What type of fluids should be given to a patient with dengue?

Fluid Management in Dengue

Direct Answer

For dengue patients without shock, use oral rehydration; for dengue shock syndrome, administer isotonic crystalloids (Ringer's lactate or 0.9% normal saline) as first-line therapy with an initial bolus of 20 mL/kg over 5-10 minutes, reserving colloids for severe or refractory cases. 1

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Algorithmic Approach to Fluid Selection

Step 1: Assess Shock Status

Patients WITHOUT shock:

• Use oral rehydration as first-line treatment 1, 2
• Encourage 5 or more glasses of fluid throughout the day, targeting approximately 2,500-3,000 mL daily 1
• Acceptable oral fluids include water, oral rehydration solutions, cereal-based gruels, soup, and rice water; avoid soft drinks due to high osmolality 1
• Critical pitfall: Avoid routine bolus intravenous fluids in patients with severe febrile illness who are NOT in shock, as this increases fluid overload and respiratory complications without improving outcomes 1

Patients WITH dengue shock syndrome:

• Proceed to Step 2 for IV fluid resuscitation 1

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Step 2: Initial Resuscitation for Dengue Shock Syndrome

First-line therapy: Isotonic crystalloids 1, 3

• Administer 20 mL/kg of Ringer's lactate or 0.9% normal saline as rapid bolus over 5-10 minutes 1
• Reassess immediately after each bolus for signs of improvement (tachycardia, tachypnea, capillary refill, mental status) 1
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy 1

Evidence supporting crystalloids:

• The majority of DSS patients can be treated successfully with isotonic crystalloid solutions alone 3
• High-quality evidence demonstrates near 100% survival with appropriate crystalloid resuscitation 1
• A 2005 randomized trial of 383 children showed no significant difference in rescue colloid requirement between Ringer's lactate and colloids for moderately severe shock (RR 1.08,95% CI 0.78-1.47) 4

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Step 3: When to Escalate to Colloids

Indications for colloid use:

• Severe dengue shock syndrome at presentation 1
• Persistent shock despite 40-60 mL/kg of crystalloid in the first hour 1
• Refractory hypotension requiring escalation of therapy 1

Colloid options and evidence:

• 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) 1
• Preferred colloid: 6% hydroxyethyl starch - A 1999 randomized trial showed dextran 70 provided most rapid normalization of hematocrit and cardiac index 5, but a larger 2005 trial demonstrated significantly more adverse reactions with dextran compared to starch, with similar efficacy 4
• Alternative colloids include gelafundin or albumin if other options are unavailable 1

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Step 4: Critical Monitoring Parameters

Signs of adequate resuscitation: 1

• Normal capillary refill time
• Absence of skin mottling
• Warm and dry extremities
• Well-felt peripheral pulses
• Return to baseline mental status
• Adequate urine output

Signs to STOP fluid resuscitation immediately: 1

• Hepatomegaly development
• Pulmonary rales on examination
• Respiratory distress
• Rising hematocrit indicating successful plasma expansion 1

When to switch from fluids to vasopressors:

• If shock persists despite adequate fluid resuscitation (40-60 mL/kg), switch strategy to inotropic support rather than continuing fluid boluses 1
• For cold shock with hypotension: use epinephrine as first-line vasopressor 1
• For warm shock with hypotension: use norepinephrine as first-line vasopressor 1

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Critical Pitfalls to Avoid

Overhydration in non-shocked patients:

• Administering excessive fluid boluses in patients without shock leads to fluid overload, pulmonary edema, and respiratory complications 1, 2
• This is particularly dangerous during the recovery phase 1

Delayed resuscitation in shock:

• Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality; once hypotension occurs, cardiovascular collapse may rapidly follow 1

Restrictive fluid strategies in shock:

• Do not use restrictive fluid strategies in established dengue shock syndrome - moderate-quality evidence shows no survival benefit and may worsen outcomes 1
• Three randomized trials demonstrated near 100% survival with aggressive fluid management 1

Missing the critical phase:

• The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock 1, 2
• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1, 2

Continuing fluids despite overload:

• Do not continue aggressive fluid resuscitation once signs of fluid overload appear; switch to inotropic support instead 1
• Evidence shows that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1

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Special Considerations

Pediatric patients:

• The same crystalloid-first approach applies, with aggressive crystalloid resuscitation achieving near 100% survival when properly administered 1
• After initial shock reversal, fluid removal may be necessary; consider continuous renal replacement therapy if fluid overload >10% develops 1

Patients with ascites:

• Oral rehydration remains first-line for patients with dengue ascites who are not in shock 2
• Avoid routine bolus IV fluids in ascites patients without shock 2