What is the management approach for a patient with Dengue Shock?

Dengue Shock Management

For dengue shock syndrome, immediately administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes, reassess after each bolus, and be prepared to repeat up to 40-60 mL/kg in the first hour before escalating to colloids or vasopressors if shock persists. 1

Initial Fluid Resuscitation Protocol

• Begin with isotonic crystalloid solutions (Ringer's lactate or 0.9% normal saline) at 20 mL/kg over 5-10 minutes as the first-line therapy 1, 2
• Immediately reassess after each bolus for signs of improvement: decreased tachycardia, improved capillary refill time (<2 seconds), warming of extremities, stronger peripheral pulses, improved mental status, and adequate urine output 1
• If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg within the first hour before changing strategy 1

Escalation to Colloid Therapy

If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch to colloid solutions rather than continuing crystalloid boluses. 1

• Colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and require significantly less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1, 2
• Dextran 70 provides the most rapid normalization of hematocrit and restoration of cardiac index without adverse effects, making it the preferred colloid for acute resuscitation 3
• Alternative colloids include gelafundin or albumin if dextran is unavailable 1, 2
• Early albumin use for crystalloid-refractory shock has demonstrated improved outcomes in critically ill children with severe dengue 4

Critical Monitoring Parameters During Resuscitation

• Stop fluid resuscitation immediately if any signs of fluid overload develop: hepatomegaly, pulmonary rales, respiratory distress, or increasing liver span 1, 5
• Track hematocrit levels closely: rising hematocrit indicates ongoing plasma leakage requiring continued resuscitation, while falling hematocrit suggests successful plasma expansion 1
• Monitor for adequate tissue perfusion markers: normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, baseline mental status, and urine output >1 mL/kg/hour 1, 2
• Perform daily complete blood count monitoring to track platelet counts and hematocrit trends 1, 5

Management of Refractory Shock

Once signs of fluid overload appear or after 40-60 mL/kg of fluid in the first hour without adequate response, switch from aggressive fluid administration to inotropic support rather than continuing fluid boluses. 1

• For cold shock with hypotension (cool extremities, weak pulses): titrate epinephrine as first-line vasopressor 1, 2
• For warm shock with hypotension (warm extremities, bounding pulses): titrate norepinephrine as first-line vasopressor 1, 2, 6
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy significantly increase mortality 1
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1

Post-Resuscitation Fluid Management

• After initial shock reversal, judicious fluid removal may be necessary during the recovery phase 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 improve when CRRT is initiated early 1
• Monitor for symptomatic abdominal compartment syndrome, which may require invasive percutaneous drainage in severe cases 4

Supportive Care Measures

• Use acetaminophen (paracetamol) only for pain and fever management 1
• Strictly avoid aspirin and NSAIDs due to significantly increased bleeding risk 1, 5
• Blood transfusion may be necessary for significant bleeding; target hemoglobin >10 g/dL if ScvO2 <70% 1
• Prophylactic platelet transfusion is not recommended 7

Critical Pitfalls to Avoid

• Never administer routine bolus IV fluids to patients with severe febrile illness who are NOT in shock, as this increases fluid overload and respiratory complications without improving outcomes 1, 2, 5
• Never delay fluid resuscitation in established dengue shock syndrome, as cardiovascular collapse may rapidly follow once hypotension occurs, and delays significantly increase mortality 1
• Never use restrictive fluid strategies in established dengue shock syndrome, as three randomized controlled trials demonstrate near 100% survival with aggressive fluid management, and restrictive approaches show no survival benefit 1, 2
• Never fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 2, 5
• Never continue aggressive fluid resuscitation once signs of fluid overload appear; this is the time to switch to inotropic support, not to give more fluids 1, 2
• Blood pressure alone is not a reliable endpoint in children, as they can maintain normal blood pressure until cardiovascular collapse is imminent 1

High-Risk Intubation Considerations

• If intubation becomes necessary, apply a high-risk intubation management protocol, as targeted ICU interventions have reduced intubation requirements from 53.3% to 18.4% in severe dengue 4
• Proactive monitoring and early intervention can decrease positive fluid balance and reduce the need for positive pressure ventilation 4