Is it safe to administer Ringer's (lactated Ringer's solution) in a patient with Dengue Hemorrhagic Fever (DHF)?

Is Ringer's Lactate Safe in Dengue Hemorrhagic Fever (DHF)?

Yes, Ringer's lactate is safe and appropriate for initial fluid resuscitation in patients with DHF, particularly for those with moderate shock, though colloids may be considered for severe dengue shock syndrome. 1

Evidence-Based Fluid Management in DHF

Initial Resuscitation Strategy

• For DHF patients with shock, administer an initial fluid bolus of 20 mL/kg with subsequent patient reassessment. 1 This recommendation comes from the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science, which specifically addresses dengue shock syndrome.

• Ringer's lactate is effective for moderately severe dengue shock syndrome. 2 A high-quality randomized trial of 383 Vietnamese children with moderately severe dengue shock demonstrated that Ringer's lactate performed similarly to colloid solutions (dextran 70 and hydroxyethyl starch) with only minor differences in efficacy.

Crystalloid vs. Colloid Selection

For moderate DHF/DSS:

• Ringer's lactate is the first-line choice 2
• Results in slightly slower hematocrit improvement and marginally longer time to initial recovery compared to colloids, but no differences in other treatment response measures 2
• Mortality was extremely low (<0.2%) across all fluid types 2

For severe dengue shock syndrome:

• Colloids may be preferred for more rapid hemodynamic stabilization 3, 2
• If colloids are used, hydroxyethyl starch is preferable to dextran 70 due to fewer adverse reactions 2
• Dextran 70 provides the most rapid normalization of hematocrit and cardiac index restoration but carries higher risk of adverse reactions 3, 2

Volume Considerations

• The majority of DSS patients can be treated successfully with isotonic crystalloid solutions. 4
• Ringer's lactate administration typically requires larger volumes than colloids to achieve similar hemodynamic endpoints 2, 5
• Monitor closely for fluid overload, particularly when using crystalloid-only resuscitation 5

Important Caveats

Avoid Ringer's lactate in specific circumstances:

• Do NOT use Ringer's lactate in DHF patients with concurrent severe head trauma 1, as hypotonic solutions can worsen cerebral edema by causing fluid shift into damaged cerebral tissue
• This is a critical safety consideration that supersedes the general recommendation for DHF

For DHF patients without shock:

• Routine bolus intravenous fluids (crystalloids or colloids) are not recommended 1
• Frequent reassessment is emphasized to detect early deterioration

Emerging Evidence

• Recent data suggests early intervention with 5% albumin in hospitalized adults with DHF grade I and II may provide superior vascular integrity control compared to Ringer's lactate, with shorter length of stay 6
• Hypertonic sodium lactate solution (HSL) achieved similar hemodynamic recovery with one-third lower fluid accumulation compared to standard Ringer's lactate volumes 5

Clinical Algorithm

1. Assess shock severity in DHF patient
2. If moderate shock present: Start Ringer's lactate 20 mL/kg bolus over 15 minutes 1, 2
3. If severe shock present: Consider colloid (preferably hydroxyethyl starch over dextran) 2
4. Reassess after bolus: Evaluate hemodynamic response, hematocrit, and signs of fluid overload
5. If inadequate response: Administer rescue colloid 2
6. Screen for contraindications: Rule out severe head trauma before using Ringer's lactate 1