What is the management for a patient with dengue hemorrhagic fever (DHF) presenting with shock?

Management of Dengue Hemorrhagic Fever with Shock

Administer an immediate fluid bolus of 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) over 5-10 minutes, reassess immediately, and be prepared to repeat boluses up to 40-60 mL/kg in the first hour before escalating to colloids and vasopressors if shock persists. 1

Initial Fluid Resuscitation Protocol

First-line therapy:

• Give 20 mL/kg of Ringer's lactate or 0.9% normal saline as a rapid bolus over 5-10 minutes 1, 2
• Reassess immediately after each bolus for signs of improvement: decreased tachycardia, improved tachypnea, better capillary refill, warming of extremities, improved mental status, and adequate urine output 1
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg within the first hour 1

Critical timing consideration: Delays in fluid resuscitation significantly increase mortality, as cardiovascular collapse can occur rapidly once hypotension develops 1

Escalation to Colloid Solutions

When to switch from crystalloids to colloids:

• If shock persists despite 40-60 mL/kg of crystalloid in the first hour 1
• In severe dengue shock syndrome presenting with very low pulse pressure 3

Colloid options and evidence:

• Dextran 70 provides the most rapid normalization of hematocrit and restoration of cardiac index 4
• However, 6% hydroxyethyl starch may be preferable due to significantly fewer adverse reactions compared to dextran, with similar efficacy 5
• Alternative colloids include gelafundin or albumin if other options are unavailable 1, 2
• Moderate-quality evidence shows colloids achieve faster shock resolution (RR 1.09,95% CI 1.00-1.19) and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 1, 2

Critical Monitoring Parameters

During resuscitation, monitor for:

• 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
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation; falling hematocrit suggests successful plasma expansion 1
• Daily complete blood count to track platelet counts and hematocrit levels 1

Signs requiring immediate cessation of fluid resuscitation:

• Hepatomegaly developing during resuscitation 1
• Pulmonary rales on lung examination 1, 2
• Respiratory distress 1, 2

Management of Refractory Shock

If shock persists despite adequate fluid resuscitation (40-60 mL/kg in first hour), switch strategy from aggressive fluid administration to vasopressor support rather than continuing fluid boluses: 1

Vasopressor selection based on hemodynamic state:

• Cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1
• Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 1, 6
• 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 are associated with major increases in mortality 1

Post-Resuscitation Fluid Management

Recovery phase considerations:

• After initial shock reversal, judicious fluid removal may be necessary during the recovery phase 1
• 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, as outcomes are better when CRRT is initiated early 1

Supportive Care Measures

• Use acetaminophen (paracetamol) only for pain and fever management 1
• Strictly avoid aspirin and NSAIDs due to increased bleeding risk 1, 7
• Blood transfusion may be necessary in cases of significant bleeding; target hemoglobin >10 g/dL if ScvO2 <70% 1, 7
• Oxygen is mandatory in all patients with shock 8

Critical Pitfalls to Avoid

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

Do not continue aggressive fluid resuscitation once signs of fluid overload appear; switch to inotropic support instead 1, 2

Do not use restrictive fluid strategies in established dengue shock syndrome, as moderate-quality evidence shows no survival benefit from colloid restriction, and restrictive fluids in severe malaria showed harm with increased need for rescue fluid (17.6% versus 0.0%; P<0.005) 1

Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 7

Do not rely solely on blood pressure as an endpoint in children, as blood pressure alone is not a reliable indicator 1

Avoid drainage of pleural effusion and ascites if possible, as it can lead to severe hemorrhages and sudden circulatory collapse 8