 2
- Do not delay fluid resuscitation in patients showing signs of shock 1, 2
- Recognize the critical phase early (typically days 3-7) when plasma leakage can rapidly progress 2
- Evidence from restrictive fluid strategies in severe malaria showed harm with increased need for rescue fluid (17.6% versus 0.0%; P<0.005), supporting the need for adequate but not excessive hydration 2