Treatment of 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, with urgent reassessment after each bolus and readiness to repeat up to 40-60 mL/kg in the first hour if shock persists. 1, 2
Initial Fluid Resuscitation Protocol
Crystalloids are first-line for all patients with dengue shock syndrome. 1, 2 The American College of Critical Care Medicine and multiple international guidelines consistently recommend isotonic crystalloid solutions as the initial resuscitation fluid, with evidence demonstrating near 100% survival when applied promptly. 1, 2
Immediate Management Steps:
- Administer the first 20 mL/kg bolus over 5-10 minutes 1, 2, 3
- Reassess immediately after each bolus for signs of improvement: decreased tachycardia, improved capillary refill (<2 seconds), warming of extremities, improved mental status, and adequate urine output 1, 3
- If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg within the first hour before considering escalation 1, 2
Critical monitoring during resuscitation: Watch for signs of fluid overload after each bolus—new hepatomegaly, pulmonary rales, or increased work of breathing signal the need to immediately stop fluid administration and switch to inotropic support. 1, 2
When to Consider Colloid Solutions
Reserve colloids for severe dengue shock syndrome with pulse pressure <10 mmHg or shock refractory to initial crystalloid resuscitation. 2 While 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), clinical outcomes including mortality are similar. 1, 4
Colloid Selection:
- Preferred colloid: Dextran 70 or gelafundin provide optimal initial plasma volume support with acceptable side-effect profiles 1, 5
- Avoid hydroxyethyl starches in septic contexts due to increased mortality and renal replacement therapy requirements 2
- Cost consideration: Colloids are significantly more expensive (albumin ~140 Euro/L, HES ~25 Euro/L versus crystalloid ~1.5 Euro/L) without clear mortality benefit 2
Management of Refractory Shock
If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch strategy from aggressive fluid administration to vasopressor support rather than continuing fluid boluses. 1, 3
Vasopressor Selection Based on Hemodynamic State:
- Cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1, 3
- Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 1, 3
- Target: Mean arterial pressure appropriate for age and ScvO2 >70% 1
- Do not delay vasopressor therapy if central access is unavailable—begin peripheral inotropic support immediately, as delays are associated with major increases in mortality 1
Critical Monitoring Parameters
Track these specific indicators to guide ongoing resuscitation:
Signs of adequate tissue perfusion: 1, 3
- Normal capillary refill time (<2 seconds)
- Absence of skin mottling
- Warm and dry extremities
- Well-felt peripheral pulses
- Return to baseline mental status
- Adequate urine output (>1 mL/kg/hour)
Hematocrit monitoring is essential: Rising hematocrit indicates ongoing plasma leakage requiring continued resuscitation, while falling hematocrit suggests successful plasma expansion. 1, 3
Post-Resuscitation Fluid Management
After initial shock reversal, proactive fluid removal may be necessary during the recovery phase. 1, 2 Evidence demonstrates that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3%. 1, 2
- Consider diuretics or continuous renal replacement therapy (CRRT) if oliguria develops after aggressive resuscitation 2
- Initiate CRRT early if fluid overload exceeds 10%, as outcomes are worse when delayed 1, 2
Critical Pitfalls to Avoid
Never 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, 3 This is one of the most common and dangerous errors in dengue management.
Do not delay fluid resuscitation once shock is identified—cardiovascular collapse may rapidly follow, and delays significantly increase mortality. 1 Blood pressure alone is not a reliable endpoint in children. 1
Stop fluid resuscitation immediately when signs of fluid overload appear—continuing aggressive fluids leads to pulmonary edema and respiratory failure. 1, 2 Switch to inotropic support instead. 1, 2
Avoid aspirin and NSAIDs completely due to increased bleeding risk; use only acetaminophen for fever and pain management. 1, 3
Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock—this is when intensive monitoring and early intervention are most crucial. 1, 2