This is a working protocol of fluid management of dengue patients based on the national guideline of Bangladesh in 2019. I prepared and presented this working protocol for the doctors of medicine unit 9 of Dhaka Medical College & Hospital and it was widely used during the Dhaka Dengue Epidemic 2019.

1. FLUID MANAGEMENT OF
DENGUE PATIENTS
Dr. Lisanul Hasan
Intern Doctor , MU-09,
DMCH

2. INTRODUCTION
1.Dengue virus has four different serotypes .
2.Transmitted by Aedes mosquitoes.
3. Incubation period of 4-7 (range 3-14) days
4. The majority of infection in children under age 15 years are
asymptomatic or minimally symptomatic

3. DENGUE SYNDROMES
1. Undifferentiated fever
2. DF
3. DHF
4. Expanded dengue syndrome (rare)

5. CLINICAL COURSE
Three phases:
• Febrile phase - lasts for 2-7 days
• Critical phase - after 3-4 days of onset of fever,
lasts for 36-48 hrs
• Convalescent phase - after 6-7 days of fever and
last for 2-3 days

6. SYMPTOMS
A sharp rise in temperature and is frequently
associated with a flushed face and headache. Occasionally, chills accompany
the
sudden rise in temperature.
The following features are usually observed:
• retro-orbital pain on eye movement or eye pressure
• photophobia
• backache, and pain in the muscles and joints/bones.
• The other common symptoms include anorexia and altered taste
sensation, constipation,
colicky pain and abdominal tenderness

7. DENGUE SHOCK SYNDROME
Dengue Shock Syndrome is a presentation of Dengue Syndromes
when there is
criteria of DHF plus signs of circulatory failure, manifested by:
• Rapid and weak pulse
• Narrow pulse pressure (≤ to 20 mm Hg)
• Hypotension for age
• Cold clammy skin
• Restlessness
• Undetectable pulse and blood pressure

8. EXPAN
DED
DENGU
E
SYNDR
OME

9. INVESTIGATIONS
1.Complete Blood Count
2.NS1 antigen , Dengue IgM , IgG
3.Serum AST and ALT
4.Serum Albumin
5. Serum Calcium
6. Coagulation Profile
7. Others: Urine R/M/E, Stool Test, Chest X ray etc. depending on the
necessity
*Within 3 days - CBC, Haematocrit , NS1 antigen, SGOT, SGPT

10. WARNING SIGNS
1.No clinical improvement or worsening of the situation just before or
during the transition to afebrile phase or as the disease progresses.
2.Persistent vomiting.
3.Severe abdominal pain.
4.Lethargy and/or restlessness, sudden behavioural changes.
5.Bleeding: Epistaxis, black stool, haematemesis, excessive menstrual
bleeding, dark colored urine (haemoglobinuria) or haematuria.
6.Giddiness.
7.Pale, cold and clammy hands and feet.
8.Less/no urine output for 4 – 6 hours
9.Liver enlargement > 2cm
10.Haematocrit >20%

11. CO - EXISTING CONDITIONS OR
RISK FACTORS*Pregnancy
*Infancy
*Old age
*Obesity
*Diabetes mellitus
*Hypertension
*Heart failure
*Renal failure
*Chronic hemolytic diseases
*Those with certain social circumstances (such as living alone, or
living far from a
health facility without reliable means of transport)

12. THREE GROUPS ARE CREATED FOR
MANAGEMENT PURPOSE
Group –A
*Do not have warning signs
*Who are able
- to tolerate adequate amount of ORAL Fluids
- to pass urine at least once in every 6 hours

13. Group-B
Patients with any of the followings
* Co-existing conditions
* Special circumstances
* Existing warning signs
Group-C
•Patients with any of the following features.
•Severe plasma leakage with shock and/or fluid accumulation with respiratory
distress
•Severe bleeding
•Severe organ impairment
•Severe Metabolic dysfunction

14. GROUP A
*Adequate rest
*Adequate fluid intake
*Paracetamol, 4 gram max. per day in adults and
accordingly in children
* Basically home treatment but tell them when to come to hospital

15. GROUP B
*In-hospital treatment
Encourage oral fluid
If not tolerated then I/V fluid
5-7ml/kg/hr for 1-2 hr, 50 drops/min
3-5ml/kg/hr for 1-2 hr , 30 drops/min
2-3ml/kg/hr for 1-2 hr , 20 drops/min
1.5ml/kg/hr for 1-2 hr , 12 drops/min
* Obtain reference Hct before fluid therapy
* Choice of fluid: Crystalloid: Normal saline , Hartman solution , Ringer lactate
solution
Colloid: Dextran , Plasmasol , Blood and blood components , Human albumin
* Reassess clinical status 2 hourly , repeat Hct and review fluid infusion rates
accordingly

16. HOLLIDAY - SEGAR FORMULA
Fluid requirements = Maintenance + 5% deficit
Maintenance =100 ml/kg for first 10 kg
50 ml/kg for next 10 kg
20 ml/kg for subsequent kgs
5% deficit = 50 ml/kg
Given over 48 hours
Remember : 1.Platelet transfusion is not recommended if not indicated
2.If platelet is not available then fresh whole blood can be
transfused .

17. GROUP-C
* Emergency management and urgent referral
The goals of fluid resuscitation
1. Improve circulation
2. Improve end organ perfusion
3. Urine output ≥ 0.5 ml/kg/hour or decreasing metabolic acidosis
Compensated shock
Manifested by narrow pulse pressure
If hypotension present then look for concealed bleeding apart from plasma
leakage .
Give 10ml/kg I/V fluid bolus
Fluid therapy should be continued for at least 24 hours by titration and
discontinued by 48 hours.

18. DECOMPENSATED SHOCK
Preferably managed in ICU
* Oxygen inhalation
* 10-20 ml/kg bolus crystalloid over 10-15 min
* If vitals and Hct improved then follow the algorithm
* If not improved then shift to colloid at 10 ml/kg bolus dose
* Highest dose of colloid is 30 ml/kg/24 hr, so bolus dose can be
repeated thrice
* If Hct falls and vitals deteriorates after initial crystalloid infusion ,
then transfuse
Whole blood @ 10ml/kg or Packed RBC @ 5ml/kg

19. SOME IMPORTANT INFORMATION
*In case of refractory hypotension, look for ABCS and IV ionotropes
with
crystalloids as per requirement is to be continued
*In case of acidosis, hyperosmolar or ringers lactate should not be
used
*Hct measurement in every hour is more important
than platelet count during management

20. ABCS
Laboratory investigations for both shock and non-shock cases if no
improvement after fluid therapy
ABCS
A- Acidosis
B- Bleeding
C- Calcium
S- Sugar

21. SOME DONT’S
Don’t give aspirin or NSAIDS
Don’t change the fluid infusion rate abruptly
Don’t give antibiotics
Avoid transfusion if not indicated
NG tube insertion is not recommended
Avoid IM injections

22. DISCHARGE CRITERIA
All of following criteria must be present:
*No fever for 48 hours
*Improvement in clinical picture
*Increasing trend of platelet count
*No respiratory distress
*Stable haematocrit without intravenous fluids

23. THANK YOU ALL