Is the management of dengue shock with normal saline, norepinephrine, and colloid appropriate?

Management of Dengue Shock Syndrome

The management approach used in this case—initial crystalloid resuscitation with normal saline, followed by colloid administration and norepinephrine for persistent hypotension—is appropriate and aligns with evidence-based guidelines for dengue shock syndrome. 1, 2, 3

Initial Fluid Resuscitation Strategy

The patient received 1500 mL of normal saline (0.9%) at the referring facility, which represents the correct first-line approach:

• Isotonic crystalloids (normal saline or Ringer's lactate) are the recommended initial resuscitation fluid for dengue shock syndrome, with 20 mL/kg boluses administered rapidly over 5-10 minutes. 1, 2, 3
• Multiple randomized controlled trials in children with dengue shock syndrome demonstrated near 100% survival with aggressive crystalloid resuscitation, regardless of fluid composition used. 4, 5
• Initial volume resuscitation commonly requires 40-60 mL/kg but can reach up to 200 mL/kg in severe cases. 4

Appropriate Escalation to Colloid Therapy

The provider's decision to administer colloid (high-molecular-weight fluid) was clinically justified:

• Colloids are specifically indicated when pulse pressure is ≤10 mmHg or when patients fail to respond adequately to initial crystalloid resuscitation. 2, 6
• Evidence shows colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids). 3
• A landmark randomized trial demonstrated that dextran 70 provided the most rapid normalization of hematocrit and restoration of cardiac index without adverse effects in dengue shock syndrome. 7
• However, a larger trial showed that while colloids work faster, Ringer's lactate is equally effective for moderately severe shock, with only minor differences in outcomes. 5

Vasopressor Management

The use and titration of norepinephrine was appropriate:

• Norepinephrine is the first-choice vasopressor for warm shock with hypotension, which this patient likely had given the clinical presentation. 4, 1, 3
• The provider correctly increased the vasopressor rate from 5 mL/h to 10 mL/h when the patient remained hypotensive despite fluid resuscitation. 1
• Vasopressors should be initiated when shock persists despite adequate fluid resuscitation, targeting a mean arterial pressure of 65 mmHg in adults. 4
• Delaying vasopressor therapy is associated with major increases in mortality, so early initiation was appropriate. 3

Critical Monitoring and Response Assessment

The clinical response after 1 hour validates the management approach:

• Blood pressure improved from 70/40 to 100/60 mmHg. 1
• Mental status improved (patient became alert and responsive). 1, 3
• Abdominal pain reduced. 1

These are the exact endpoints recommended for assessing adequate resuscitation: normal capillary refill time, absence of skin mottling, warm extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output. 1, 2, 3

Important Caveats and Pitfalls Avoided

The provider successfully avoided several common errors:

• Did not delay fluid resuscitation, which significantly increases mortality in established dengue shock syndrome. 3
• Did not continue aggressive fluid resuscitation once hemodynamic improvement occurred, appropriately switching focus to vasopressor support rather than risking fluid overload. 1, 3
• Did not use restrictive fluid strategies, which have no survival benefit and may worsen outcomes in dengue shock syndrome. 3

Ongoing Management Considerations

Moving forward, the provider should:

• Monitor hematocrit closely, as rising hematocrit indicates ongoing plasma leakage and need for continued vigilance. 1
• Watch for signs of fluid overload (hepatomegaly, pulmonary rales, respiratory distress) and immediately stop fluid resuscitation if these develop. 1, 3
• Consider switching from norepinephrine to epinephrine if the patient develops "cold shock" physiology (low cardiac output). 1, 3
• Maintain hemoglobin ≥10 g/dL if significant bleeding occurs, as oxygen delivery depends on hemoglobin concentration. 1
• Avoid aspirin and NSAIDs due to bleeding risk; use only acetaminophen for fever/pain management. 1, 3

Evidence Quality Assessment

The management approach is supported by high-quality evidence:

• Multiple Level 1 randomized controlled trials specifically in dengue shock syndrome patients demonstrate the efficacy of this stepwise approach. 4, 7, 5
• The 2012 Surviving Sepsis Campaign guidelines provide strong recommendations (Grade 1B) for crystalloids as initial fluid and norepinephrine as first-choice vasopressor, which apply to dengue shock syndrome as a form of distributive shock. 4
• Recent consensus guidelines from multiple societies (American College of Critical Care Medicine, World Health Organization, American College of Cardiology) consistently support this management strategy. 1, 2, 3