What is the recommended fluid management for a patient with suspected dengue in the critical phase in Malaysia to avoid under‑resuscitation and fluid overload?

Fluid Management for Dengue Critical Phase in Malaysia

For patients with suspected dengue in the critical phase, administer an initial fluid bolus of 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) over 5-10 minutes if shock is present, with immediate reassessment after each bolus; however, avoid routine bolus intravenous fluids in patients without shock, as this increases fluid overload and respiratory complications without improving outcomes. 1

Initial Assessment: Distinguish Shock from Non-Shock States

The critical decision point is whether the patient has dengue shock syndrome or is simply in the critical phase without shock:

Signs of Dengue Shock Syndrome (requiring immediate fluid boluses):

• Tachycardia with weak peripheral pulses 1
• Capillary refill time ≥3 seconds 2
• Cold extremities or skin mottling 1
• Hypotension or narrow pulse pressure (≤20 mm Hg) 1
• Altered mental status or lethargy 1
• Hematocrit rise ≥20% above baseline with rapidly falling platelets 1, 3

Warning Signs Without Shock (requiring oral rehydration only):

• Abdominal pain, persistent vomiting, or clinical fluid accumulation (ascites/pleural effusion) 1, 4
• Mucosal bleeding 1
• Lethargy or restlessness 1
• Hepatomegaly 1

Fluid Resuscitation Protocol for Dengue Shock Syndrome

First-Line Crystalloid Resuscitation:

• Give 20 mL/kg of Ringer's lactate or 0.9% normal saline as a rapid bolus over 5-10 minutes 1, 5
• Reassess immediately after each bolus for improvement in tachycardia, tachypnea, capillary refill, and mental status 1, 6
• Repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour if shock persists 1, 5

Escalation to Colloids for Refractory Shock:

• If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch to colloid solutions 1, 7
• Colloids provide faster resolution of shock (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
• Dextran 70 is the preferred colloid, providing the most rapid normalization of hematocrit and restoration of cardiac index without adverse effects 6
• Alternative colloids include gelafundin or albumin if dextran is unavailable 1, 6

Vasopressor Support for Persistent Hypoperfusion:

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 7
• Target age-appropriate mean arterial pressure and maintain ScvO2 >70% 1
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy increase mortality 1

Monitoring Parameters During Resuscitation

Signs of Adequate Resuscitation:

• Normal capillary refill time (<3 seconds) 1
• Warm and dry extremities with well-felt peripheral pulses 1
• Return to baseline mental status 1
• Adequate urine output 1
• Improvement in tachycardia and tachypnea 1

Signs of Fluid Overload (STOP fluid boluses immediately):

• Development of hepatomegaly during fluid therapy 1, 4
• Pulmonary rales on auscultation 1
• New-onset respiratory distress 1
• When these signs appear, switch from aggressive fluid administration to inotropic support rather than continuing fluid boluses 1

Laboratory Monitoring:

• Daily complete blood count to track platelet counts and hematocrit levels 1
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 1
• Falling hematocrit suggests successful plasma expansion 1

Management for Non-Shock Critical Phase

Oral Rehydration Strategy:

• Encourage 5 or more glasses of fluid throughout the day, targeting approximately 2,500-3,000 mL daily 1
• Use any locally available fluids: water, oral rehydration solutions, cereal-based gruels, soup, or rice water 1
• Avoid soft drinks due to high osmolality 1

Critical Pitfall: Do NOT give routine bolus IV fluids to patients with "severe febrile illness" who are NOT in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes 1, 4

Post-Resuscitation Fluid Management

After initial shock reversal, judicious fluid removal may be necessary during the recovery phase:

• Evidence shows that aggressive shock management followed by fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when CRRT is initiated early 1

Critical Pitfalls to Avoid in Malaysian Context

• Do not delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow 1, 4
• Do not use restrictive fluid strategies in dengue shock syndrome—moderate-quality evidence shows no survival benefit, and aggressive fluid management achieves near 100% survival 1
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 1
• Do not fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 4
• Do not use aspirin or NSAIDs due to increased bleeding risk 1, 4
• Blood pressure alone is not a reliable endpoint in children—shock can be present with normal blood pressure, making perfusion markers more clinically useful for early recognition 1

Supportive Care

• Use acetaminophen (paracetamol) only for pain and fever management 1
• Blood transfusion may be necessary for significant bleeding; target hemoglobin >10 g/dL if ScvO2 <70% 1, 4
• Resume age-appropriate diet as soon as appetite returns 1