What is the ideal fluid for patients with dengue?

Ideal Fluid in Dengue

For dengue patients without shock, oral rehydration is first-line treatment; for dengue shock syndrome, initiate resuscitation with 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) over 5-10 minutes, reserving colloids only for refractory shock after adequate crystalloid administration. 1, 2

Fluid Management Based on Clinical Presentation

Dengue Without Shock

• Oral rehydration is the cornerstone of treatment for patients who are hemodynamically stable without warning signs 1, 2
• Encourage intake of 5 or more glasses of fluid throughout the day, targeting approximately 2,500-3,000 mL daily 2
• Any locally available fluids are acceptable including water, oral rehydration solutions, cereal-based gruels, soup, and rice water; avoid soft drinks due to high osmolality 2
• Oral isotonic solutions show trends toward better tolerability with less nausea and vomiting compared to plain water, though differences are not statistically significant 3

Dengue Shock Syndrome: Initial Resuscitation

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes 1, 2, 4
• Reassess immediately after each bolus for signs of improvement: improved tachycardia, tachypnea, capillary refill time, warm extremities, adequate urine output, and return to baseline mental status 1, 2
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 2, 4
• The highest quality evidence from a 2005 New England Journal of Medicine randomized trial demonstrated that Ringer's lactate achieves similar outcomes to colloids in moderately severe dengue shock, with mortality <0.2% 5

Colloid Solutions: When and Which Type

• Reserve colloids for severe dengue shock that persists despite adequate crystalloid resuscitation (40-60 mL/kg in first hour) 2, 4
• 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) 2, 4
• 6% hydroxyethyl starch is preferable to dextran 70 based on the 2005 NEJM trial showing similar efficacy but significantly fewer adverse reactions with starch 5
• Alternative colloids include gelafundin or albumin if hydroxyethyl starch is unavailable 2, 4
• A 2008 study confirmed that 10% hydroxyethyl starch (Haes-steril) is as effective as 10% dextran-40 with no differences in renal function, hemostasis, or complications 6

Critical Monitoring Parameters

During Resuscitation

• Track hematocrit levels closely: rising hematocrit indicates ongoing plasma leakage requiring continued resuscitation, while falling hematocrit suggests successful plasma expansion 2
• Monitor daily complete blood counts, particularly platelet counts and hematocrit, as a 20% rise in hematocrit with dropping platelets signals impending shock 1, 2, 7
• Watch for signs of adequate tissue perfusion rather than relying solely on blood pressure: normal capillary refill, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, baseline mental status, and adequate urine output 1, 2, 4

Signs of Fluid Overload Requiring Immediate Action

• Stop fluid resuscitation immediately if hepatomegaly, pulmonary rales, or respiratory distress develop 2, 4
• Switch from aggressive fluid administration to inotropic support rather than continuing fluid boluses once overload appears 2, 4
• Evidence shows that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 2

Management of Refractory Shock

Vasopressor Selection

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 2, 4
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 2, 4
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 2, 4
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy increase mortality 2

Critical Pitfalls to Avoid

Excessive Fluid Administration

• Do not administer routine bolus intravenous fluids to patients with dengue who are not in shock, as this increases fluid overload and respiratory complications without improving outcomes 1, 2, 4
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear 2, 4
• Restrictive fluid strategies have no survival benefit in established dengue shock syndrome and may worsen outcomes 2, 4

Timing and Recognition Errors

• Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 2, 4
• Do not delay fluid resuscitation in patients with dengue shock syndrome, as cardiovascular collapse may rapidly follow once hypotension occurs 2
• Blood pressure alone is not a reliable endpoint in children with dengue shock 2

Medication Errors

• Avoid NSAIDs and aspirin due to increased bleeding risk 1, 2
• Use only acetaminophen (paracetamol) for pain and fever management 2