Fluid Therapy in Dengue

FLUID
MANAGEMENT
LEARNING OBJECTIVES (1)
Fluid therapy (oral and IV) is the mainstay

of therapy in dengue infection
Appropriate Intravenous fluid therapy will

improve clinical outcome
Calculation of IV fluid maintenance therapy

based on weight (adjusted body weight for
those obese patient )
CPG Management of Dengue Infection in Adults (3rd Edition)
LEARNING OBJECTIVES
(2)
IV fluid therapy only indicated for those who

has on going plasma leakage
Recognition of DSS compensated shock is

most important
Recognition of occult bleeding in DSS

require blood transfusion
CPG Management of Dengue

Infection in Adults (3rd Edition)
Whats in the current CPG?

CPG 2015
Common pitfalls in fluid
therapy
Emphasis on oral fluid
intake
IV fluid therapy only
indicated in certain group
Easier calculation of
maintenance fluid
requirement (NICE)
Stress on adjusted body
weight in obese patient
CPG revised edition 2010

Common pitfalls in fluid
therapy
IV boluses fluid therapy
being emphasized for
warning signs patient
Calculation of
maintenance fluid
according to HallidaySegar formula (4/2/1)
Applying IBW for
overweight/ obese patient
In severe dengue
Algorithm A - compensated
shock (no change)
Algorithm B Decompensated shock
Algorithm C Refractory
shock (non responders)
(NEW)
Assessment:
Stress on fluid responsiveness

parameter
Clinical
Laboratory
Imaging
Algorithm A compensated
shock
Algorithm B Decompensated
shock
Assessment :
Clinical parameters
Laboratory
3rd CPG Fluid therapy

Non Shock dengue patient :
In patients without co-morbidities who can
tolerate orally, adequate oral fluid intake of
2-3 litres daily should be encouraged.
This group of patients may not require
intravenous fluid therapy.
Inappropriate intravenous fluid therapy had
been shown to prolong hospitalisation with
a tendency to develop more fluid
accumulation
Indication for IV fluid

therapy
increasing HCT with evidence of ongoing
plasma leakage, despite increased oral
intake.
IV fluid therapy should also be considered in
patients who are vomiting, severe diarrhoea
and not tolerating orally
The normal maintenance requirement for IV fluid

therapy
Non-obese patients
Maintenance fluid can be calculated based on the following formula :

- 1.2-1.5 ml/kg/hour
Adapted : National Clinical Guideline Centre (UK). Intravenous Fluid Therapy: Intravenous
Fluid Therapy in Adults in Hospital [Internet]. London: Royal College of Physicians
(UK); 2013 Dec. Available from http://www.ncbi.nlm.nih.gov/books/NBK247761/
Overweight and obese patients (BMI >23 kg/m 2)*
Maintenance fluid can be calculated based on adjusted body weight
Adjusted bodyweight (ABW) can be calculated using the formula.

o ABW = IBW + 0.4 (actual weight - IBW)**
o
Ideal bodyweight (IBW) can be estimated based on the following formula.

Female: 45.5 kg + 0.91(height -152.4) cm
Male: 50.0 kg + 0.91(height -152.4) cm
CAUTION : Fluid intake and urine output must be reviewed and adjusted according to
clinical response. Use of volumetric pumps is encouraged, especially in
patients requiring close fluid monitoring.
Example
Dengue infection in Day 4 with vomiting and

poor oral intake,
Day 3 HCT 40 and now Day 4 HCT is 42
Temp 38 degree C
Body weight : 50 kg
Oral intake minimal ~ 500 cc /day
Full maintenance :
1.5 ml X 50/h = 75 cc/ hour ; 1800 cc/ day
IVD = 1800 500 = 1300cc ( roughly 1500
cc /day )
Caution
Frequent adjustment of maintenance fluid regime

is needed during the critical phase.
Often 1.2 to 1.5 X the maintenance will be
required during the critical phase.
Patients may be able to take oral fluids after a
few hours of IV therapy.(need to adjust rate)
If the fluid infusion rate > the maintenance
requirement, the infusion rate should be
reviewed within 2 to 4 hours.

10
In patients with persistent warning signs with

increasing or persistently high HCT, the
graded fluid bolus may be initiated with
caution
Obtain a baseline
before fluid
therapy.
Graded
FluidHCT
Bolus
Regime
Give crystalloids solution (such as 0.9% saline).
Start with 5 ml/kg/hour for 12 hours, then reduce to 3 ml/kg/hr for 24

hours, and then reduce to 2 ml/kg/hr or less according to the clinical
response.
If the clinical parameters are worsening and HCT is rising, increase the
rate of infusion.
Reassess the clinical status, repeat the HCT and review fluid infusion
rates accordingly.
11
12
TO REDUCE IV DRIP
Reduce or consider discontinuation of IV

fluid therapy when patients begin to show
signs of recovery (usually after 24-48 hours
of defervescence, or the HCT drops in a
stable patient).
CPG Management of Dengue Infection in Adults (3rd Edition) 13
Recommendation
Recommendation 5
In dengue patients without co-morbidities who can tolerate orally,
adequate oral fluid intake of two to three litres daily should be
encouraged. These patients may not require intravenous (IV)
fluid therapy.
IV fluid should be instituted in dengue patients with:
o vomiting, unable to tolerate oral fluids or severe diarrhoea
o increasing haematocrit (with other signs of ongoing plasma
leakage) despite increased oral intake
In patients with persistent warning signs with increasing or
persistently high HCT, the graded fluid bolus may be initiated with
caution.
Crystalloids solution should be the fluid of choice for non-shock
dengue patients.
14
DSS
Dengue shock syndrome is a medical emergency.
Recognition of shock in its early stage

(compensated shock) and prompt fluid
resuscitation will give a good clinical outcome.
Pulse pressure of < 20 mmHg and systolic

pressure < 90 mmHg are late signs of shock in
adults.
Failure to recognise the phase of compensated

shock will ultimately lead to decompensated
(hypotensive) shock with a more complicated
disease course and organ failures.
15
DSS- GICU/HDU
All patients DSS should be managed in high

dependency or intensive care units.
Prompt fluid resuscitation should be done and

should not be delayed while waiting for admission
to ICU or high dependency unit.
Following initial resuscitation there maybe

recurrent episodes of shock because capillary
leakage can continue for 24 to 48 hours.
Continue to closely monitor clinically and

laboratory + imaging (fluid responsiveness to
therapy)
16
Choice of fluid in DSS
IV fluid therapy is the mainstay of treatment for

dengue shock.
This CPG recommendations are extrapolated from
studies of fluid therapy in children with DSS
There is no clear advantage of using any of
the colloids over crystalloids in terms of the
overall outcome and mortality.
However colloid may be preferable as the fluid
of choice in patients with intractable shock in
the initial resuscitation.

17
In this CPG
Colloids
choice of colloids include gelatin solution and
albumin
HES should not be used as in the recent metaanalysis, in non-dengue critically ill patients with
sepsis, was associated with an increase in the rate
of renal replacement therapy and coagulation
abnormalities
Colloid should be used mainly for
resuscitation.
Prolonged use of colloid as sole maintenance fluid
should be avoided.
18
Other solutions
Albumin as resuscitation fluid in DSS has not

been studied, however from extensive use in
critically ill patients, 4%-5% albumin is
comparable to crystalloid and may be better in
subgroup of septic patients
Hypertonic sodium lactate in DSS has shown

positive results in only one study.However, there
is lack of clear evidence to support the use of this
solution and furthermore, the product is not
available in this country.
19
COMPENSATED
SHOCK
ALGORITHM A
20
CPG Management of Dengue Infection in Adults (3rd

Edition)
21
Improvement clinically

Edition)
22
Assessment
23
After first 5-10 ml/kg resuscitation YES

improving

24
Edition)
After first 5-10 ml/kg

resuscitation
NOT improving
25
DECOMPENSATED
SHOCK
ALGORITHM B

26
27
Improvement clinically

Edition)
28
After first 10-20 ml/kg resuscitation YES improving
NO IMPROVEMENT
AFTER FIRST 10-20
ML/KG RESUS
30
AFTER 2ND
10-20
ML/KG
1-2H
1-2H
1-2H
CONSIDE
R
BLEEDING
31
REFRACTORY SHOCK
WITH NOT MUCH CHANGE ON HCT
ALGORITHM C
32
TAKE HOME MESSAGE

Recommendation 6
Crystalloids solution should be the preferred choice in Dengue
Shock Syndrome (DSS).
Patients with DSS who do not respond to initial crystalloid
resuscitation should receive colloids as the second fluid bolus.
In DSS with persistent shock, other causes of shock should be
aggressively looked for and treated accordingly.
Case 1
History
In OPD:
23 year old lady
Fever for 4 days
High grade fever, nausea , and vomit once
Myalgia
Headaches
Temp: 39 degree C
BP 115/74
HR : 90
FBC : TW 1.95/ Hb 13/ HCT 36.7/ Plt 102
am)
(11.30
Q1 What is the diagnosis?

Dengue fever
Dengue infection in febrile
phase
Dengue infection with warning sign in
critical phase
Dengue hemorrhagic
fever
Diagnosis:
Dengue infection in febrile phase
Poor oral intake : NOT a warning sign
Mild nausea and vomiting is NOT
warning sign
Persistent vomiting (> 3X/day) is
warning signs
Febrile phase not yet critical phase
No hemo concentration (HCT 36.7)
Admission
HX : D4 fever, nausea and
vomiting
HCT 36.2 , plt 102, TW 1.95
Temp: 39 degree C
BP 115/74 HR : 90
CCTVR OK
Weight : 72 kg
Height : 1.58 m
Ideal body weight : 54 Kg
Adjusted BW = 60 Kg
Q2 What is the fluid regime for

this patient?
resuscitation 10 ml/kg/H for 2 H and then 7
ml/kg/H for 2 H , followed by 5 ml/kg/H for 2 H
Graded boluses IVD 5 ml/Kg/H X 2 H then 3
ml/Kg/H X 2 H, then 2 ml/Kg/H X 2
Full maintenance IVD 90ml/H (60 X 1.5 ml/H)
No IVD, encourage orally
In real life
ABW 60
Kg
FBC
D4 11.30
am
D4 6.30
pm
D5 4am
TW
1.95
1.64
1.21
HCT
36.7
34.9
32.7
PLT
102
78
60
BP
115/75
120/80
HR
90
124/85
N/V +/
80 abd
pain
86
N/V +
5/3/2
(1360 cc)
5/3/2
(1360cc)
TOTAL 4760 cc over 18 H
7/5/3
(2040cc)
Urine
Output:
2200 cc
CRITICAL PHASE
14H
CRITICAL
PHASE
Temp
37
FBC
39
38.5
37.6
D4 11.30
am
D4 6.30
pm
D5 4am
D5 8 am
TW
1.95
1.64
1.21
1.41
HCT
36.7
34.9
32.7
34.4
PLT
102
78
60
48
BP
115/75
120/80
124/85
115/78
HR
90
86
80
80
c/o abdominal
discomfort
Total input 4760 ml/ Output

2200 cc
+ 2560cc
IVD 5
pint /day
CRITICAL
PHASE
CRITICAL PHASE
22 H
Temp
37
FBC
39
38.5
37.6
D4 11.30 D4 6.30
am
pm
D5 4am
D5 8 am
D5 4 pm
TW
1.95
1.64
1.21
1.41
1.59
HCT
36.7
34.9
32.7
34.4
37.7
PLT
102
78
60
48
41
BP
115/75
120/80
124/85
115/78
114/82
HR
90
86
80
80
86
+ Balance 2560 cc
37
IVD 5
pint /day
Still complaint of nausea , and abdominal pain

(distended)
WHAT WOULD YOU DO ?
Q3 WHAT WOULD YOU DO ?

Continue IVD Full Maintenance 5 pint / day
Graded bolus therapy 5/3/2
Reduce IVD to 1ml/kg/hour (60 ml/h) and
monitor closely
IV frusemide due to fluid overloaded
CRITICAL
PHASE
CRITICAL PHASE
22 H
Temp
37
FBC
39
38.5
37.6
D4 11.30 D4 6.30
am
pm
D5 4am
D5 8 am
D5 4 pm
TW
1.95
1.64
1.21
1.41
1.59
HCT
36.7
34.9
32.7
34.4
37.7
PLT
102
78
60
48
41
BP
115/75
120/80
124/85
115/78
114/82
HR
90
86
80
80
86
+ Balance 2560 cc
37
IVD 5
pint /day
Still complaint of nausea , and abdominal pain

(distended)
IN REALPARAMETER
LIFE :
Duewithout
to HCTsigns
37.7 of HD instability
HCT rising as a SINGLE
MO(GOOD
decided
to do again
5/3/2
resuscitation
CCTVR)
bolus
fluid
therapy
CRITICAL PHASE
26 H
CRITICAL
PHASE
FBC
D4
11.30
am
D4 6.30 D5 4am D5 8
pm
am
D5 4
pm
D5 8
pm
TW
1.95
1.64
1.21
1.41
1.59
2.3
HCT
36.7
34.9
32.7
34.4
37.7
39.8
PLT
102
78
60
48
41
24
BP
115/75
120/80
124/85
115/78
114/82
123/84
HR
90
86
80
80
86
80
+ 2560 ml
IVD 5
pint /day
5/3/2
Bolus
Pt c/o severe
abdomen
distension
CRITICAL PHASE
26H
FBC
D4
11.30
am
D4
6.30
pm
D5
4am
D5 8
am
D5 4
pm
D5 8
pm
D6 8
am
TW
1.95
1.64
1.21
1.41
1.59
2.3
2.6
HCT
36.7
34.9
32.7
34.4
37.7
39.8
39.8
PLT
102
78
60
48
41
24
26
BP
115/75 120/80 124/85 115/78 114/82 123/84 110/78
HR
90
86
80
80
86
80
CONTINUE FULL
MAINT
70
C/O severe
abdomen
distension
Q4
Which phase is this ?
FBC
D4
D4
D5
11.30
4am
am
6.30p
m
D5
D5
D5
8 am 4 pm 8 pm
D6
D6
8 am 4 pm
TW
1.95
1.64
1.21
1.41
1.59
2.3
2.6
4.1
HCT
36.7
34.9
32.7
34.4
37.7
39.8
39.8
40.2
PLT
102
78
60
48
41
24
26
28
BP
115/7
5
120/8
0
124/8
5
115/7
8
114/8
2
123/8
4
110/7
8
118/8
0
HR
90
86
80
80
86
80
70
80
Which phase is this ?

FBC
D4
D4
11.30 6.30
am
pm
D5
4am
D5 8
am
D5 4
pm
D5 8
pm
D6 8
am
D6 4
pm
TW
1.95
1.64
1.21
1.41
1.59
2.3
2.6
4.1
HCT
36.7
34.9
32.7
34.4
37.7
39.8
39.8
40.2
PLT
102
78
60
48
41
24
26
28
BP
115/7
5
120/8
124/8 by
115/7
114/8 123/8
Reviewed
specialist
:
0
5
8
2
4
110/7
8
118/8
0
Afebrile 24 H
HR
90
86
80
80
86
80
70
80
Patient CCTVR good, abdominal pain is distended
due to ascitis
Off IVD
Lungs basal crepitations
Impression: fluid overloaded (positive balance of
> 6 L for two days)
Decided to stop IVD even HCT 39.8-40
FBC
D5
4am
D5 8
am
D5 4
pm
D5 8
pm
D6 8
am
D6 4
pm
D7
12
mn
D7
6am
D8
6 am
TW
1.21
1.41
1.59
2.3
2.6
4.1
4.3
4.2
5.4
HCT
32.7
34.4
37.7
39.8
39.8
40.2
38.2
36.3
34
PLT
60
48
41
24
26
28
28
30
42
BP
124/8 115/7 114/8 123/8 110/7 118/8 110/7 110/7 110/72

5
8
2
4
8
0
0
5
HR
80
80
86
80
70
80
Stop IVD
70
75
IV Frusemide 20 mg stat dose at D7 8 am

Abdomen distension less
74
Pitfall in fluid therapy
Common pitfalls in fluid therapy:

Treating patient with unnecessary fluid bolus based on
raised HCT as the sole parameter without considering
other clinical parameters.
Excessive and prolonged fixed fluid regime in stable
patients.
Infrequent monitoring and adjustment of infusion rate.
Continuation of intravenous fluid during the recovery
phase.
Inappropriate fluid therapy in patients with comorbidities (such as heart disease and renal disease).
Point to learn
DO not resuscitate with 5/3/2 if patient is just

complaining about nausea and vomiting
Review input and output chart cautiously
Overzealous fluid therapy caused more leakage
and more ascitis with pleural effusion
Abdominal pain : distension with ascitis
(mistaken as warning sign)
Do not chase after HCT (assess patient clinically)
HCT may rise at the end of critical phase, may
not need to increase IVD with bolus if patient is
tolerating orally.
NICE
Normal maintenance fluid therapy is 25-30 ml/Kg/day
~ 1.25 ml/kg/H
Intravenous fluid therapy in

In Dengue taking
intoin
consideration
of
fever, additional
adults
hospital
overview
100-300 cc/day is acceptable
30ml/kg (50 Kg)/ day = 1500 cc/ day
In dengue : 1.5 X 50 X 24 = 1800 cc /day (+ 300 cc / day)

52
Hyperosmolar sodium
lactate

53
SAFE (Albumin vs NS)
THE SAFE Study (Saline versus Albumin fluid evaluation)

Of the 6997 patients who underwent randomization, 3497 were
assigned to receive albumin and 3500 to receive saline;
There were 726 deaths in the albumin group, as compared with 729
deaths in the saline group (relative risk of death, 0.99; 95 percent
confidence interval, 0.91 to 1.09; P=0.87).
The proportion of patients with new single-organ and multiple-organ
failure was similar in the two groups (P=0.85).
There were no significant differences between the groups in the mean
(SD) numbers of days spent in the ICU (6.56.6 in the albumin group
and 6.26.2 in the saline group, P=0.44), days spent in the hospital
(15.39.6 and 15.69.6, respectively; P=0.30), days of mechanical
ventilation (4.56.1 and 4.35.7, respectively; P=0.74), or days of
renal-replacement therapy (0.52.3 and 0.42.0, respectively; P=0.41).
Conclusion:use of either 4 percent albumin or normal saline for fluid
resuscitation results in similar outcomes at 28 days.

54

Fluid Therapy in Dengue

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FLUID

LEARNING OBJECTIVES (1)

Fluid therapy (oral and IV) is the mainstay

Appropriate Intravenous fluid therapy will

Calculation of IV fluid maintenance therapy

CPG Management of Dengue Infection in Adults (3rd Edition)

IV fluid therapy only indicated for those who

Recognition of DSS compensated shock is

Recognition of occult bleeding in DSS

CPG Management of Dengue

Whats in the current CPG?

CPG revised edition 2010

Stress on fluid responsiveness

3rd CPG Fluid therapy

Indication for IV fluid

The normal maintenance requirement for IV fluid

Maintenance fluid can be calculated based on the following formula :

Adjusted bodyweight (ABW) can be calculated using the formula.

Ideal bodyweight (IBW) can be estimated based on the following formula.

CPG Management of Dengue Infection in Adults (3rd Edition)

Dengue infection in Day 4 with vomiting and

Frequent adjustment of maintenance fluid regime

CPG Management of Dengue

In patients with persistent warning signs with

Give crystalloids solution (such as 0.9% saline).

Start with 5 ml/kg/hour for 12 hours, then reduce to 3 ml/kg/hr for 24

CPG Management of Dengue Infection in Adults (3rd Edition)

CPG Management of Dengue Infection in Adults (3rd Edition)

Reduce or consider discontinuation of IV

CPG Management of Dengue Infection in Adults (3rd Edition) 13

CPG Management of Dengue Infection in Adults (3rd Edition)

Dengue shock syndrome is a medical emergency.

Recognition of shock in its early stage

Pulse pressure of < 20 mmHg and systolic

Failure to recognise the phase of compensated

All patients DSS should be managed in high

Prompt fluid resuscitation should be done and

Following initial resuscitation there maybe

Continue to closely monitor clinically and

Choice of fluid in DSS

IV fluid therapy is the mainstay of treatment for

CPG Management of Dengue

Albumin as resuscitation fluid in DSS has not

Hypertonic sodium lactate in DSS has shown

CPG Management of Dengue Infection in Adults (3rd Edition)

CPG Management of Dengue Infection in Adults (3rd Edition)

CPG Management of Dengue Infection in Adults (3rd

CPG Management of Dengue Infection in Adults (3rd

CPG Management of Dengue Infection in Adults (3rd Edition)

After first 5-10 ml/kg resuscitation YES

CPG Management of Dengue Infection in Adults (3rd

After first 5-10 ml/kg

CPG Management of Dengue Infection in Adults (3rd Edition)

CPG Management of Dengue

CPG Management of Dengue Infection in Adults (3rd Edition)

CPG Management of Dengue Infection in Adults (3rd

After first 10-20 ml/kg resuscitation YES improving

CPG Management of Dengue Infection in Adults (3rd Edition) 29