What is the initial fluid management for patients with dengue hemorrhagic fever (DHF)?

Initial Fluid Management for Dengue Hemorrhagic Fever

For patients with dengue hemorrhagic fever (DHF) who are NOT in shock, oral rehydration is the appropriate initial management, targeting 2,500-3,000 mL daily intake; however, if dengue shock syndrome (DSS) develops, immediately administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes. 1

Fluid Strategy Based on Shock Status

Non-Shock DHF Patients

• Encourage oral hydration with 5 or more glasses of fluid throughout the day, using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1, 2
• Avoid soft drinks due to high osmolality 2
• 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 1

Dengue Shock Syndrome (DSS)

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes 1, 3, 2
• Reassess immediately after each bolus for signs of improvement: improved tachycardia, improved tachypnea, normal capillary refill time, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output 1, 2
• If shock persists after initial crystalloid bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 1, 3, 2

When to Escalate to Colloid Solutions

If shock persists despite adequate crystalloid resuscitation (40-60 mL/kg in first hour), switch to colloid solutions. 1

• Colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1, 3
• Preferred colloid options include 6% hydroxyethyl starch or gelafundin, as dextran 70 is associated with significantly more adverse reactions despite similar efficacy 4, 5
• The landmark 2005 NEJM trial demonstrated that while dextran 70 and 6% hydroxyethyl starch perform similarly in severe shock, starch may be preferable given the adverse reactions associated with dextran 4

Critical Monitoring Parameters

Watch for these clinical indicators of adequate tissue perfusion rather than relying solely on laboratory values:

• Normal capillary refill time and absence of skin mottling 1, 2
• Warm and dry extremities with well-felt peripheral pulses 1, 2
• Return to baseline mental status 1, 2
• Adequate urine output 1, 2
• Monitor hematocrit closely, as rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 2
• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1, 3

When to STOP Fluid Resuscitation

Immediately stop fluid resuscitation if any of these signs of fluid overload appear:

• Hepatomegaly 1, 3
• Rales on lung examination 1, 3
• Respiratory distress 1, 3

Switch to inotropic support rather than continuing aggressive fluid administration 1, 2

Management of Refractory Shock

If shock persists despite adequate fluid resuscitation and signs of fluid overload appear:

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 2
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1, 3
• 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

Critical Pitfalls to Avoid

• Do NOT delay fluid resuscitation in established dengue shock syndrome, as once hypotension occurs, cardiovascular collapse may rapidly follow 1
• Do NOT continue aggressive fluid resuscitation once signs of fluid overload appear—this is the most common error leading to pulmonary edema, particularly during the recovery phase 1, 3
• Do NOT use restrictive fluid strategies in established dengue shock syndrome, as moderate-quality evidence shows no survival benefit and may worsen outcomes, with three RCTs demonstrating near 100% survival with aggressive fluid management 1, 3
• Do NOT fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 3
• Avoid aspirin and NSAIDs due to increased bleeding risk 1, 2

Supportive Care

• Use acetaminophen (paracetamol) only for pain and fever management 1, 2
• Blood transfusion may be necessary in cases of significant bleeding, maintaining hemoglobin at a minimum of 10 g/dL 1, 2
• Resume age-appropriate diet as soon as appetite returns 1