What is the treatment for critical stage dengue?

Treatment of Critical Stage Dengue

For critical stage dengue with shock, immediately administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes, with aggressive fluid resuscitation up to 40-60 mL/kg in the first hour if shock persists, as this approach achieves near 100% survival with appropriate fluid management. 1

Immediate Resuscitation Protocol

Initial fluid management:

• Administer 20 mL/kg isotonic crystalloid bolus over 5-10 minutes for dengue shock syndrome 1
• Reassess after each bolus for signs of improvement: reduced tachycardia, improved tachypnea, better capillary refill, and normalized mental status 1
• Repeat crystalloid boluses up to 40-60 mL/kg total in the first hour before escalating therapy if shock persists 1
• Crystalloids (Ringer's lactate or 0.9% normal saline) are first-line for initial resuscitation 1, 2

Escalation to colloids:

• Switch to colloid solutions (dextran, gelafundin, or albumin) if shock persists despite adequate crystalloid resuscitation 1
• Moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and require less total volume (31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1
• The ideal fluid management includes both crystalloids and colloids for massive plasma leakage 3

Critical Monitoring During Resuscitation

Signs of adequate resuscitation:

• Normal capillary refill time, 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) 1
• Rising hematocrit of 20% with dropping platelet count signals impending shock and requires immediate intervention 3

Signs to STOP fluid resuscitation immediately:

• Hepatomegaly development 1
• Pulmonary rales on examination 1
• Respiratory distress 1
• These indicate fluid overload and mandate switching from fluids to inotropic support 1

Management of Refractory Shock

Vasopressor selection based on hemodynamic state:

• Cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1
• 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 significantly increase mortality 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1
• Norepinephrine should be considered when fluid leakage leads to pulmonary edema and restricts further fluid administration 2

Monitoring Parameters Throughout Critical Phase

Daily laboratory monitoring:

• Complete blood count to track platelet counts and hematocrit levels 1
• Frequent hematocrit determinations are essential for evaluating treatment response 3

Clinical vigilance during days 3-7 of illness (critical phase):

• This is when plasma leakage can rapidly progress to shock 1, 4
• Monitor for warning signs: severe abdominal pain, persistent vomiting, lethargy or restlessness, mucosal bleeding 1
• High hematocrit with rapidly falling platelet count signals severe disease progression 1

Management of Complications

Bleeding complications:

• Blood transfusion, fresh frozen plasma, and platelet transfusions may be necessary for significant bleeding or DIC 1, 3
• Avoid aspirin and NSAIDs due to increased bleeding risk 1, 4

Pleural effusion and ascites:

• Avoid drainage if possible, as it can lead to severe hemorrhages and sudden circulatory collapse 3
• These represent plasma leakage and typically resolve with appropriate fluid management 4

Metabolic disturbances:

• Correct electrolyte and metabolic abnormalities as they arise 3
• Provide oxygen to all patients in shock 3

Critical Pitfalls to Avoid

DO NOT delay fluid resuscitation in established dengue shock syndrome:

• Once hypotension occurs, cardiovascular collapse may rapidly follow 1
• Delays significantly increase mortality 1
• Blood pressure alone is not a reliable endpoint in children 1

DO NOT use restrictive fluid strategies in dengue shock syndrome:

• Three RCTs demonstrate near 100% survival with aggressive fluid management 1
• 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) 1

DO NOT give routine bolus IV fluids to patients NOT in shock:

• This increases risk of fluid overload and respiratory complications without improving outcomes 1, 4
• Oral rehydration is appropriate for patients without shock 1, 4

DO NOT continue aggressive fluid resuscitation once signs of fluid overload appear:

• Switch to inotropic support instead 1
• Evidence shows that aggressive shock management combined with judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1

DO NOT use aspirin or NSAIDs for fever control:

• Use acetaminophen (paracetamol) only for pain and fever management 1, 4
• NSAIDs worsen bleeding tendencies 1, 4

Prognosis and Outcomes

• With early recognition and appropriate aggressive fluid management, survival approaches 100% 1
• Mortality in severe dengue ranges from 1-5% with good supportive care 5
• Death typically occurs within 2 days of hospitalization in patients with multi-organ dysfunction despite supportive care 6
• Prognosis depends mainly on early recognition and treatment of shock 3