Treatment of Dengue with Compensated Shock in a Child
Administer an immediate fluid bolus of 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) over 5-10 minutes, then reassess immediately for signs of shock resolution. 1, 2
Initial Fluid Resuscitation Protocol
For compensated shock (narrow pulse pressure, tachycardia, cool extremities, but still maintaining blood pressure):
- Give 20 mL/kg of isotonic crystalloid as a rapid bolus over 5-10 minutes 1, 2
- Reassess immediately after each bolus for clinical indicators of adequate perfusion: normal capillary refill time, absence of skin mottling, warm extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output 1, 3
- If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour 1, 3
The evidence strongly supports crystalloids as first-line therapy. A high-quality randomized trial of 383 children demonstrated that Ringer's lactate performed similarly to colloids in moderately severe dengue shock, with only minor differences in speed of hematocrit normalization but no differences in clinical outcomes 4. The American College of Cardiology and multiple other societies recommend crystalloids as first-line for this indication 1, 2.
When to Escalate to Colloids
Consider colloid solutions only if:
- Pulse pressure drops below 10 mmHg (severe shock) 2
- Shock persists despite 40-60 mL/kg of crystalloid in the first hour 1
If colloids are needed, use 6% hydroxyethyl starch rather than dextran 70. While dextran 70 provides the most rapid normalization of hematocrit 5, a larger trial of 129 children with severe dengue shock showed that hydroxyethyl starch performed similarly to dextran but with significantly fewer adverse reactions 4. The typical colloid dose is 10-20 mL/kg 2.
Critical Monitoring Parameters
Watch for these endpoints after each bolus:
- Improvement in tachycardia and tachypnea indicates adequate resuscitation 1
- Rising hematocrit signals ongoing plasma leakage and need for continued resuscitation 3
- Falling hematocrit suggests successful plasma expansion 1
Stop fluid resuscitation immediately if signs of fluid overload develop:
- New onset hepatomegaly 1, 2
- Pulmonary rales on lung examination 1, 2
- Increased work of breathing or respiratory distress 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, 3
- For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 3
- For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 3
- Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1
Post-Resuscitation Fluid Management
After initial shock reversal, proactive fluid removal may be necessary during the recovery phase. A retrospective study of 210 children demonstrated that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 6. Consider diuretics or continuous renal replacement therapy if fluid overload exceeds 10% of body weight 1, 2.
Critical Pitfalls to Avoid
- Do not delay fluid resuscitation in compensated shock. Once hypotension occurs, cardiovascular collapse may rapidly follow, and blood pressure alone is not a reliable endpoint in children 1
- Do not continue aggressive fluid resuscitation once signs of fluid overload appear. Switch to inotropic support instead 1, 2
- Do not use aspirin or NSAIDs for fever control. Use only acetaminophen (paracetamol) due to increased bleeding risk 1, 3
- Do not miss the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to decompensated shock 1, 2