What are the blood pressure cutoffs for pediatric patients with dengue (Dengue Virus Infection)?

Blood Pressure Cutoffs for Pediatric Dengue Shock Syndrome

The specific blood pressure cutoffs for pediatric dengue shock syndrome are age-dependent mean arterial pressure (MAP) targets, though the guidelines emphasize that hypotension is a late and unreliable sign in children—shock should be recognized earlier through clinical perfusion indicators rather than waiting for blood pressure to drop. 1, 2

Critical Concept: Blood Pressure is NOT the Primary Diagnostic Criterion

• In pediatric patients, shock can be present with normal blood pressure, making BP cutoffs less clinically useful than perfusion markers for early recognition of dengue shock syndrome 1, 2
• The guidelines do not provide specific systolic/diastolic cutoffs because hypotension represents late, decompensated shock in children, and waiting for BP to drop significantly increases mortality 2
• Instead, dengue shock syndrome should be diagnosed based on narrow pulse pressure (≤20 mmHg) combined with tachycardia and poor perfusion, which occurs before frank hypotension develops 1, 2

Clinical Indicators That Precede Hypotension

Monitor these perfusion parameters rather than relying solely on blood pressure:

• Poor capillary refill time (>2 seconds) 2
• Skin mottling and cold extremities 2
• Weak or absent peripheral pulses 2
• Altered mental status (lethargy or restlessness) 2, 3
• Tachycardia out of proportion to fever 2
• Decreased urine output 2

Target MAP During Resuscitation

• Once shock is identified and treatment initiated, target age-appropriate mean arterial pressure while maintaining ScvO2 >70% 2
• The American College of Critical Care Medicine recommends using age-specific MAP targets, though specific numerical cutoffs vary by age and are not explicitly stated in dengue-specific guidelines 1, 2

Warning Signs That Predict Progression to Shock

These clinical and laboratory parameters independently predict severe dengue and should trigger intensive monitoring: 4, 5, 6

• Clinical fluid accumulation (pleural effusion, ascites) - strongest predictor with hazard ratio 2.19 5, 6
• Hematocrit ≥0.40 concurrent with platelet count <100 × 10⁹/L - hazard ratio 1.715 5, 6
• Persistent vomiting 5, 6
• Severe abdominal pain or tenderness 4, 5
• Mucosal bleeding 4, 5, 6
• Hepatomegaly >2 cm 4, 5
• Lethargy or restlessness 3, 4, 5

Critical Pitfalls to Avoid

• Do not wait for hypotension to develop before initiating aggressive fluid resuscitation - by the time BP drops, cardiovascular collapse may rapidly follow 2
• Do not use blood pressure alone as an endpoint in children - it is an insensitive marker of adequate resuscitation 1, 2
• Do not fail to recognize the critical phase (days 3-7 of illness) when plasma leakage can rapidly progress to shock, even with normal BP 2, 7
• Do not give routine bolus IV fluids to febrile children without shock based on BP readings alone, as this increases fluid overload risk without improving outcomes 2, 3

Practical Approach

When dengue shock syndrome is suspected (narrow pulse pressure, tachycardia, poor perfusion):

1. Administer 20 mL/kg isotonic crystalloid bolus over 5-10 minutes immediately 2, 3
2. Reassess perfusion markers (not just BP) after each bolus 2
3. Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists 2, 3
4. If shock remains refractory, escalate to colloids and vasopressors while targeting age-appropriate MAP 2, 7