Dengue Fever Fluid Rates
For Dengue Shock Syndrome: Administer 20 mL/kg of isotonic crystalloid as a rapid bolus over 5-10 minutes, with immediate reassessment after each bolus, and repeat up to 40-60 mL/kg in the first hour if shock persists before escalating to colloids or vasopressors. 1, 2
Initial Assessment for Shock
Before determining fluid rates, rapidly assess for shock indicators:
- Hemodynamic signs: Tachycardia, hypotension, narrow pulse pressure (<20 mmHg), poor capillary refill (>2 seconds) 1
- Perfusion markers: Cold extremities, skin mottling, altered mental status, decreased urine output 1
- Warning signs of progression: Persistent vomiting, severe abdominal pain, lethargy/restlessness, mucosal bleeding, rising hematocrit with rapidly falling platelets 1, 2
Fluid Management Algorithm by Clinical Presentation
Non-Shock Dengue (Stable Patients)
Oral rehydration is the cornerstone of management for patients without shock. 2
- Target oral intake: 2,500-3,000 mL daily (approximately 5 or more glasses throughout the day) 1, 3
- Fluid options: Water, oral rehydration solutions, cereal-based gruels, soup, rice water 1
- Avoid: Soft drinks due to high osmolality 1
- Evidence: This oral intake volume reduces hospitalization rates 1, 3
Critical caveat: Do NOT administer routine bolus IV fluids to patients with severe febrile illness who are not in shock—this increases fluid overload and respiratory complications without improving outcomes. 4, 2
Dengue Shock Syndrome (Established Shock)
Aggressive fluid resuscitation is life-saving and achieves near 100% survival with appropriate management. 2
Initial Resuscitation (First Hour)
First bolus: 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) over 5-10 minutes 1, 2
Reassess immediately after each bolus for improvement:
If shock persists: Repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour 1, 2
Escalation to Colloids (If Crystalloids Insufficient)
Switch to colloids if shock persists despite adequate crystalloid resuscitation. 2
- Colloid advantage: Moderate-quality evidence shows 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, 2, 5
- Preferred colloid: Dextran 70 provides the most rapid normalization of hematocrit and restoration of cardiac index without adverse effects 5
- Alternatives: Gelafundin or albumin if dextran unavailable 2
Vasopressor Support (Refractory Shock)
If shock persists despite adequate fluid resuscitation (40-60 mL/kg), switch to inotropic support rather than continuing aggressive fluids. 1, 2
- Cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1, 2
- Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 1, 2
- Targets: Mean arterial pressure appropriate for age, ScvO2 >70% 2
- Critical point: Begin peripheral inotropic support immediately if central access not readily available—delays in vasopressor therapy significantly increase mortality 2
Critical Monitoring During Resuscitation
Signs of Adequate Resuscitation
- Normal capillary refill time (<2 seconds)
- Absence of skin mottling
- Warm and dry extremities
- Well-felt peripheral pulses
- Return to baseline mental status
- Adequate urine output (>1 mL/kg/hour) 1, 2
Signs of Fluid Overload (STOP Fluids Immediately)
- Hepatomegaly (enlarging liver edge)
- Pulmonary rales on lung examination
- Respiratory distress
- Rising hematocrit despite fluids (indicates ongoing plasma leakage, not overload) 1, 2
Laboratory Monitoring
- Daily complete blood count: Track hematocrit (rising indicates ongoing plasma leakage and need for continued resuscitation) and platelet count 1, 2
- Hematocrit is key: Rising hematocrit indicates ongoing plasma leakage; falling hematocrit after initial rise indicates recovery phase 1
Critical Pitfalls to Avoid
Do NOT use restrictive fluid strategies in established dengue shock syndrome—moderate-quality evidence shows no survival benefit, and restrictive fluids in severe malaria showed harm with increased need for rescue fluid (17.6% versus 0.0%; P<0.005). 4, 2
Do NOT delay fluid resuscitation in dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow, and delays significantly increase mortality. 2
Do NOT continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead. Evidence shows that aggressive shock management combined with judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3%. 2
Do NOT give routine bolus IV fluids to patients without shock—this leads to fluid overload and respiratory complications without improving outcomes. 4, 2
Do NOT fail to recognize the critical phase (days 3-7 of illness)—this is when plasma leakage can rapidly progress to shock and fluid management becomes most crucial. 2
Do NOT rely solely on blood pressure in children—blood pressure alone is not a reliable endpoint, as hypotension is a late finding in pediatric shock. 2
Nuances in the Evidence
The 2015 International Consensus guidelines 4 acknowledge limited evidence specifically for dengue shock syndrome but recommend 20 mL/kg boluses based on weak recommendations with low-quality evidence. However, the most recent and comprehensive guidelines 1, 2 provide stronger recommendations based on multiple RCTs showing near 100% survival with aggressive fluid management in dengue shock syndrome.
Important distinction: The FEAST trial, which showed harm from bolus fluids in "severe febrile illness," specifically excluded patients in established shock and was conducted in a different clinical context (African children with malaria and other infections, not dengue). 4, 2 This trial should NOT be extrapolated to dengue shock syndrome, where aggressive fluid resuscitation is life-saving.