What is the appropriate intravenous (IV) fluid for patients with dengue?

Appropriate Intravenous Fluid for Dengue

Initial Fluid Selection

For patients with dengue shock syndrome, administer isotonic crystalloid solutions (Ringer's lactate or 0.9% normal saline) as the initial bolus of 20 mL/kg over 5-10 minutes, with reassessment after each bolus. 1, 2

• Crystalloid solutions are the first-line fluid for resuscitation in both moderate and severe dengue shock syndrome 2
• If shock persists after the initial crystalloid bolus, repeat crystalloid boluses up to 40-60 mL/kg in the first hour may be necessary before escalating to colloids 1, 2
• The majority of patients with dengue shock syndrome can be treated successfully with isotonic crystalloid solutions alone 3

Escalation to Colloid Solutions

If shock persists despite adequate crystalloid resuscitation (40-60 mL/kg in the first hour), escalate to colloid solutions rather than continuing aggressive crystalloid administration. 1, 2

• Moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) compared to crystalloids 1, 2
• Colloids require less total volume for resuscitation (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1, 2
• 6% hydroxyethyl starch (HES) may be preferable over dextran 70 for severe shock, as both perform similarly but dextran is associated with more adverse reactions 4
• Alternative colloids include gelafundin or albumin if other options are unavailable 1, 2

Fluid Management by Clinical Scenario

For Patients WITHOUT Shock:

• Oral rehydration is appropriate and should be the first-line approach 2, 5
• Avoid routine use of bolus intravenous fluids in patients with severe febrile illness who are not in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes 2, 5

For Patients WITH Moderate Shock:

• Crystalloid solutions (Ringer's lactate or 0.9% normal saline) are first-line 2, 4
• Large-scale randomized trial showed no significant difference in requirement for rescue colloid between Ringer's lactate and colloid solutions in moderate shock (RR 1.08,95% CI 0.78-1.47) 4

For Patients WITH Severe Shock:

• Start with crystalloid boluses up to 40-60 mL/kg in the first hour 1, 2
• If inadequate response, switch to colloid solutions (6% HES or dextran 70) 1, 2, 4
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear; switch to inotropic support instead 1, 2

Critical Monitoring Parameters

Watch for clinical indicators of adequate tissue perfusion rather than relying solely on laboratory values: 1, 2

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

Monitor for signs of fluid overload that necessitate stopping fluid resuscitation: 1, 2

• Hepatomegaly
• Rales on lung examination
• Respiratory distress

Daily complete blood count monitoring is essential to track hematocrit levels, which reflect vascular permeability and guide fluid management 1, 2

Management of Refractory Shock

If shock persists despite 40-60 mL/kg of fluid in the first hour, switch from aggressive fluid administration to vasopressor support: 1, 2

• 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, 6
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1, 2

Critical Pitfalls to Avoid

Do not administer excessive fluid boluses in patients without shock, as this leads to fluid overload, respiratory complications, and potential electrolyte derangements 1, 2, 5

Do not use restrictive fluid strategies in established dengue shock syndrome, as moderate-quality evidence shows no survival benefit and may worsen outcomes 1, 2

Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock and fluid management becomes most crucial 1, 2, 5

Do not delay switching from crystalloids to colloids in severe shock, as persistent hypoperfusion despite adequate crystalloid resuscitation requires escalation of therapy 1

Do not continue aggressive fluid resuscitation once hypernatremia or fluid overload appears; switch to inotropic support instead 1, 2