Immediate Management of Dengue 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, with urgent reassessment after each bolus and readiness to repeat up to 40-60 mL/kg in the first hour if shock persists. 1
Initial Resuscitation Protocol
Crystalloid solutions are the first-line therapy for dengue shock syndrome. 1 The rapid bolus approach is critical because cardiovascular collapse can occur quickly once hypotension develops, and delays in fluid resuscitation significantly increase mortality. 1
After each 20 mL/kg bolus, immediately reassess for:
- Improvement in tachycardia and tachypnea 1
- Normal capillary refill time 1
- Warm and dry extremities with well-felt peripheral pulses 1
- Return to baseline mental status 1
- Adequate urine output 1
If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before escalating therapy. 1 This aggressive approach achieves near 100% survival when properly administered. 1
Escalation to Colloid Solutions
If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch to colloid solutions rather than continuing crystalloid administration. 1 Moderate-quality evidence demonstrates that colloids achieve faster resolution of shock (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
Colloid options include:
- 6% hydroxyethyl starch (preferred due to fewer adverse reactions) 3
- Dextran 70 (provides fastest normalization of hematocrit but higher adverse reaction rate) 4, 3
- Gelafundin or albumin if other options unavailable 1, 2
Critical Monitoring During Resuscitation
Stop fluid resuscitation immediately if signs of fluid overload develop: 1, 2
Monitor hematocrit closely—rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation, while falling hematocrit suggests successful plasma expansion. 5 Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels. 1
Management of Refractory Shock
If shock persists despite adequate fluid resuscitation (40-60 mL/kg crystalloid plus colloids), immediately switch to vasopressor support rather than continuing aggressive fluid administration. 1, 5
Vasopressor selection based on hemodynamic state:
- Cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1, 5
- Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 1, 5
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
Critical Pitfalls to Avoid
Do NOT give routine bolus IV fluids to patients with severe febrile illness who are NOT in shock—this increases fluid overload and respiratory complications without improving outcomes. 1, 2 This is one of the most common and dangerous errors in dengue management.
Do NOT use restrictive fluid strategies in established dengue shock syndrome. 1, 2 Moderate-quality evidence shows no survival benefit from colloid restriction, and restrictive approaches may worsen outcomes. 1
Do NOT continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead. 1, 2 Evidence shows that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3%. 6
Do NOT use aspirin or NSAIDs for fever or pain—use acetaminophen (paracetamol) only, as aspirin and NSAIDs increase bleeding risk. 1, 5
Do NOT rely solely on blood pressure as an endpoint in children—blood pressure may remain normal until cardiovascular collapse is imminent. 1 Focus on clinical indicators of tissue perfusion instead.
Post-Resuscitation Management
After initial shock reversal, judicious fluid removal may be necessary during the recovery phase. 1, 5 Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when CRRT is initiated early. 1
Blood transfusion may be necessary for significant bleeding—target hemoglobin >10 g/dL if ScvO2 <70%. 1, 5