Management of

Dengue in Adults
Part II : Fluid
Management

Dr Ker Hong Bee

Hospital Raja Permaisuri
Bainun
Ipoh

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 Causes of death in DHF patients
1. Prolonged shock

Delayed diagnosis/ delayed resuscitation

Untreated prolonged shock > 4 hours will lead to organ
failure and prognosis is very grave
2. Fluid overload

excess fluids or fluid given beyond the time of leakage
3. Massive bleeding
4. Unusual manifestations

Encephalopathy

Fulminant hepatitis

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Clinical Course of DHF

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Immunopathogenesis of Severe
Increased capillary
Dengue permeability

Systemic vascular
leakage becomes
apparent around the
time of defervescence

Warning signs If
clinically significant
leakage develops

Compensated shock

Decompensated shock

Simmons. Current concepts: Dengue. NEJM

2012;366:1423-32 4
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 Warning signs :
Patients who may deteriorate into
Severe Dengue

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 Assessment in Dengue
• Look for • Warning signs
defervescence • Evidence of
• Hours since plasma leakage
onset of
leakage
Identify
Symptoms
phase of
& signs
illness

Assess
Lab
peripheral
parameters
circulation
• Most useful • BP, pulse
HCT & WBC pressure, PR
count trend • Capillary filling
• Respiratory rate
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 DIAGNOSIS
• Day of illness
• Dengue fever / severe dengue
• ± warning signs
• Febrile phase / Defervescence by hours
• Haemodynamic stable / in shock

D4 , Severe dengue with DHF

with warning signs
defervesence phase 6 hours
in compensated shock

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 Fluid Management in Dengue

Maintenance
fluid
1. Non shock patients
unable to tolerate orally
2. Patients in shock
Resuscitation
fluid
1. With warning signs
2. Compensated shock
3. Decompensated shock

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 Fluid in Non shock Dengue patients
• IV fluid (0.9% saline) is indicated in those with
o increasing HCT (indicating on-going plasma leakage)
despite increased oral intake
o who are vomiting and not tolerating orally
• 1.2 - 1.5 X Maintenance in critical phase
• 4-6 hourly fluid adjustment during critical phase

• Fluid resuscitation if warning signs or deterioration to shock

• Reduce and consider discontinuation of IV fluid after 24-48

hours of defervescence in stable patients

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 Fluid management - maintenance
• Calculations for normal maintenance of intravenous fluid
infusion per hour:
(Equivalent to Halliday-Segar formula)

4 mL/kg/h for first 10kg body weight

+ 2 mL/kg/h for next 10kg body weight
+ 1 mL/kg/h for subsequent kg body weight

*For overweight/obese patients calculate normal maintenance fluid based

on ideal body weight

Ideal bodyweight can be estimated based on the following formula

Female: 45.5 kg + 0.91(height -152.4) cm
Male: 50.0 kg + 0.91(height -152.4) cm

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 If patient weighs 60kg ……..

4 mL/kg/h for first 10kg body weight

+ 2 mL/kg/h for next 10kg body weight
+ 1 mL/kg/h for subsequent kg body weight for 1x maintainance

4ml/kg/hr x 10 = 40 ml/hr
2ml/kg/hr x 10 = 20 ml/hr
1ml/kg/hr x 40 = 40 ml/hr
total = 100 ml/hr = 1 pint over 5 hrs
( 2400 ml/day )

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Dengue with warning signs : should be monitored in
hospitals

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Fluid for Dengue with Warning Signs

5-7

3-5
ml/kg/hr

2-3 1.2 – 1.5 x maintenance

pending clinical parameters and
HCT
1 2 3 4 5 6 7 8

Hours

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 Dengue Shock Syndrome – DHF Grade 3 and 4

• Dengue shock syndrome is a medical emergency

• Recognition of shock in its early stage (compensated

shock) and prompt fluid resuscitation will give a good
clinical outcome

• Pulse pressure of < 20 mmHg and systolic pressure < 90

mmHg are late signs of shock in adults

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 Blood pressure, pulse pressure, heart rate in
hypovolemic shock
PULSE
HR PRESSURE
120 ( SBP-DBP )
110
100
90 RESPIRATORY
80 • Narrowing pulse RATE
pressure
70
• Tachycardia
60 • SBP maintains
• Tachypnoeic
Compensated shock Decompensated shock

Time

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 Dengue Shock Syndrome
• All patients with dengue shock should be managed in
HDU/ICU
• Fluid resuscitation must be initiated promptly and should
not be delayed while waiting for admission to ICU or high
dependency unit
• The volume of initial and subsequent fluid resuscitation
depends on the degree of shock
• Following initial resuscitation there maybe recurrent
episodes of shock because capillary leakage can continue
for 24-48 hours

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 IV fluid in Dengue Shock Syndrome
• IV fluid therapy is the mainstay of treatment for dengue
shock
• Studies# showed no clear advantage of using any of the
colloids over crystalloids in terms of the overall outcome
• Colloids may be preferable as the fluid of choice in
patients with intractable shock in the initial resuscitation
• The choice of colloids includes gelatin solution (e.g.
Gelafusine) and starch solution (e.g. Voluven)
# Dung NM, Day NP, Tam DT, et al. Fluid replacement in dengue shock syndrome: a randomized, double-blind comparison of four intravenous-fluid
regimens. Clin Infect Dis. 1999 Oct;29:787-94.
Ngo NT, Cao XT ,Kneen R, et al. Acute management of dengue shock syndrome : a randomized double-blind comparison of 4 intravenous fluid regiments in
the first hour. Clin Infect Dis. 2001. 32:(2) 204-13.
Wills BA, Nguyen MD, Ha TL, et al. Comparison of three fluid solutions for resuscitation in dengue shock syndrome. N Engl J Med. 2005 Sep 1;353(9):877-89.

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 Assessment after each bolus of fluid
resuscitation
Clinical parameters Laboratory parameters

1.Improvement of general 1.Decrease in HCT

well being / mental state 2.Improvement in
2.Warm peripheries metabolic acidosis
3.CRT < 2sec
4.BP stable
5.Improving pulse pressure
6.Less tachycardic and less
tachypnoiec
7.Increase in urine output (≥
0.5ml/kg/hr)
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 Dengue Shock Syndrome
• Fluid therapy has to be judiciously controlled
to avoid fluid overload, result in massive pleural
effusion, pulmonary oedema or ascites

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 Fluid for DHF with Compensated Shock

5-
10
ml/kg/hr

5-7

3-5

2-3
1.2-1.5x maintenance Aim
To further reduce fluid if patient continues to improve to
stop
1 2 3 4 5 6 7 8 9 10 1 12 1 14 15 1 1 1 1 2 2 2 2 2 24-48
1 3 6 7 8 9 0 1 2 3 4

Hours

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 Assessment after each bolus of fluid
resuscitation
Clinical parameters Laboratory parameters

1.Improvement of general 1.Decrease in HCT

well being / mental state 2.Improvement in
2.Warm peripheries metabolic acidosis
3.CRT < 2sec
4.BP stable
5.Improving pulse pressure
6.Less tachycardic and less
tachypnoiec
7.Increase in urine output (≥
0.5ml/kg/hr)
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If still unstable after fluid resuscitation ?

Patient remains in shock after the first 2 cycles

of fluid resuscitation with crystalloids
(about 40 ml/kg)

Repeat HCT remains high Repeat HCT drops

Colloids should be Suspect significant bleed

considered for the 3rd (often occult) and blood
cycle transfusion should be
instituted ASAP

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Persistent shock despite 60 ml/kg IV fluid
resuscitation

Consider :

• Significant occult bleeds

• Cardiogenic shock (due to myocarditis or ischaemic
heart disease)
• Sepsis

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 Fluid for DHF with Decompensated Shock
2
0

1
0

5-7
ml/kg/hr

3-5

2-3

1.2-1.5x maintenance
To further reduce fluid if patient continues to improve

Aim to
stop

1 2 3 4 5 6 7 8 9 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 24-48

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 Remember
• The chart on the rate of fluid administration is only a guide

• Individual patient's rate of fluid requirement will depend on

the rate of leakage in that patient

• The rate of IV fluid administration has to be adjusted all the

time with FREQUENT MONITORING of
vital signs ( BP, pulse pressure, periperal perfusion and urine
output ) and
laboratory parameters ( HCT / HCO3 ± Se lactate )

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 Dengue hepatitis and liver failure
• Hepatitis is common in patients with DF/DHF
• Maybe mild or severe regardless of the degree of plasma
leakage
• Fulminant hepatitis with liver failure may occur
higher propensity to bleed, especially gastrointestinal
bleeding
Supportive therapy
Not to fluid overload patient
 IV N-acetylcysteine (NAC) therapy may be beneficial – need further
clinical trials

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Clinical Course of DHF

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 Recovery Phase
• After 24-48 hours of defervescence, plasma leakage stops and
is followed by reabsorption of extravascular fluid

• HCT level stabilises or drops further due to haemodilution

following reabsorption of extravascular fluid

• The recovery of white cell count (WCC) is followed by the

recovery of platelet count

• Discontinue IVD during reabsorption phase to avoid fluid

overload

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 Common pitfalls in fluid therapy

1. Treating patient with unnecessary fluid bolus based on

raised HCT as the sole parameter without considering
other clinical parameters
2. Excessive and prolonged fixed fluid regime in stable
patients
3. Infrequent monitoring and adjustment of infusion rate
4. Continuation of intravenous fluid during the recovery
phase

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The role of blood and blood
products

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 How to Recognize Significant Occult
Bleeding?

Significant bleeding or DIVC usually occurs following

prolonged shock and acidosis

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Management of bleeding in dengue

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Role of prophylactic transfusions in
dengue ?

NO !

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Thank You

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