What is the management approach for severe dengue?

Management of Severe Dengue

For severe dengue, immediate aggressive fluid resuscitation with 20 mL/kg isotonic crystalloid bolus over 5-10 minutes is the cornerstone of management, with readiness to escalate to colloids and vasopressors if shock persists. 1

Initial Fluid Resuscitation Protocol

Administer 20 mL/kg of Ringer's lactate or 0.9% normal saline as a rapid bolus over 5-10 minutes for dengue shock syndrome. 1 Reassess immediately after each bolus for signs of improvement, including resolution of tachycardia and tachypnea. 1

• If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy. 1
• Moderate-quality evidence demonstrates that colloids achieve faster resolution of shock compared to crystalloids alone (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (mean 31.7 mL/kg versus 40.63 mL/kg). 1
• For severe dengue shock syndrome, colloid solutions (gelafundin or albumin) may be beneficial when available. 1

Critical Monitoring Parameters

Watch for clinical indicators of adequate tissue perfusion: normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output (>0.5 mL/kg/hour in adults). 1, 2

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels. 1, 3
• Monitor for warning signs of progression: high hematocrit with rapidly falling platelet count, severe abdominal pain, persistent vomiting, lethargy or restlessness, and mucosal bleeding. 1, 3
• The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock. 1, 2

Management of Refractory Shock

Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop, and switch to inotropic support. 1

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor. 1
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor. 1
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy are associated with major increases in mortality. 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%. 1

Supportive Care and Complications Management

Avoid aspirin and all non-steroidal anti-inflammatory drugs due to increased bleeding risk. 1, 3, 2 Use acetaminophen (paracetamol) only for pain and fever management. 3

• Blood transfusion may be necessary in cases of significant bleeding. 1, 3, 2
• Obtain blood and urine cultures and chest radiograph if fever persists to diagnose secondary bacterial infections. 3
• Monitor with continuous cardiac telemetry and pulse oximetry for patients with dengue shock syndrome. 3

Critical Pitfalls to Avoid

Do not delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow. 1 Three RCTs demonstrate near 100% survival with aggressive fluid management. 1

• Avoid routine bolus IV 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. 1
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear (hepatomegaly, rales, respiratory distress). 1
• Restrictive fluid strategies have no survival benefit in dengue shock syndrome and may worsen outcomes. 1
• Do not fail to recognize the critical phase when plasma leakage can rapidly progress to shock. 1, 2
• Avoid overhydration during the recovery phase, which can lead to pulmonary edema. 1