What is the recommended fluid management strategy for patients with dengue?

Dengue Fluid Management

Initial Assessment and Risk Stratification

For patients without shock, oral rehydration is the cornerstone of management, targeting 2,500-3,000 mL daily (approximately 5 or more glasses throughout the day), while patients with dengue shock syndrome require immediate intravenous crystalloid resuscitation with 20 mL/kg boluses. 1

The critical distinction is identifying whether the patient is in shock versus having uncomplicated dengue fever:

• Monitor for shock indicators: tachycardia, hypotension, poor capillary refill, altered mental status, cold extremities, and narrow pulse pressure 1, 2
• Track warning signs of progression: persistent vomiting, severe abdominal pain, lethargy/restlessness, mucosal bleeding, rising hematocrit with rapidly falling platelet count 1, 3
• Recognize the critical phase: days 3-7 of illness when plasma leakage can rapidly progress to shock 1, 2

Fluid Management for Non-Shock Dengue

Avoid 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. 1

• Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water; avoid soft drinks due to high osmolality 1
• Target approximately 2,500-3,000 mL daily oral intake, which evidence shows reduces hospitalization rates 1, 4
• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1, 3

Fluid Management for Dengue Shock Syndrome

Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes, with immediate reassessment after each bolus. 1, 5

Initial Resuscitation Protocol:

• Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists after initial bolus 1
• Reassess after each bolus for improvement in tachycardia, tachypnea, capillary refill, mental status, and urine output 1
• High-quality evidence from randomized trials demonstrates near 100% survival with appropriate aggressive fluid management 1

When to Escalate to Colloids:

• Consider colloid solutions (6% hydroxyethyl starch preferred over dextran 70) for severe shock when crystalloids alone are insufficient 1, 5
• Moderate-quality evidence shows colloids provide faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reduce total bolus volume needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1
• A 2005 randomized trial of 512 children found hydroxyethyl starch and dextran 70 performed similarly, but starch had fewer adverse reactions, making it preferable 5
• Alternative colloids include gelafundin or albumin if dextran is unavailable 1

Critical Monitoring Parameters

Stop fluid resuscitation immediately if signs of fluid overload develop: hepatomegaly, pulmonary rales, or respiratory distress. 1, 6

• Target endpoints: normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, adequate urine output (>0.5 mL/kg/hour) 1, 2
• Monitor hematocrit closely: rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 3
• The risk for respiratory distress with fluid accumulation increases significantly as infused volume increases (hazard ratio 1.18 per 10 mL/kg increase) 7

Management of Refractory Shock

If shock persists despite adequate fluid resuscitation (40-60 mL/kg), switch from fluids to inotropic support rather than continuing aggressive fluid administration. 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
• Consider invasive monitoring in resource-rich settings with persistent shock to guide therapy 1

Critical Pitfalls to Avoid

• Never delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow, and delays significantly increase mortality 1
• Do not use restrictive fluid strategies in dengue shock syndrome—moderate-quality evidence shows no survival benefit from colloid restriction, and restrictive fluids may worsen outcomes 1
• Avoid excessive fluid boluses in patients without shock—this leads to fluid overload and respiratory complications without improving outcomes 1, 7
• Never use aspirin or NSAIDs due to increased bleeding risk and worsening of hemorrhagic manifestations 1, 3
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 1

Supportive Care

• Use acetaminophen (paracetamol) only for pain and fever management 1, 3
• Blood transfusion may be necessary in cases of significant bleeding 1, 2
• Maintain hemoglobin at minimum of 10 g/dL, as oxygen delivery depends on hemoglobin concentration 8