Orris

Dengue shock syndrome management

Reading File
Reading File
Finding Sources
Finding Sources
Searching PubMed

dengue shock AND fluid

Searching the Web

WHO dengue shock syndrome management fluid resuscitation guideline

Reading File
Reading File
Reading File
Finding Sources
Finding Sources
Searching the Web

site:cdc.gov dengue clinical care severe dengue shock intravenous fluid resuscitation

Reading Web Page

https://www.cdc.gov/dengue/media/pdfs/2024/05/20240521_34284…

Dengue shock syndrome (DSS) management

DSS is an emergency. It is severe dengue with plasma leakage causing compensated or hypotensive shock. Admit to a high-dependency unit or ICU, obtain senior critical-care input, and begin resuscitation without delay.

1. Immediate actions

  • ABC approach: give oxygen if hypoxemic or in respiratory distress.
  • Establish 1-2 large-bore IV lines.
  • Send CBC with hematocrit (Hct), group and crossmatch, glucose, electrolytes, renal and liver tests, blood gas/lactate, coagulation studies if bleeding.
  • Continuous or very frequent monitoring:
    • Pulse, blood pressure and pulse pressure, capillary refill, mental status, respiratory effort
    • Urine output with catheter in shock
    • Input-output chart and serial Hct, before and after fluid boluses
  • Look actively for bleeding, pleural effusion/ascites, myocarditis, acidosis, and coinfection.
Warning signs often precede shock, including abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy/restlessness, hepatomegaly, and oliguria. Plasma leakage typically lasts only 24-48 hours. Park's Textbook of Preventive and Social Medicine, p. 292.

2. Fluid resuscitation

Use isotonic crystalloid, either 0.9% saline or Ringer's lactate.
For compensated or hypotensive shock:
  1. Give 20 mL/kg IV crystalloid over 15-30 minutes, then reassess.
  2. Reassess perfusion, pulse pressure/BP, capillary refill, mental state, urine output, Hct, respiratory status, and signs of fluid overload.
  3. If shock persists and there is no overload, give up to two further 20 mL/kg crystalloid boluses, each over 15-30 minutes, with reassessment after every bolus.
  4. If the patient improves, step down fluids progressively, for example:
    • 10 mL/kg/hour for 1-2 hours
    • 5-7 mL/kg/hour for 2-4 hours
    • 3-5 mL/kg/hour for 2-4 hours
    • 2-4 mL/kg/hour, then stop IV fluid as oral intake becomes adequate and the critical phase resolves.
The goal is restored perfusion with the minimum fluid necessary, not a fixed high-volume replacement. Aim for improving clinical status and urine output generally at least 0.5 mL/kg/hour in adults and often >1 mL/kg/hour in children, while avoiding pulmonary edema. The CDC dengue case guide provides this 20 mL/kg shock algorithm.

3. Use hematocrit to decide what persistent shock means

Clinical pattern after fluidsLikely issueAction
Persistent shock + rising/high HctOngoing plasma leakage, inadequate intravascular replacementRepeat carefully assessed isotonic-fluid bolus; ICU input. Consider colloid only for refractory shock after adequate crystalloid, following local protocol.
Persistent shock + falling Hct, especially with bleedingOccult or overt hemorrhageGive blood, not repeated large crystalloid volumes.
Improving perfusion + stable/minimally changing HctResponse to resuscitationTaper fluid rate promptly.
Respiratory distress, crackles, rising JVP, effusions, falling Hct during recoveryFluid overload/reabsorptionReduce or stop IV fluid, give oxygen, reassess cardiac function and consider diuresis only when intravascular status is adequate.
For hemorrhagic shock, the CDC guide recommends packed red cells 5-10 mL/kg or whole blood 10-20 mL/kg. Use urgent blood products when there is clinically significant bleeding or a falling Hct with shock. Avoid delaying transfusion while repeatedly administering crystalloid.

4. Refractory shock

Manage in ICU:
  • Recheck diagnosis and contributors: bleeding, severe acidosis, myocarditis/cardiac dysfunction, bacterial sepsis, adrenal causes, or excessive fluid loss.
  • Bedside ultrasound/echocardiography can help assess cardiac function and pleural/abdominal fluid.
  • Correct hypoglycemia, hypocalcemia or severe metabolic derangements where present.
  • If perfusion remains inadequate after appropriately guided volume resuscitation, use vasopressors to maintain adequate mean arterial pressure, while assessing cardiac function and avoiding further fluid overload. The CDC clinical guidance emphasizes prompt intensive IV-fluid support for severe dengue.

5. What to avoid

  • No prophylactic platelet transfusion solely for thrombocytopenia. It does not prevent bleeding and may worsen fluid overload.
  • Do not give aspirin, ibuprofen, other NSAIDs, or intramuscular injections.
  • Do not use corticosteroids or IV immunoglobulin routinely for DSS.
  • Avoid hypotonic solutions.
  • Avoid excessive IV fluids, especially once leakage stops and the recovery phase begins.
Early recognition, careful fluid titration, serial Hct interpretation, and immediate treatment of bleeding can reduce mortality markedly. Red Book 2021, p. 523. The CDC Yellow Book dengue guidance also stresses that IV fluids are usually needed mainly during the 24-48 hour leakage phase and must be tapered to prevent overload.

Create a quick-reference PDF for dengue shock management

Reading File
Reading File
Finding Sources
Finding Sources
Searching PubMed

dengue shock AND fluid

Searching the Web

CDC dengue shock case management 20 mL/kg 15 30 minutes PDF

Browsing Directory

~/

Running Command

mkdir -p "/tmp/workspace/dengue-shock-quick-reference/src" "/tmp/workspace/dengue-shock-quick-reference/output" && python -c "import reportlab; print('reportlab available')"

Writing File

~/dengue-shock-quick-reference/src/create_pdf.py

from reportlab.lib import colors
from reportlab.lib.colors import HexColor
from reportlab.lib.pagesizes import landscape, A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_LEFT, TA_CENTER
from reportlab.lib.units import mm
from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, KeepTogether
from reportlab.pdfbase.ttfonts import TTFont
from reportlab.pdfbase import pdfmetrics
from reportlab.lib.fonts import addMapping

OUT = '/tmp/workspace/dengue-shock-quick-reference/output/Dengue_Shock_Management_Quick_Reference.pdf'
PAGE = landscape(A4)
MARGIN = 11*mm
NAVY = HexColor('#0B2942')
TEAL = HexColor('#007C83')
PALE_TEAL = HexColor('#E7F5F5')
RED = HexColor('#A82F2F')
PALE_RED = HexColor('#FDEBEC')
AMBER = HexColor('#A65B00')
PALE_AMBER = HexColor('#FFF4E2')
GRAY = HexColor('#53616B')
LIGHT = HexColor('#F3F6F7')
BORDER = HexColor('#C8D3D7')

styles = getSampleStyleSheet()
base = ParagraphStyle('base', parent=styles['BodyText'], fontName='Helvetica', fontSize=7.25, leading=9.1, textColor=NAVY, spaceAfter=0)
small = ParagraphStyle('small', parent=base, fontSize=6.55, leading=7.7)
tiny = ParagraphStyle('tiny', parent=base, fontSize=5.85, leading=6.8, textColor=GRAY)
section = ParagraphStyle('section', parent=base, fontName='Helvetica-Bold', fontSize=8.3, leading=10, textColor=colors.white, alignment=TA_LEFT)
title = ParagraphStyle('title', parent=base, fontName='Helvetica-Bold', fontSize=18, leading=21, textColor=colors.white)
subtitle = ParagraphStyle('subtitle', parent=base, fontSize=7.6, leading=9.5, textColor=HexColor('#DCEBF0'))
boxhead = ParagraphStyle('boxhead', parent=base, fontName='Helvetica-Bold', fontSize=8.1, leading=10, textColor=NAVY)
center = ParagraphStyle('center', parent=base, alignment=TA_CENTER, fontName='Helvetica-Bold', fontSize=7.8, leading=9)

P = lambda text, style=base: Paragraph(text, style)

def box(title_text, body, bg=colors.white, head_color=NAVY):
    data = [[P(title_text, ParagraphStyle('bh_'+title_text[:5], parent=boxhead, textColor=head_color)), P(body, base)]]
    t = Table(data, colWidths=[42*mm, 75*mm])
    t.setStyle(TableStyle([
        ('BACKGROUND',(0,0),(-1,-1),bg), ('BOX',(0,0),(-1,-1),0.45,BORDER),
        ('VALIGN',(0,0),(-1,-1),'TOP'), ('LEFTPADDING',(0,0),(-1,-1),4.5),
        ('RIGHTPADDING',(0,0),(-1,-1),4.5), ('TOPPADDING',(0,0),(-1,-1),4), ('BOTTOMPADDING',(0,0),(-1,-1),4),
        ('LINEAFTER',(0,0),(0,0),0.35,BORDER),
    ]))
    return t

story=[]
# Header
header = Table([[P('DENGUE SHOCK MANAGEMENT', title), P('QUICK REFERENCE  |  ADULTS & CHILDREN', subtitle)]], colWidths=[165*mm, 100*mm])
header.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),NAVY),('VALIGN',(0,0),(-1,-1),'MIDDLE'),('LEFTPADDING',(0,0),(-1,-1),7),('RIGHTPADDING',(0,0),(-1,-1),7),('TOPPADDING',(0,0),(-1,-1),6),('BOTTOMPADDING',(0,0),(-1,-1),6)]))
story += [header, Spacer(1,4)]

alert = Table([[P('<b>EMERGENCY:</b> DSS = severe dengue with plasma leakage causing compensated or hypotensive shock. Admit, obtain senior/critical-care support, and start isotonic IV resuscitation immediately.', ParagraphStyle('alert', parent=base, fontSize=8, leading=10, textColor=RED))]], colWidths=[265*mm])
alert.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),PALE_RED),('BOX',(0,0),(-1,-1),0.7,RED),('LEFTPADDING',(0,0),(-1,-1),6),('RIGHTPADDING',(0,0),(-1,-1),6),('TOPPADDING',(0,0),(-1,-1),5),('BOTTOMPADDING',(0,0),(-1,-1),5)]))
story += [alert, Spacer(1,4)]

# Two-column body
left = []
left.append(box('1. RECOGNIZE SHOCK', '<b>Compensated:</b> tachycardia, cool extremities, delayed capillary refill, weak pulse, narrow pulse pressure, oliguria, restlessness. <b>Hypotensive:</b> late and preterminal. Warning signs: abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy/restlessness, hepatomegaly, oliguria.', PALE_AMBER, AMBER))
left.append(Spacer(1,3))
left.append(box('2. FIRST 5 MINUTES', '• ABC, oxygen if hypoxemic/respiratory distress<br/>• 1-2 large-bore IV lines; monitor ECG, BP, SpO<sub>2</sub><br/>• CBC + <b>hematocrit before and after bolus</b>, group & crossmatch, glucose, electrolytes/renal function, blood gas/lactate; coagulation tests if bleeding<br/>• Strict input-output, catheterize in shock; frequent reassessment', PALE_TEAL, TEAL))
left.append(Spacer(1,3))
left.append(box('3. INITIAL FLUID', '<b>Use isotonic crystalloid only:</b> 0.9% saline or Ringer lactate.<br/><br/><b>20 mL/kg IV over 15-30 min</b> → reassess perfusion, BP/pulse pressure, mental status, urine output, Hct, breathing and fluid overload. If shock persists without overload, give up to <b>2 additional 20 mL/kg boluses</b>, reassessing after every bolus.', colors.white, NAVY))

right = []
right.append(box('4. AFTER EACH BOLUS', '<b>Improved:</b> taper promptly: 10 mL/kg/h for 1-2 h, then 5-7 mL/kg/h for 2-4 h, 3-5 mL/kg/h for 2-4 h, then 2-4 mL/kg/h. Stop IV fluids when oral intake is adequate and critical phase is resolving.<br/><br/><b>Target:</b> restored perfusion with minimum fluid needed. Urine output generally ≥0.5 mL/kg/h in adults; often >1 mL/kg/h in children.', PALE_TEAL, TEAL))
right.append(Spacer(1,3))
right.append(box('5. PERSISTENT SHOCK: USE HCT', '<b>Shock + rising/high Hct:</b> ongoing plasma leakage → carefully reassess and repeat guided crystalloid. Consider colloid only for refractory shock after adequate crystalloid, per local protocol.<br/><br/><b>Shock + falling Hct / overt bleeding:</b> hemorrhage → transfuse blood, not repeated large crystalloid volumes. <b>PRBC 5-10 mL/kg</b> or <b>whole blood 10-20 mL/kg</b>.', PALE_AMBER, AMBER))
right.append(Spacer(1,3))
right.append(box('6. ICU / REFRACTORY SHOCK', 'Evaluate occult bleeding, acidosis, myocarditis/cardiac dysfunction, sepsis/coinfection and other causes. Use bedside ultrasound/echocardiography where available. Correct hypoglycemia and severe metabolic derangements. If hypoperfusion persists after appropriately guided volume resuscitation, use vasopressors with critical-care support.', colors.white, NAVY))

columns = Table([[left, right]], colWidths=[130*mm,130*mm])
columns.setStyle(TableStyle([('VALIGN',(0,0),(-1,-1),'TOP'),('LEFTPADDING',(0,0),(-1,-1),0),('RIGHTPADDING',(0,0),(-1,-1),0)]))
story += [columns, Spacer(1,4)]

# Bottom safety band
avoid_body = '<b>AVOID:</b> prophylactic platelet transfusion (does not prevent bleeding and may overload), aspirin/NSAIDs, IM injections, hypotonic fluids, routine corticosteroids or IVIG, and excessive IV fluid after leakage resolves.'
overload_body = '<b>FLUID OVERLOAD:</b> respiratory distress, crackles, pleural effusion, rising JVP, falling Hct during recovery. Reduce/stop IV fluid, oxygenate, assess cardiac function. Diuresis only after intravascular volume is adequate.'
bottom = Table([[P(avoid_body, small), P(overload_body, small)]], colWidths=[130*mm,130*mm])
bottom.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),PALE_RED),('BOX',(0,0),(-1,-1),0.45,RED),('VALIGN',(0,0),(-1,-1),'TOP'),('LEFTPADDING',(0,0),(-1,-1),5),('RIGHTPADDING',(0,0),(-1,-1),5),('TOPPADDING',(0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),4),('LINEAFTER',(0,0),(0,0),0.35,RED)]))
story += [bottom, Spacer(1,3)]

foot = P('<b>Clinical-use note:</b> This aid supports, but does not replace, local dengue protocols, senior clinical judgement, or ICU consultation. Use lower volumes and closer monitoring in pregnancy, age >65 years, heart failure, chronic liver disease, or kidney failure. Sources: CDC Dengue Case Management Pocket Guide (2024); CDC Yellow Book Dengue guidance; <i>Red Book 2021</i>, p. 523; <i>Park\'s Textbook of Preventive and Social Medicine</i>, p. 292.', tiny)
story.append(foot)

doc = SimpleDocTemplate(OUT, pagesize=PAGE, rightMargin=MARGIN, leftMargin=MARGIN, topMargin=8*mm, bottomMargin=7*mm, title='Dengue Shock Management Quick Reference', author='Orris')
doc.build(story)
print(OUT)
Running Command

python "/tmp/workspace/dengue-shock-quick-reference/src/create_pdf.py" && ls -lh "/tmp/workspace/dengue-shock-quick-reference/output/Dengue_Shock_Management_Quick_Reference.pdf"

Running Command

python -c "from pypdf import PdfReader; p='/tmp/workspace/dengue-shock-quick-reference/output/Dengue_Shock_Management_Quick_Reference.pdf'; r=PdfReader(p); print('pages=',len(r.pages)); text=r.pages[0].extract_text(); print('chars=',len(text)); print(text[:1000])"

Dengue Shock Management Quick Reference

PDF Document · PDF

This is a shared conversation. Sign in to Orris to start your own chat.