What is the appropriate immediate management of a patient with severe dengue?

Management of Severe Dengue

Immediately administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes, reassess after each bolus, and repeat up to 40-60 mL/kg in the first hour if shock persists before escalating to colloids and vasopressors. 1, 2, 3

Immediate Resuscitation Protocol

Initial Fluid Bolus

• Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) over 5-10 minutes as the first-line intervention 1, 2, 3
• Reassess immediately after each bolus for signs of improvement: improved capillary refill, decreased tachycardia, improved mental status, warming of extremities 1, 2
• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before changing strategy 1, 2

Escalation to Colloids

• If shock persists despite adequate crystalloid resuscitation (40-60 mL/kg), switch to colloid solutions 1, 2
• 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) 2
• Options include albumin, gelafundin, or dextran 2

Critical Monitoring During Resuscitation

Signs of Adequate Resuscitation

• Normal capillary refill time (<3 seconds) 1, 2
• Absence of skin mottling 1, 2
• Warm and dry extremities with well-felt peripheral pulses 1, 2
• Return to baseline mental status 1, 2
• Adequate urine output 1, 2
• Improvement in tachycardia and tachypnea 2

Signs of Fluid Overload (STOP Fluids Immediately)

• Development of hepatomegaly during fluid therapy 1, 2
• Pulmonary rales on auscultation 1, 2
• New-onset respiratory distress 1, 2

Hematocrit Monitoring

• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 1, 2
• A ≥20% increase in hematocrit from baseline defines dengue hemorrhagic fever 2
• Falling hematocrit suggests successful plasma expansion 2

Management of Refractory Shock

When to Switch from Fluids to Vasopressors

• If shock persists despite 40-60 mL/kg of fluid in the first hour, switch from aggressive fluid administration to inotropic support rather than continuing fluid boluses 1, 2
• Delays in vasopressor therapy are associated with major increases in mortality 2

Vasopressor Selection Based on Hemodynamic State

• Cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1, 2
• Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 1, 2
• Target age-appropriate mean arterial pressure and maintain ScvO2 >70% 1, 2
• Begin peripheral inotropic support immediately if central venous access is not readily available 2

Management of Complications

Bleeding Management

• Blood transfusion may be necessary for significant bleeding 1, 2, 3
• Target hemoglobin >10 g/dL if ScvO2 <70%, as oxygen delivery depends on hemoglobin concentration 1, 2, 3

Fluid Overload Management

• After initial shock reversal, judicious fluid removal may be necessary during the recovery phase 2
• Evidence shows that aggressive shock management followed by fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 2, 4
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, with better outcomes when initiated early 2
• Proactive monitoring for symptomatic abdominal compartment syndrome may require invasive percutaneous drainage 4

Supportive Care

Pain and Fever Management

• Use acetaminophen (paracetamol) only for pain and fever management 1, 3
• Strictly avoid aspirin and NSAIDs under any circumstances due to increased bleeding risk 1, 2, 3

Oral Hydration for Non-Shock Patients

• For patients without shock, encourage oral intake of approximately 2,500-3,000 mL daily, which reduces hospitalization rates 1, 3
• Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1, 3
• Avoid soft drinks due to high osmolality 1, 3

Critical Pitfalls to Avoid

Do NOT Give Routine Bolus IV Fluids to Non-Shock Patients

• Avoid routine bolus IV fluids in patients with severe febrile illness who are NOT in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes 2

Do NOT Continue Aggressive Fluids Once Overload Appears

• Once signs of fluid overload develop (hepatomegaly, rales, respiratory distress), immediately stop fluid resuscitation and switch to inotropic support 1, 2

Do NOT Delay Fluid Resuscitation in Established Shock

• Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality 2
• Once hypotension occurs, cardiovascular collapse may rapidly follow 2
• Blood pressure alone is not a reliable endpoint, especially in children, as shock can be present with normal blood pressure 2

Do NOT Use Restrictive Fluid Strategies in Established Shock

• Restrictive fluid strategies have no survival benefit in dengue shock syndrome and may worsen outcomes 2
• Three RCTs demonstrate near 100% survival with aggressive fluid management when properly administered 2
• Evidence shows aggressive crystalloid resuscitation is life-saving in dengue shock syndrome 2, 5