What is the recommended hydration rate in ml/kg/hour for patients with dengue (Dengue Fever) showing warning signs?

Hydration in Dengue with Warning Signs

For patients with dengue showing warning signs who are NOT in shock, oral rehydration is the appropriate first-line approach, with a target of approximately 2,500-3,000 mL daily (roughly 5 or more glasses throughout the day), and routine bolus intravenous fluids should be avoided as they increase fluid overload and respiratory complications without improving outcomes. 1

Initial Assessment and Fluid Strategy

The critical distinction is whether the patient has warning signs alone versus established shock:

Patients with Warning Signs WITHOUT Shock

• Oral rehydration is the cornerstone of management for dengue patients with warning signs who maintain adequate perfusion 1, 2
• Encourage approximately 2,500-3,000 mL of fluid daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water (avoid soft drinks due to high osmolality) 1
• Avoid routine bolus IV fluids in this population, as high-quality evidence demonstrates this increases risk of fluid overload and respiratory complications without improving outcomes 1, 3

Warning Signs to Monitor

Watch for progression indicators that signal need for escalation 1:

• High hematocrit with rapidly falling platelet count
• Severe abdominal pain or persistent vomiting
• Lethargy or restlessness
• Mucosal bleeding
• Clinical fluid accumulation (ascites, pleural effusion)

Transition to IV Fluids: When Shock Develops

If shock develops (hypotension, narrow pulse pressure, poor perfusion), immediately 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

Escalation Protocol for Dengue Shock Syndrome

• Reassess after each bolus for signs of improvement: improved capillary refill, stronger pulses, normalized mental status, adequate urine output 1
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before considering colloids 1, 3
• Moderate-quality evidence shows colloids achieve faster shock resolution (RR 1.09) and require less total volume (31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1, 4

Critical Monitoring During the Critical Phase

The critical phase (typically days 3-7 of illness) requires vigilant monitoring 1, 2:

• Daily complete blood count to track hematocrit (rising indicates ongoing plasma leakage) and platelet counts 1
• Clinical perfusion indicators: capillary refill time, skin temperature, peripheral pulses, mental status, urine output 1, 3
• Stop fluid resuscitation immediately if hepatomegaly, pulmonary rales, or respiratory distress develop 1

Key Pitfalls to Avoid

• Do not give routine IV fluid boluses to patients with warning signs who are not in shock - this is the most common error and leads to preventable fluid overload 1, 3
• Do not delay fluid resuscitation once shock is established - cardiovascular collapse can rapidly follow hypotension 1
• Do not continue aggressive fluids once fluid overload appears - switch to inotropic support instead 1, 3
• Do not use aspirin or NSAIDs due to increased bleeding risk 1, 2
• Do not fail to recognize the critical phase when plasma leakage can rapidly progress 1, 2

Management of Refractory Cases

If shock persists despite 40-60 mL/kg crystalloid in the first hour 1:

• Switch strategy from aggressive fluid to inotropic support
• For cold shock with hypotension: titrate epinephrine as first-line vasopressor
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor
• Target age-appropriate mean arterial pressure and ScvO2 >70%

The evidence strongly supports a conservative fluid approach for warning signs without shock, with aggressive escalation only when shock is established, achieving near 100% survival with proper management 1, 4.