What is the recommended initial intravenous fluid for a dengue patient developing plasma leakage or shock?

Initial Intravenous Fluid for Dengue Shock Syndrome

Administer isotonic crystalloid solutions (Ringer's lactate or 0.9% normal saline) as the initial fluid bolus of 20 mL/kg over 5-10 minutes for all patients with dengue shock syndrome or plasma leakage. 1, 2

Initial Resuscitation Protocol

Crystalloids are first-line for all dengue shock patients:

• Give 20 mL/kg of Ringer's lactate or 0.9% normal saline as a rapid bolus over 5-10 minutes 1, 2
• Reassess immediately after each bolus for signs of improvement: improved capillary refill time (<3 seconds), warming of extremities, stronger peripheral pulses, improved mental status, and adequate urine output 1, 2
• If shock persists after the initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour before considering escalation 1, 2

The evidence strongly supports this approach—high-quality research demonstrates near 100% survival with appropriate crystalloid resuscitation in dengue shock syndrome. 2 The majority of DSS patients can be successfully treated with isotonic crystalloid solutions alone. 3

When to Escalate to Colloids

Consider colloid solutions only after adequate crystalloid resuscitation (40-60 mL/kg in first hour) if shock persists:

• Moderate-quality evidence shows colloids achieve 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, 2
• Dextran 70 provides the most rapid normalization of hematocrit and restoration of cardiac index 4
• However, 6% hydroxyethyl starch may be preferable to dextran 70 due to fewer adverse reactions, with similar efficacy 5
• Alternative colloids include gelafundin or albumin if other options are unavailable 1

The key distinction here is that colloids are not first-line—they are reserved for refractory cases. A landmark randomized trial of 383 children found that initial resuscitation with Ringer's lactate is indicated for moderately severe dengue shock syndrome, with colloids reserved for severe shock. 5

Critical Monitoring During Resuscitation

Watch for these specific indicators to guide fluid management:

• Signs of adequate resuscitation: Capillary refill time <3 seconds, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, adequate urine output 1, 2
• Signs requiring immediate cessation of fluids: Development of hepatomegaly, pulmonary rales on lung examination, or respiratory distress 1, 2
• Hematocrit monitoring: Rising hematocrit (≥20% increase from baseline) indicates ongoing plasma leakage and need for continued resuscitation; falling hematocrit suggests successful plasma expansion 2, 6
• Daily complete blood count: Essential to track platelet counts and hematocrit levels 1, 2

Management of Refractory Shock

If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch strategy from aggressive fluid administration to vasopressor support:

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 2
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 1, 2
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear 1, 2

Critical Pitfalls to Avoid

Do not administer bolus IV fluids to patients with plasma leakage (ascites, pleural effusion) who are NOT in shock:

• This increases risk of fluid overload and respiratory complications without improving outcomes 2, 7
• Oral rehydration is appropriate for patients without signs of shock 2, 7

Do not use restrictive fluid strategies in established dengue shock syndrome:

• Moderate-quality evidence shows no survival benefit from fluid restriction, and aggressive fluid management achieves near 100% survival 2
• Delaying fluid resuscitation in established shock significantly increases mortality 2

Do not fail to recognize the critical phase (typically days 3-7 of illness):

• This is when plasma leakage can rapidly progress to shock and fluid management becomes most crucial 1, 2, 7
• A rise in hematocrit of 20% along with continuing drop in platelet count is an important indicator for onset of shock 6

Do not continue aggressive fluid boluses once fluid overload develops:

• Evidence shows that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 2
• Switch to inotropic support instead of continuing fluid administration 1, 2