1. 2. Fluid Management in
Dengue Hemorrhagic Fever
Dengue Expert Advisory
Group

2. Dengue Virus Infection
• Asymptomatic
• Symptomatic
– Undifferentiated Febrile Illness
– Dengue Fever
– Dengue Hemorrhagic Fever
 Non Shock
 Shock

3. Dengue Hemorrhagic Fever
• Febrile Phase
• Critical phase characterized by plasma
leak
• Convalescent Phase

4. Dengue “Leak” Fever
• Plasma leak during critical phase is the
hall mark
• Leading to 3rd space losses
– peritoneal cavity
– pleural cavity
• Variable in magnitude and exact timing

6. Pathogenesis of leak
• Infection with a virulent dengue virus
• Presence of antibodies that enhance
dengue virus infection (ADE)
• Intense immune activation

7. Pathogenesis
• Rapidly elevated cytokines (TNF-a, IL-2,
IL-6, IL-8, IL-10, IL-12, and IFN-g)
• Malfunction of vascular endothelial cells
• Plasma leakage from intra to extravascular
space

8. Pathogenesis
• In severe DHF the loss of plasma is critical
• Patient becomes hypovolaemic
• Signs of circulatory compromise
• Progress to shock, organ failure, death

9. Pathogenesis
• Cytokine Storm
• Self limited
• Ends after 48 hours

10. Clinical Implications
• Extravascular fluid loss at variable rate
that has to be matched ml for ml
• Lasting 48 hours
• Resorption of fluid during convalescent
phase

11. Key Points
• Manage critical phase with appropriate
volume
– Don’t under transfuse
– Don’t over transfuse
• Meticulous monitoring during critical phase
to match rate of fluid infusion with rate of
leak

12. Monitoring Parameters
• Clinical
– Pulse Rate
– Blood and Pulse Pressure
– Capillary Refill Time
– Urinary Output
• Lab
– Hematocrit

13. Fluid Management
Critical Phase

14. Amount of Fluid?
• Based on weight
• Adults
– If less than 50kg use actual weight
– If more take weight as 50 kg
• Paediatrics
– Current OR Ideal body weight whichever
is lower

15. Ideal Body Weight
• Weight for height using a growth chart
• Weight for age
• Formulae in emergency

16. Growth Charts

19. Formulae
• <1 year : Age (in Months)+ 9/2
• 1-7 years : (Age x 2)+ 8
• >7 years : Age x 3
• APLS : (Age in years + 4) x 2

20. Fluid Quota
• M + 5% = Maintenance + 5% of body
weight
• Over 48 hours if patient presents in the
beginning of critical phase (without shock)
• Over 24 hours for patients coming in
shock

23. M + 5% - Adults
• Maintenance
– 1st 10 kg – 1000 mls
– 2nd 10 kg – 500 mls
– Remaining 30kgs – 600 mls
– Sum = 2100 mls
• 5% deficit – 50 x 50 = 2500 mls
• Total = 4600 mls

24. Child 22 kg
• Maintenance
– 1000 + 500 + 40 = 1540 mls
• 5% Deficit – 50 x 22 = 1100 mls
• Total 2640 mls

25. Types of Fluid
• Crystalloids
– 0.9% Saline
– 5%Dextrose 0.9% Saline
– 5% Dextrose ½ saline

27. Monitoring – Critical Phase
• Vital parameters - hourly
• Fluid balance chart - assess three hourly
• HCT - six hourly

28. Fluid Management in
Dengue Shock
Syndrome

29. Compensated
• Body compensates for fluid loss
• Tachycardia
• Pulse Pressure narrows
• Prolonged CRT
• Fall in urine output to 0.5 mls/kg/hr

30. Decompensated
• Pulse pressure narrows further leading to
unrecordable pulse and BP
• Urine output falls less than 0.5 mls/kg/hour
• Supply to myocardium and brain
compromised

31. Fluid Resuscitation
• Crystalloids – N Saline
• Colloids
– Dextran 40 in saline
– 6% Starch
• All boluses part of fluid quota

32. Indications for Colloid
• Failure of crystalloid boluses to normalize
pulse /BP
• Development of shock
– with fluid overload
– amount of fluid exceeding M + 5%
deficit
• 10 ml/kg over 1 hour

33. Colloids
• Dextran may sometimes interfere with
grouping and cross matching
• 3 doses of Dextran 40 during a 24 hour
• 5 doses of 6% Starch during 24 hour
• Remain in circulation for much longer

36. Refractory Shock - ABCS
• Blood
– packed cells
– whole blood
• Bicarbonate
• Glucose
• Calcium

37. Monitoring During Shock
• 15 minute monitoring of vital signs
• HCT immediately before and after each
fluid bolus and then at least two to four
hourly

38. Key Points – Managing DHF
• Recognizing the start of critical phase of
DHF
• Predicting the rate of leak which may vary
from patient to patient and within the same
patient
• Matching the rate of infusion to rate of leak
• Being cognizant of the end of critical

39. Key Points – Managing DSS
• Meticulous monitoring
• Switching appropriately from crystalloids to
colloids
• Recognizing need for blood transfusion