What is the recommended approach for volume control in patients with dengue?

Volume Control in Dengue

Risk Stratification Determines Fluid Strategy

The fundamental principle is to avoid routine intravenous fluids in dengue patients without shock, as this increases fluid overload and respiratory complications without improving outcomes, while patients with dengue shock syndrome require aggressive initial crystalloid resuscitation of 20 mL/kg boluses. 1, 2

Non-Shock Dengue: Oral Rehydration Only

For patients without signs of shock (normal capillary refill, warm extremities, adequate blood pressure, normal mental status):

• Encourage oral intake of 2,500-3,000 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1, 2
• Avoid soft drinks due to high osmolality 2
• Critical pitfall: Do NOT administer routine IV fluid boluses to patients with "severe febrile illness" who lack shock, as recent evidence demonstrates this increases fluid overload and respiratory complications without survival benefit 1, 3
• Recent research from 2024 confirms that high IV fluid volumes (>2000 mL/day) in non-shock patients increased risk of progression to severe dengue, particularly in those under 55 years old 4

Dengue Shock Syndrome: Aggressive Initial Resuscitation

When shock indicators appear (tachycardia, hypotension, poor capillary refill, altered mental status, cold extremities, narrow pulse pressure):

Initial Crystalloid Phase

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes 1, 2, 3
• Reassess immediately after each bolus for signs of improvement: improved capillary refill, warming of extremities, decreased heart rate, improved mental status 1, 2
• Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists before escalating therapy 1, 2

Escalation to Colloids

• If shock persists after adequate crystalloid resuscitation (40-60 mL/kg), switch to colloid solutions 1, 3
• 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, 3
• Alternative colloids include dextran, gelafundin, or albumin 1, 3

Critical Monitoring Parameters During Resuscitation

• Stop fluid resuscitation immediately if signs of fluid overload develop: hepatomegaly, pulmonary rales, or respiratory distress 1, 2, 3
• Monitor hematocrit closely—rising hematocrit indicates ongoing plasma leakage requiring continued resuscitation, while falling hematocrit suggests successful plasma expansion 2
• Track clinical perfusion endpoints rather than blood pressure alone: normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, adequate urine output 1, 2

Refractory Shock: Switch to Vasopressors

If shock persists despite 40-60 mL/kg of fluid in the first hour, switch strategy from aggressive fluid administration to inotropic support rather than continuing fluid boluses 1, 2, 3:

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 2, 3
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 2, 3
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1
• Begin peripheral inotropic support immediately if central access unavailable, as delays in vasopressor therapy increase mortality 1

Recovery Phase: Judicious Fluid Removal

• After initial shock reversal, fluid removal may be necessary during the recovery phase (typically days 3-7 of illness when plasma leakage peaks) 1, 2
• Evidence shows aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1
• Consider continuous renal replacement therapy if fluid overload >10% develops, as outcomes improve with early initiation 1

Key Clinical Pitfalls to Avoid

• Do not continue aggressive fluid resuscitation once signs of fluid overload appear—this is the most common error leading to pulmonary edema and respiratory failure 1, 3
• Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 3
• Do not delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow with significantly increased mortality 1
• Do not use restrictive fluid strategies in established dengue shock syndrome—moderate-quality evidence shows no survival benefit and may worsen outcomes 1, 3
• Blood pressure alone is not a reliable endpoint in children—use clinical perfusion parameters instead 1