Is the use of colloids (fluid resuscitation fluids), specifically albumin, indicated in a patient showing the first symptoms of dengue shock?

Colloid Use in Early Dengue Shock: Not Recommended as First-Line

Crystalloid solutions (isotonic saline or Ringer's lactate) should be used as the initial fluid of choice for dengue shock syndrome, with colloids reserved only for severe shock (pulse pressure <10 mmHg) or crystalloid-refractory cases. 1, 2

Initial Fluid Resuscitation Strategy

Start with crystalloid boluses of 20 mL/kg over 5-10 minutes and reassess immediately. 1, 2 This approach has demonstrated near 100% survival in pediatric dengue shock when applied promptly, regardless of fluid composition used. 3

Why Crystalloids First?

• Isotonic crystalloids (normal saline or Ringer's lactate) are the evidence-based first-line choice for dengue shock syndrome. 1, 2
• Multiple randomized controlled trials in dengue-specific populations show that crystalloids achieve similar mortality outcomes to colloids in moderate dengue shock (WHO stage III). 4
• The largest comparative trial (383 children with moderate dengue shock) found no significant difference in rescue colloid requirements between Ringer's lactate and colloid solutions (relative risk 1.08,95% CI 0.78-1.47, P=0.65). 4
• Crystalloids are significantly more cost-effective: isotonic saline costs approximately 1.5 Euro per liter versus 25-140 Euro for colloid solutions. 1

When to Consider Colloids

Colloids should only be considered in two specific scenarios:

Severe Dengue Shock

• Use colloids when pulse pressure is <10 mmHg, indicating severe shock with profound vascular collapse. 1, 2
• In severe dengue shock (WHO stage IV), colloids provide more rapid normalization of hematocrit and restoration of cardiac index compared to crystalloids. 5

Crystalloid-Refractory Shock

• Consider colloids when patients fail to respond to initial crystalloid resuscitation with persistent shock despite adequate volume administration. 1, 6
• Early albumin administration for crystalloid-refractory shock has shown improved outcomes, including decreased positive fluid balance and reduced complications. 6

Choice of Colloid When Indicated

If colloids are necessary, albumin or hydroxyethyl starch are preferred over dextran:

• Albumin (5%) demonstrates superior control of vascular integrity with lower hemoconcentration, higher platelet counts, and reduced proteinuria compared to crystalloids in hospitalized DHF patients. 7
• Hydroxyethyl starch (6% HES 130/0.4) may be preferable to dextran 70 due to fewer adverse reactions, despite similar efficacy in severe shock. 4
• Dextran 70, while providing rapid hematocrit normalization, causes significantly more adverse reactions than starch solutions. 4
• Avoid hydroxyethyl starches in septic shock contexts, as they increase mortality and renal replacement therapy requirements. 3

Critical Monitoring After Fluid Administration

Reassess immediately after each bolus for:

• Hemodynamic improvement (pulse pressure, blood pressure, heart rate). 8, 1
• Signs of adequate tissue perfusion (capillary refill time, skin temperature, mental status, urine output). 1
• Signs of fluid overload (new onset rales, increased work of breathing, hepatomegaly). 3

Continue fluid boluses only as long as hemodynamic parameters improve. 8 Stop when perfusion normalizes or fluid overload develops. 8

Common Pitfalls to Avoid

• Do not delay fluid resuscitation while awaiting colloid availability - start with crystalloids immediately. 8, 2
• Do not use colloids as first-line therapy in moderate dengue shock - this increases costs without mortality benefit. 4
• Avoid excessive fluid administration in patients without shock, as this leads to fluid overload and respiratory complications. 1
• Do not fail to recognize the critical phase (days 3-7 of illness) when plasma leakage rapidly progresses to shock. 1
• Monitor for symptomatic abdominal compartment syndrome in patients requiring large-volume resuscitation, as this complication significantly increases mortality. 6

Subsequent Management

If shock persists despite adequate fluid resuscitation:

• Consider vasopressor support (dopamine or norepinephrine) targeting MAP ≥65 mmHg. 3, 2
• Implement proactive fluid removal strategies (diuretics or dialysis) if oliguria develops after aggressive resuscitation, as this approach improves outcomes. 3
• Patients with >10% fluid overload requiring continuous renal replacement therapy have worse outcomes than those treated earlier. 3