2.

Fluid Management in
Dengue Hemorrhagic Fever
Dengue Expert Advisory
Group
• No Conflict of Interest
 Dengue Virus Infection
• Asymptomatic (75%)

• Symptomatic (25%)
– Mild fever/Undifferentiated
Febrile Illness –
Dengue Fever
– Dengue Hemorrhagic Fever (5%)
 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 is at a variable rate
that must be matched ml for ml

• Lasts 48 hours

• Resorption of fluid during convalescent

phase
 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
 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 : Age x 3

• APLS : (Age in years + 4) x 2

 Fluid Quota
• M + 5% = Maintenance + 5% of body
weight
 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
 Child 22 kg
• Maintenance
– 1000 + 500 + 40 = 1540 mls

• 5% Deficit
– 50 x 22 = 1100 mls

• Total 2640 mls

 Length of time?
• Over 48 hours if patient presents in the
beginning of critical phase (without shock)

• Over 24 hours for patients coming in

shock
 Types of Fluid?
• Crystalloids
– 0.9% Saline (adults)
– 5%Dextrose 0.9%
Saline (children)
– 5% Dextrose ½ saline (<6months)

• Colloids –
Dextran 40 in Saline
– 6% Starch
 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

• Supply to myocardium and brain

compromised
 Fluid Resuscitation
• Crystalloids – N Saline

• Colloids
– Dextran 40 in 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
• Myocarditis
• Adrenal Insufficiency/ Sepsis
 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

Thank you