Management of Dengue Fever with Plasma Leakage
Immediate Fluid Resuscitation for Dengue Shock Syndrome
For patients with dengue shock syndrome, administer an initial bolus of 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) over 5-10 minutes, with immediate reassessment after each bolus and readiness to repeat up to 40-60 mL/kg in the first hour if shock persists. 1
Initial Crystalloid Resuscitation Protocol
Start with isotonic crystalloid solutions as first-line therapy - either Ringer's lactate or 0.9% normal saline are equally effective for initial resuscitation 1, 2
Administer the 20 mL/kg bolus as rapidly as possible over 5-10 minutes, then immediately reassess for signs of improvement 1, 3
If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg within the first hour before considering escalation to colloids 1, 2
Evidence demonstrates that aggressive crystalloid resuscitation achieves near 100% survival when properly administered in dengue shock syndrome 1
When to Escalate to Colloid Solutions
If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch to colloid solutions rather than continuing aggressive crystalloid administration. 1, 4
Moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) compared to crystalloids alone 1
Colloids require significantly less total volume for resuscitation - mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids 1
Dextran 70 is the preferred colloid as it 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
Both dextran and haes-steril (hydroxyethyl starch) are equally effective with no differences in renal function or hemostasis complications 6
Critical Monitoring Parameters During Resuscitation
Clinical Endpoints of Adequate Resuscitation
Target these specific clinical indicators rather than arbitrary fluid volumes: 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
Monitor hematocrit closely - rising hematocrit indicates ongoing plasma leakage requiring continued resuscitation, while falling hematocrit suggests successful plasma expansion 1, 2
Track improvement in tachycardia and tachypnea as signs of adequate resuscitation 1
Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1
Signs Requiring Immediate Change in Strategy
Stop fluid resuscitation immediately if any of these develop: 1, 2
- Hepatomegaly (indicates fluid overload)
- Pulmonary rales on lung examination
- Respiratory distress
- Pleural effusion or ascites requiring drainage (avoid drainage as it can lead to severe hemorrhage and sudden circulatory collapse) 3
Management of Refractory Shock
When shock persists despite adequate fluid resuscitation (40-60 mL/kg crystalloid plus colloids), switch from aggressive fluid administration to inotropic support rather than continuing fluid boluses. 1, 2
Vasopressor Selection Based on Hemodynamic State
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, 4
Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1
Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy significantly increase mortality 1
Fluid Management for Non-Shock Dengue with Plasma Leakage
Oral Rehydration Strategy
Encourage approximately 2,500-3,000 mL daily oral intake, which evidence shows reduces hospitalization rates 1, 2
Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1, 2
Practical approach: encourage 5 or more glasses of fluid throughout the day 1
Warning Signs Requiring IV Fluid Therapy
Monitor for these indicators that plasma leakage is progressing and IV fluids may be needed: 1, 2
- High hematocrit with rapidly falling platelet count
- Severe abdominal pain
- Persistent vomiting
- Lethargy or restlessness
- Mucosal bleeding
- Tachycardia, poor capillary refill, cold extremities, narrow pulse pressure
Critical Pitfalls to Avoid
Do NOT Give Routine Bolus IV Fluids to Patients Without Shock
The most important pitfall is administering bolus intravenous fluids to patients with "severe febrile illness" who are not in shock - this increases fluid overload and respiratory complications without improving outcomes 1, 2
- High-quality evidence shows no benefit from routine bolus fluids in patients without shock 1
Do NOT Use Restrictive Fluid Strategies in Established Shock
Moderate-quality evidence shows no survival benefit from restrictive fluid strategies in dengue shock syndrome 1
Restrictive fluids in severe malaria showed harm with increased need for rescue fluid (17.6% versus 0.0%; P<0.005), suggesting similar risks in dengue shock 1
Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality 1
Do NOT Continue Aggressive Fluids Once Overload Develops
After initial shock reversal, fluid removal may be necessary - evidence shows that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1
Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops 1
Do NOT Fail to Recognize the Critical Phase
The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock 1, 2
A rise in hematocrit of 20% along with continuing drop in platelet count is an important indicator for onset of shock 3