Hemoperfusion Has No Role in Dengue Hemorrhagic Syndrome Management
Hemoperfusion is not indicated in dengue hemorrhagic syndrome; the cornerstone of management is aggressive fluid resuscitation with crystalloids and colloids, not extracorporeal blood purification techniques. The provided evidence contains no recommendations for hemoperfusion in dengue management from any major guideline or research study 1, 2, 3.
Why Hemoperfusion Is Not Used
Dengue hemorrhagic syndrome is fundamentally a disease of increased capillary permeability and plasma leakage, not toxin accumulation or metabolic derangement that would benefit from hemoperfusion 1, 4. The pathophysiology involves:
- Massive plasma losses through increased vascular permeability requiring volume replacement 4
- Hemoconcentration from intravascular volume depletion 1, 5
- Thrombocytopenia and coagulopathy from viral effects and consumption 4, 6
The management priority is rapid restoration of intravascular volume, not blood purification 1, 7.
Evidence-Based Management Instead
Immediate Fluid Resuscitation for Shock
- 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
- Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists before escalating therapy 1, 3
- Colloids (dextran 70, gelafundin, or albumin) achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and require less total volume (31.7 mL/kg versus 40.63 mL/kg for crystalloids) compared to crystalloids alone 1, 7
When Renal Replacement Is Actually Needed
The only extracorporeal therapy with evidence in dengue complications is continuous veno-venous hemodialysis (CVVHD) for acute kidney injury with anuria, not hemoperfusion 8. CVVHD is used to:
- Remove excess fluid reabsorbed during the recovery phase 8
- Prevent heart failure and pulmonary edema from fluid overload 8
- Manage electrolyte and metabolic disturbances in renal failure 8
This is fundamentally different from hemoperfusion, which removes toxins through adsorption rather than providing renal replacement 8.
Critical Monitoring Parameters
Watch for clinical indicators of adequate tissue perfusion rather than pursuing unproven therapies 1, 3:
- Normal capillary refill time and absence of skin mottling 1
- Warm and dry extremities with well-felt peripheral pulses 1
- Return to baseline mental status and adequate urine output 1
- Improvement in tachycardia and tachypnea 1
Management of Severe Complications
For Refractory Shock
- Epinephrine for cold shock with hypotension 1, 3
- Norepinephrine for warm shock with hypotension 1, 3
- Target age-appropriate mean arterial pressure and maintain ScvO2 >70% 1
For Coagulopathy and Bleeding
- Blood transfusion may be necessary in cases of significant bleeding 1, 2
- Fresh frozen plasma for established coagulopathy with PT/aPTT >1.5 times normal 9
- Platelet transfusion targeting minimum count of 75 × 10⁹/L in massive hemorrhage 9
Common Pitfalls to Avoid
- Do not pursue unproven extracorporeal therapies like hemoperfusion when the evidence strongly supports fluid resuscitation as the definitive treatment 1, 7
- Do not continue aggressive fluid resuscitation once signs of fluid overload appear; switch to inotropic support instead 1, 3
- Do not use restrictive fluid strategies in established dengue shock syndrome, as this worsens outcomes 1, 3
- Do not delay fluid resuscitation seeking alternative therapies, as cardiovascular collapse may rapidly follow once hypotension occurs 1