2.

Fluid Management in
Dengue Hemorrhagic Fever
Dengue Expert Advisory
Group

Dengue Virus Infection

Asymptomatic
Symptomatic
Undifferentiated Febrile Illness
Dengue Fever
Dengue
Hemorrhagic Fever
Non Shock
Shock

Dengue Hemorrhagic Fever

Febrile Phase
Critical phase characterized by plasma
leak
Convalescent Phase

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

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

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

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

Pathogenesis
Cytokine Storm
Self limited
Ends after 48 hours

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

Key Points
Manage critical phase with appropriate
volume
Dont under transfuse
Dont over transfuse
Meticulous monitoring during critical
phase to match rate of fluid infusion with
rate of leak

Monitoring Parameters
Clinical
Pulse Rate
Blood and Pulse
Pressure

Capillary Refill Time

Urinary Output
Lab
Hematocrit

Fluid Management
Critical Phase

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

Ideal Body Weight

Weight for height using a growth chart
Weight for age
Formulae in emergency

Growth Charts

Formulae
<1 year

Age (in Months)+ 9/2

1-7 years : (Age x 2)+ 8

>7 years

APLS

: (Age in years + 4) x 2

Age x 3

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

M + 5% - Adults
Maintenance
1st 10 kg

1000 mls
2 nd 10 kg

500 mls

Remaining 30kgs 600 mls

Sum
= 2100 mls
5% deficit 50 x 50 = 2500 mls
Total
= 4600 mls

Child 22 kg
Maintenance
1000 + 500 + 40 = 1540 mls
5% Deficit 50 x 22 = 1100 mls
Total

2640 mls

Types of Fluid
Crystalloids
0.9% Saline
5%Dextrose 0.9%
Saline
5% Dextrose saline

Monitoring Critical Phase

Vital parameters - hourly
Fluid balance chart - assess three hourly
HCT - six hourly

Fluid Management in
Dengue Shock
Syndrome

Compensated
Body compensates for fluid loss

Tachycardia
Pulse Pressure narrows
Prolonged CRT
Fall in urine output to 0.5 mls/kg/hr

Decompensated
Pulse pressure narrows further leading to
unrecordable pulse and BP
Urine output falls less than 0.5 mls/kg/hour

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

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

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

Refractory Shock - ABCS

Blood
packed cells
whole blood
Bicarbonate
Glucose
Calcium

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

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

phase

Key Points Managing DSS

Meticulous monitoring
Switching appropriately from crystalloids
to colloids
Recognizing need for blood transfusion