When is albumin infusion preferred over intravenous fluid replacement in a patient with severe dengue characterized by significant plasma leakage, hemorrhage, or shock?

Albumin Infusion for Dengue vs Intravenous Fluid

For dengue shock syndrome, start with isotonic crystalloid boluses (10-20 mL/kg over 5-10 minutes), and reserve albumin or other colloids only for severe shock with pulse pressure <10 mmHg or persistent shock despite adequate crystalloid resuscitation. 1

Initial Fluid Resuscitation Strategy

Crystalloids are the first-line fluid of choice for dengue shock syndrome. 1 The evidence demonstrates near 100% survival when crystalloid fluid resuscitation is provided promptly to children with dengue shock, regardless of the specific fluid composition used. 2

• Administer isotonic crystalloid solutions (normal saline or Ringer's lactate) as 10-20 mL/kg boluses over 5-10 minutes. 1
• Reassess immediately after each bolus for signs of improved perfusion (normal capillary refill time, warm extremities, well-felt peripheral pulses, return to baseline mental status, adequate urine output). 1
• Stop fluid administration when perfusion normalizes or signs of fluid overload develop (new onset rales, increased work of breathing, hepatomegaly). 2, 1

The 2020 International Consensus on Cardiopulmonary Resuscitation recommends 20 mL/kg boluses for dengue shock syndrome, though this is a weak recommendation based on low-quality evidence. 2 The more recent Praxis Medical Insights guideline suggests the slightly more conservative 10-20 mL/kg range. 1

When to Consider Albumin or Colloid Solutions

Albumin should be reserved for specific severe presentations:

• Severe dengue shock with pulse pressure <10 mmHg is the primary indication for colloid use. 1
• Persistent shock despite adequate crystalloid resuscitation (typically after 40-60 mL/kg of crystalloids). 2, 1

The rationale is that severe dengue shock with extremely narrow pulse pressure requires more aggressive plasma volume expansion, which colloids provide more effectively than crystalloids. 1 However, this comes at significantly higher cost (albumin costs approximately 140 Euro per liter versus 1.5 Euro for isotonic saline). 1

Evidence Supporting This Approach

The evidence base strongly favors crystalloids as initial therapy:

• Multiple randomized trials in dengue shock demonstrated near 100% survival with crystalloid resuscitation alone when applied promptly. 2
• A 2024 randomized controlled trial showed that early 5% albumin intervention in DHF grade I-II patients resulted in better control of vascular integrity, lower hemoconcentration, and shorter hospital stays compared to Ringer's lactate. 3 However, this study examined early intervention in less severe cases (grade I-II DHF), not established shock.
• A 2008 study comparing 10% dextran-40 with 10% hydroxyethyl starch (HES) in DHF patients with severe plasma leakage found both equally effective, but notably, both groups had higher complications than patients responding to crystalloids alone. 4

Critical caveat: Hydroxyethyl starches should be avoided entirely, as they increase mortality and renal replacement therapy requirements in septic shock contexts. 1, 5 This recommendation from the European Society of Intensive Care Medicine applies to dengue shock as well.

Practical Algorithm for Fluid Management

Step 1: Initial resuscitation (first 60 minutes)

• Give 10-20 mL/kg isotonic crystalloid over 5-10 minutes. 1
• Reassess perfusion immediately.
• If shock persists, repeat crystalloid bolus (up to 40-60 mL/kg total). 2, 1

Step 2: Persistent shock after adequate crystalloid

• If pulse pressure <10 mmHg or shock persists despite 40-60 mL/kg crystalloids, switch to colloid (albumin preferred). 1
• Give 10-20 mL/kg of 5% albumin or 10 mL/kg of 25% albumin. 6
• Consider vasopressor support (dopamine or norepinephrine targeting MAP ≥65 mmHg). 1

Step 3: Ongoing management

• Monitor closely for fluid overload (rales, hepatomegaly, increased work of breathing). 2, 1
• If oliguria develops after aggressive resuscitation, implement proactive fluid removal with diuretics or dialysis. 2, 1
• Patients with >10% fluid overload requiring continuous renal replacement therapy have worse outcomes. 1

Common Pitfalls to Avoid

• Delaying initial crystalloid resuscitation while waiting for colloids increases mortality. 1 Every hour of delay in restoring normal blood pressure doubles mortality risk. 2
• Administering excessive fluid boluses in patients without shock leads to fluid overload and respiratory complications. 2, 1
• Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage rapidly progresses to shock. 1
• Using hydroxyethyl starches in any dengue patient, as they worsen outcomes. 1, 5
• Prophylactic platelet transfusion is not recommended and does not prevent bleeding complications. 7, 8

Special Considerations

For dengue patients with concurrent severe malaria and shock with coma, albumin may be preferred over crystalloids based on evidence showing lower mortality (5% vs 46%) in this specific subgroup. 2 However, this represents a different clinical scenario than isolated dengue shock.

The rate of albumin administration matters: in hypoproteinemic patients with normal blood volumes, albumin should not exceed 2 mL per minute to avoid circulatory embarrassment and pulmonary edema. 6 However, in acute shock resuscitation, more rapid administration is appropriate.

Human albumin solution is contraindicated in severe traumatic brain injury, where it increases mortality. 2 This is relevant if dengue patients develop dengue encephalopathy with increased intracranial pressure.