ISSN - 0973-0958

Pediatric Oncall Journal

Dengue shock syndrome

Dengue shock syndrome

Dr Ira Shah.
Medical Services Department, Pediatric Oncall, Mumbai.

Dr Ira Shah, Medical Sciences Department, Pediatric Oncall, 1, B Saguna, 271, B St. Francis Road, Vile Parle {W}, Mumbai 400056.
Clinical Problem
Case :- A 6 years old boy presented with fever since 4 days, pain in abdomen and puffiness of eyes since 2 days and vomiting since 1 day. There is no oliguria, rash, joint pains, jaundice or bleeding. On examination, pulse was 62/min, respiratory rate was 32/min and blood pressure was 88/66 mm of Hg. Periorbital puffiness was present. Perfusion was normal. On systemic examination, there was non-tender hepatomegaly and bilateral pleural effusion. Other systems were normal. Investigations showed hemoglobin of 11.6 gm%, WBC count of 6,400/cumm (45% polymorphs, 55% lymphocytes) and platelet count of 21,000/cumm. Peripheral smear for malarial parasites was negative. Liver transaminases were elevated (SGOT = 873 IU/L, SGPT = 1470 IU/L). He had hypoalbuminemia (Albumin = 2.1 gm/dl). Renal function tests, serum electrolytes and blood gases were normal. Both prothrombin time (PT) and partial thromboplastin time (PTT) were prolonged more than 1 minute. Leptospira tridot was negative and Dengue IgM was positive (1.1 AI). Ultrasound abdomen and Chest showed hepatomegaly with minimal ascitis and bilateral moderate pleural effusion. He was diagnosed as a case of Dengue shock syndrome and treated with normal saline boluses and IV fluids (4 cc/kg/hour) which was gradually increased to 10 cc/kg/hour in view of increasing PCV and oliguria and hypotension. He required plasma and platelet transfusion in view of malena. After 24 hours, child’s blood pressure was maintained and fluids were decreased to 4 cc/kg/hour. Subsequently, child suddenly became tachypneic (respiratory rate of 60/min) and had tachycardia with bilateral basal crepitations suggestive of pulmonary edema. Echocardiography showed good left ventricular functions with mild left ventricular hypertrophy, however, ECG showed ectopics. He was started on ionotropic support, furosemide infusion fluid restriction and artificial ventilation. Central venous pressure at that time was 30 cm of water. Patient responded to the same and stabilized within 24 hours. His parameters normalized within 3 days of presentation.

How to manage fluids in Dengue Shock syndrome?
Expert’s opinion: Dr Ira Shah

The fluids to be given should be isotonic normal saline or ringer lactate or even colloids and the rate of infusion should be adjusted as per severity of the leak. Too rapid intravenous infusion increases capillary hydrostatic pressure which increases the efflux of fluids over leaky capillaries. Also, remember that though the child has hypovolemia due to fluid losses, all the fluid is still in the body and there are no external losses as seen in diarrhea. Thus, total amount of fluids should not exceed too much as during the resorptive phase, all these extra fluids will be reabsorbed in the circulation and if very large amount of fluid has been given initially, then chances of pulmonary edema increases. Urine output is a good measure to determine amount of fluids to be given. Urine output should be maintained at 0.5-1 ml/kg/hour. The goal of fluid resuscitation is to maintain perfusion to vital organs during the plasma leak phase which may be 48-72 hours. Hence ensuring just adequate urine output and good capillary refill time may be enough measures to achieve perfusion to vital organs even if blood pressure remains in the low normal range. Do not try to achieve blood pressure in the 50th – 90th centile as that will require more fluid resuscitation and problems during the resorptive phase.
Fluids should be given starting at 4-6 ml/kg/hour in patients with hypovolemia and can be increased or decreased depending upon the clinical response. If fluid requirement exceeds more than 10 ml/kg/hour for more than 2 hours, then colloid infusion in form of dextran may be required. The child should be assessed every 1-2 hours to determine the next fluid rate. Inspite of fluid resuscitation and fall in hematocrit, if the child remains hemodynamically unstable, one must suspect a bleed and may consider blood transfusion. If the child does not seem to improving and is developing signs of pulmonary edema then ventilation and ionotropic support may be required. Once the patient improves, fluids must be gradually decreased and omitted to prevent fluid overload and congestive cardiac failure and pulmonary edema. Hypotonic fluids should be avoided as they tend to leak even more in the third spaces.
Compliance with ethical standards
Funding:  None  
Conflict of Interest:  None
Cite this article as:
Shah I. Dengue Shock Syndrome. Pediatr Oncall J. 2008;5: 121.
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