Dengue with Warning Signs: IV Fluid Management
Initial Fluid Resuscitation Rate
For patients with dengue and warning signs, administer isotonic crystalloid at 5-7 mL/kg/hour for the first 1-2 hours, then reduce to 3-5 mL/kg/hour or 2-3 mL/kg/hour based on clinical response, with no difference in the rate between adults and children. 1
Fluid Type Selection
- Use only isotonic crystalloid solutions (0.9% saline or lactated Ringer's solution) for dengue patients with warning signs 1, 2
- Isotonic crystalloids are the cornerstone of resuscitation and prevent the development of hyponatremia that can occur with hypotonic solutions 2, 3
- Both normal saline and lactated Ringer's solution are equally effective, with no mortality difference between balanced crystalloids and saline in critically ill patients 4
Initial Management Algorithm
First 1-2 Hours:
- Start with 5-7 mL/kg/hour of isotonic crystalloid 1
- For a 70 kg adult: approximately 350-490 mL/hour
- For a 20 kg child: approximately 100-140 mL/hour
- Reassess vital signs, hematocrit, and urine output every 1-2 hours 1
After Initial Stabilization (2-4 hours):
- If clinical improvement occurs (stable vital signs, adequate urine output ≥0.5 mL/kg/hour), reduce to 3-5 mL/kg/hour for 2-4 hours 1
- If further improvement continues, reduce to 2-3 mL/kg/hour or less 1
- Continue monitoring hematocrit levels as a guide to plasma leakage 1
Critical Reassessment Parameters
After each adjustment in fluid rate, evaluate for:
- Vital signs stability: ≥10% rise in systolic/mean arterial pressure and ≥10% reduction in heart rate indicate adequate resuscitation 2
- Urine output: Target >0.5 mL/kg/hour in adults, >1 mL/kg/hour in children 2
- Hematocrit trends: Decreasing hematocrit with stable vital signs suggests adequate plasma volume replacement 1
- Peripheral perfusion: Capillary refill ≤2 seconds and warm extremities 2
Warning Signs Requiring Fluid Bolus
If shock develops (hypotension, narrow pulse pressure, cold extremities):
- Administer 20 mL/kg bolus of isotonic crystalloid over 15-20 minutes 1, 2
- Reassess immediately after each bolus 1, 2
- May repeat up to 60 mL/kg in the first hour with mandatory reassessment after each 20 mL/kg bolus 1, 2
- For refractory shock, consider inotropic support rather than continuing aggressive fluid administration 2
Critical Pitfalls to Avoid
- Do not use hypotonic fluids (such as D5W or 0.45% saline), as they increase the risk of hyponatremia and do not provide adequate resuscitation 2, 5
- Do not rely on blood pressure alone to assess perfusion in children, as hypotension is a late sign 1
- Stop fluid administration immediately if signs of fluid overload develop: pulmonary rales/crackles, hepatomegaly, progressive peripheral edema, increased work of breathing, or worsening oxygenation 2
- Do not continue aggressive fluids beyond 60 mL/kg/hour without reassessment, as excessive volumes are associated with worse outcomes 2
- Monitor for the critical phase (typically days 3-7 of illness) when plasma leakage is maximal and fluid requirements may increase 6, 7
Transition to Maintenance Fluids
Once the patient demonstrates:
- Normal vital signs with stable blood pressure
- Adequate urine output (>0.5 mL/kg/hour)
- Decreasing or stable hematocrit
- Resolution of warning signs
Reduce to maintenance rates using the Holliday-Segar formula for children: 100 mL/kg/day for first 10 kg + 50 mL/kg/day for next 10 kg + 25 mL/kg/day for each additional kg 2
For adults, typical maintenance is approximately 1.5-2 mL/kg/hour of isotonic crystalloid 2