What is the recommended treatment for severe Dengue (Dengue hemorrhagic fever)?

Treatment of Severe Dengue (Dengue Hemorrhagic Fever)

Immediate aggressive fluid resuscitation with 20 mL/kg isotonic crystalloid bolus over 5-10 minutes is the cornerstone of severe dengue management, with escalation to colloids if shock persists after initial crystalloid resuscitation. 1

Initial Fluid Resuscitation Protocol

For dengue shock syndrome, administer 20 mL/kg of Ringer's lactate or 0.9% normal saline as a rapid bolus over 5-10 minutes, then immediately reassess the patient. 1, 2

• If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 1
• Reassess after each bolus for signs of improvement: decreased tachycardia, decreased tachypnea, improved capillary refill, and warming of extremities 1
• This aggressive approach demonstrates near 100% survival when applied promptly 1, 3

Escalation to Colloid Solutions

Switch from crystalloids to colloids if shock persists despite adequate crystalloid resuscitation (40-60 mL/kg in first hour). 1, 4

• 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
• Dextran 70 provides the most rapid normalization of hematocrit and restoration of cardiac index without adverse effects 5
• Alternative colloids include gelafundin or albumin if dextran is unavailable 1, 6
• Avoid hydroxyethyl starches as they increase mortality and renal replacement therapy requirements 3

Critical Monitoring Parameters

Monitor for clinical indicators of adequate tissue perfusion rather than relying solely on blood pressure, especially in children where blood pressure is an unreliable endpoint. 1, 2

• Normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output 1, 2
• Daily complete blood count to track platelet counts and hematocrit levels 1, 2
• Stop fluid resuscitation immediately if signs of fluid overload develop: hepatomegaly, pulmonary rales, or respiratory distress 1, 3

Management of Refractory Shock

If shock persists despite adequate fluid resuscitation (crystalloids followed by colloids), initiate vasopressor support immediately—delays in vasopressor therapy are associated with major increases in mortality. 1

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 2
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 2, 3
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1, 2
• Begin peripheral inotropic support immediately if central venous access is not readily available 1

Fluid Overload Management

Once perfusion normalizes or fluid overload develops, stop fluid resuscitation and switch to inotropic support. 3, 4

• Implement proactive fluid removal strategies (diuretics or dialysis) if oliguria develops after aggressive resuscitation 3, 6
• Aggressive shock management combined with judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1, 6
• Patients with more than 10% fluid overload requiring continuous renal replacement therapy have worse outcomes than those treated earlier 3

Blood Product Transfusion

Blood transfusion may be necessary in cases of significant bleeding or major hemorrhage. 1

• Monitor for mucosal bleeding, severe abdominal pain, and rapidly falling platelet count as warning signs 1

Critical Pitfalls to Avoid

Do NOT delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow, and delays significantly increase mortality. 1

• Do NOT use restrictive fluid strategies in dengue shock syndrome—three RCTs demonstrate near 100% survival with aggressive fluid management, and restrictive approaches show no survival benefit 1, 2
• Do NOT continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 1, 2, 3
• Do NOT administer routine bolus IV fluids in patients with severe febrile illness who are NOT in shock—this increases risk of fluid overload and respiratory complications without improving outcomes 1, 2
• Do NOT use aspirin or NSAIDs—these worsen bleeding tendencies 1
• Do NOT fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 2, 3

Supportive Care

• Use acetaminophen (paracetamol) only for pain and fever management 1
• Encourage oral rehydration with approximately 2,500-3,000 mL daily for patients without signs of shock 1
• Resume age-appropriate diet as soon as appetite returns 1