What are the current recommendations for managing dengue shock syndrome?

Management of Dengue Shock Syndrome: Current Recommendations

Initial Fluid Resuscitation

Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus 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, 2

• Crystalloid solutions remain first-line therapy for initial resuscitation in dengue shock syndrome, with evidence demonstrating near 100% survival when properly administered 1
• If shock persists after initial crystalloid boluses, colloid solutions (6% hydroxyethyl starch preferred over dextran 70 due to fewer adverse reactions) may provide faster shock resolution and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1, 3
• The key advancement is recognizing that aggressive initial fluid resuscitation is life-saving, but must be balanced with vigilant monitoring for fluid overload 1

Critical Monitoring Parameters During Resuscitation

Monitor for signs of adequate tissue perfusion including 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

• Track hematocrit closely: rising hematocrit indicates ongoing plasma leakage requiring continued resuscitation, while falling hematocrit suggests successful plasma expansion 1
• Stop fluid resuscitation immediately if hepatomegaly, pulmonary rales, or respiratory distress develop—these signal fluid overload and necessitate switching to inotropic support rather than continuing fluid boluses 1
• Improvement in tachycardia and tachypnea indicates adequate resuscitation 1

Management of Refractory Shock

If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch from aggressive fluid administration to inotropic support rather than continuing fluid boluses. 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
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy are associated with major increases in mortality 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1

Post-Resuscitation Fluid Management: A Major Advancement

After initial shock reversal, judicious fluid removal may be necessary and represents a critical advancement in dengue shock management. 1

• Evidence demonstrates that aggressive shock management followed by proactive fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1, 4
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when CRRT is initiated early 1
• This represents a paradigm shift from older WHO guidelines that focused solely on aggressive fluid administration without addressing the recovery phase 4

Critical Pitfalls to Avoid

Do not give routine bolus IV fluids to patients with "severe febrile illness" who are NOT in shock—this increases risk of fluid overload and respiratory complications without improving outcomes. 1, 2

• Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality, as cardiovascular collapse may rapidly follow once hypotension occurs 1
• Do not use restrictive fluid strategies in established dengue shock syndrome—moderate-quality evidence shows no survival benefit from colloid restriction, and restrictive fluids in similar conditions showed harm 1
• Avoid aspirin and NSAIDs due to increased bleeding risk 1
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear 1
• Recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 5

Supportive Care and Adjunctive Therapies

Blood transfusion may be necessary for significant bleeding, with target hemoglobin >10 g/dL if ScvO2 <70%. 1, 2

• Use acetaminophen only for pain and fever management 2, 5
• Monitor for symptomatic abdominal compartment syndrome, which may require percutaneous drainage in severe cases 6
• Early albumin may be beneficial for crystalloid-refractory shock in ICU settings 6

What's Truly New

The most significant advancement in dengue shock syndrome management is the recognition that aggressive initial resuscitation must be followed by proactive fluid removal strategies to prevent fluid overload complications. 1, 4, 6 This two-phase approach—aggressive resuscitation followed by judicious fluid removal—has dramatically reduced mortality rates compared to older protocols that focused solely on fluid administration. 4 Additionally, the evidence now clearly supports avoiding routine bolus fluids in febrile patients without shock, as this practice increases complications without benefit. 1, 2