Dengue: the plasma leak and its fluid management

Manage now— do this, in order

• There is no antiviral treatment for dengue — management is entirely supportive: analgesia, meticulous fluid titration and recognition of complications, replacing hour by hour only the plasma that has leaked, for only as long as it is leaking.
• Paracetamol only for fever and pain: adult 500 mg–1 g orally or IV 6-hourly, max 4 g in 24 hours (max 2 g with marked transaminitis or tender hepatomegaly); child 10–15 mg/kg per dose 6-hourly, max 4 doses in 24 hours (max 60 mg/kg/day). NSAIDs and aspirin are contraindicated at every platelet count, and nothing is given intramuscularly — no drug at all (deep haematoma). Where paracetamol cannot be given, physical cooling is the only alternative.
• Group A (no warning signs, tolerating oral fluid, passing urine at least 6-hourly, stable haematocrit, no comorbidity, responsible adult at home): outpatient with daily review — oral rehydration solution first choice with a specific daily target volume, not "drink plenty"; daily FBC and haematocrit from day 3 until 48 hours after defervescence, plus a written list of warning signs a relative can repeat back.
• Group B (any warning sign, or comorbidity, pregnancy, infancy or old age): admit, weigh the patient, and begin isotonic crystalloid (0.9% sodium chloride or Hartmann's / Ringer's lactate) as a stepped, tapering regimen: 5–7 mL/kg/h for 1–2 hours, then 3–5 mL/kg/h for 2–4 hours, then 2–3 mL/kg/h. Reassess before every step change — vital signs with pulse pressure, hourly urine output targeting 0.5–1 mL/kg/h (sufficient, not more), haematocrit 4–6-hourly; if the haematocrit rises or observations deteriorate, step back up to 5–10 mL/kg/h for 1–2 hours. Never use 5% dextrose or other hypotonic fluid for resuscitation.
• Compensated shock: isotonic crystalloid 5–10 mL/kg over 1 hour, reassessed clinically and with a repeat haematocrit; if improving, step down through 5–7, then 3–5, then 2–3 mL/kg/h, tapering to stop over 24–48 hours. Hypotensive shock (dengue shock syndrome): 20 mL/kg as a rapid bolus over 15 minutes, given by hand — squeezing the bag, or syringe and three-way tap in a small child, since a gravity line will not deliver this through a 22G cannula; if the pressure recovers, continue at 10 mL/kg/h for 1 hour then step down.Doctor / Nurse
• If the patient is not improving, repeat the haematocrit and let it choose the next move: still high or rising — the leak is continuing: second crystalloid bolus 10–20 mL/kg over 1 hour, then colloid 10–20 mL/kg over 30–60 minutes if still unresponsive; fallen — concealed haemorrhage until proved otherwise: cross-match and transfuse packed red cells 5–10 mL/kg or fresh whole blood 10–20 mL/kg over 1–2 hours. Do not give repeated reflex crystalloid boluses to a non-responder, and do not transfuse platelets for a number — reserve platelets for clinically significant bleeding or an unavoidable invasive procedure.Doctor / NurseNot available at your setup — Blood & blood products.
• Recognise fluid overload and reduce or stop the fluid — do not reach first for a diuretic: rising respiratory rate, basal crackles, reduced air entry, puffy eyelids, tense abdomen, raised JVP. Sit the patient up and give oxygen to 94–98%. Furosemide 0.5–1 mg/kg IV (adult 20–40 mg) only once the patient is out of the leak phase, haemodynamically stable and overloaded — given to a patient still leaking and still shocked it will kill them.Doctor / Nurse
• Recognise the recovery phase and stop the fluid — that is itself a treatment: returning well-being and appetite, haemodynamic stability, good or rising urine output, a stabilising or falling haematocrit from haemodilution, a rising platelet count, relative bradycardia, and the confluent itchy rash with islands of normal skin. The commonest iatrogenic death in dengue is fluid given for one day too long.
• If the diagnosis is insecure in a shocked patient, take blood cultures and give empirical antibiotics, stopping once dengue is confirmed and cultures are negative. A vasopressor cannot replace lost plasma volume — noradrenaline or dopamine only for the patient still hypotensive after adequate volume with a haematocrit no longer rising and no bleeding. Advise daytime mosquito precautions from the outset — the patient is infective for roughly the first three days.Not available at your setup — Blood culture.