This document discusses fluid management for dengue hemorrhagic fever and dengue shock syndrome. It notes that during the critical phase of dengue hemorrhagic fever, plasma leaks from blood vessels causing fluid loss. Proper volume replacement with crystalloids, at a rate matching fluid loss, is important to manage this. For dengue shock syndrome, rapid fluid resuscitation with crystalloids and possibly colloids is needed to treat circulatory compromise. Careful monitoring of vital signs and fluid balance is essential during the critical phases of both conditions.

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