In Dengue, fluid management is very important. As a doctor, you must know how to manage fluids according to the sign-symptoms in a Dengue patient. You need a Dengue Fluid Management Guideline to do so. So, here is the Dengue Fluid Management Guideline.
NOTE: THIS ARTICLE IS FOR DOCTORS ONLY!
Oral Fluid for uncomplicated non-critical dengue patient
- Adequate oral fluid intake of around 2500 ml for 24 hours (if the body weight is less than 50 kg give fluids as 50 ml/kg for 24 hours).
- This should consist of oral rehydration salt, glucose saline, coconut water, other fruit juices, soup, barley, milk, etc. (Encourage electrolyte-rich fluid rather than plain water)
Intravenous fluid therapy in DHF during the critical period
Indications for IV fluid:
- when the patient cannot have adequate oral fluid intake or is vomiting.
- when HCT continues to rise 10%–20% despite oral rehydration.
- impending shock/shock.
Symptoms suggestive of Impending shock (Pre-shock)/Shock (from 3rd day of illness)
- Abdominal pain
- Persistent vomiting
- Restlessness / altered conscious level
- Postural dizziness
- Decreased urine output (<0.5 ml/kg/hour)
Signs suggestive of Pre-shock/Shock (from 3rd day of illness)
- Cold extremities
- Prolonged capillary refill time >2 seconds
- Unexplained tachycardia
- Increasing diastolic pressure with normal systolic pressure
- Narrowing of pulse pressure ≤ 20 mmHg
- Postural drop ≥ 20 mmHg of systolic blood pressure
- Hypotension (< 20% from patient’s baseline or SBP <90 mmHg if baseline not known or mean BP 60 mmHg)
- Increased respiratory rate
Types of fluids recommended during the critical period
- 0.9% NaCl (isotonic normal saline solution) (0.9% NS)
- 0.45% half-strength normal saline solution (0.45% NS) (For children)
- 5% dextrose in lactated Ringer’s solution (5% DRL)
- 5% dextrose in acetated Ringer’s solution (5% DRA)
- Hartman solution
- Dextran 40
- Human Albumin
Blood or blood products
- Whole fresh blood
- Platelet concentrate
General principles of IV fluid management during the critical period of plasma leakage:
- Isotonic crystalloid solutions should be used throughout the critical period except in the very young infants < 6 months, in whom 0.45% sodium chloride (5% N/2) may be used.
- Hyper-oncotic colloid solutions or plasma expander (Osmolarity>300 mOsm/L) such as dextran-40, Plasmasol should be used in patients with massive plasma leakage, and those not responding to the minimum volume of crystalloid
- A minimum volume of maintenance + 5% dehydration (M + 5%D) should be given to maintain a just adequate intravascular volume and circulation. This volume includes both IV and oral intake.
- Usually, the maximum bodyweight used for adults is 50 kgs. In older children >10 years old whose ideal body weight is 35 kg or more, may use the adult rate of IV fluid to prevent fluid overload.
- The duration of intravenous fluid therapy
– For shock: should not exceed 24 to 48 hours.
– For non-shock: the duration of intravenous fluid therapy may have to be longer, but not more than 60 to 72 hours.
- In obese patients, the ideal body weight should be used as a guide to calculate the fluid volume
The requirement of fluid based on ideal body weight
|Ideal body weight (Kgs)||Maintenance (ml)||M +5%|
|Ideal body weight (kgs)||Maintenance (ml)||M +5% deficit (ml)|
|5||500||750||35||1 800||3 550|
|10||1 000||1 500||40||1 900||3 900|
|15||1 250||2 000||45||2 000||4 250|
|20||1 500||2 500||50||2 100||4 600|
|25||1 600||2 850||55||2 200||4 950|
|30||1 700||3 200||60||2 300||5 300|
Source: Holiday M.A., Segar W.E. Maintenance need for water in parenteral fluid therapy. Pediatrics 1957;19: 823.78
Rate of IV fluid in adults and children
|Note||Children rate (ml/kg/hour)||Adult rate (ml/hour)|
|Half the maintenance M/2||1.5||40–50|
|M + 5% deficit||5||100–120|
|M + 7% deficit||7||120–150|
|M + 10% deficit||10||300–500|
Source: Holiday M.A., Segar W.E. Maintenance need for water in parenteral fluid therapy. Pediatrics 1957; 19:823.78
Fluid calculation during the critical phase
When the patient is in the critical phase (leakage phase)
The fluid requirement, both oral and intravenous, in critical phase (48 hours) is calculated as M+5% (maintenance + 5% deficit). Maintenance(M) is calculated as follows:
- For the 1st 10 kg -100 ml/kg
- For the 2nd 10 kg – 50 ml/kg
- From 20 kg and above up to 50 kg – 20 ml/kg
- 5% deficit is calculated as 50 ml/kg up to 50 kg
Example of fluid calculation for a 65 kg person (maximum bodyweight for fluid calculations 50 kg)
- For the 1st 10 kg – 100 ml/kg = 1000 ml
- For the 2nd 10 kg – 50 ml/kg = 500 ml
- From 20 kg and above up to 50 kg -20 ml/kg = 600 ml
- 5% deficit is calculated as 50 ml/kg up to 50 kg = 2500 ml
Therefore the maximum fluid requirement for an average adult for the entire phase of critical 48 hours is 4600 ml.
*For overweight/obese patients calculate normal maintenance fluid based on ideal body weight (IBW), using the following formula: Female: 45.5 kg + 0.91(height–152.4) cm Male: 50.0 kg + 0.91(height–152.4).cm
Fluid for non-shock patients:
- The admitted patient should be started with recommended fluid at a rate of 5 ml/kg/hr for a child or 40-50 ml/hr (10-12 d/min) for adults and should be given for 6 hours. If patients vital signs are stable, then the escalation of fluid is not needed and the same rate can be maintained for a period of 48 hours.
- If patient started with 1.5 ml/kg/hr (adult 40-50 ml/hr) for 6 hours doesn’t have stable vital signs, the fluid should be escalated to 3 ml/kg/hr (adult 80 ml/hr or 20-25 drops/min) for another 6 hours. This fluid can be escalated to 5 ml/kg/hr (adult 120 ml/hr or 30 d/min and then up to 7 ml/kg/hr or adult 200 ml/hr or 50 d/min) if every 6 hours doesn’t have stable vital sign.
The patient should be monitored every 2 hours with special attention to vital signs, urine output, respiratory signs, and hematocrit, etc.
In 6 hours of escalation, if the patient becomes stable regarding clinical parameters, the fluids can be gradually declined from 7 to 5 to 3 to 1.5 (ml/kg /hr) or from stages where he was stable. But the fluids should be maintained always for at least 48 hours
Management of fluid in compensated shock:
- Give oxygen
- Most cases of DSS (Compensated shock) will respond to crystalloid 10 ml/kg in children or 300–500 ml (75-125 d/min) in adults over one to two hours.
- If the patient improves, fluid administration should step down according to the below-mentioned chart within 24 to 48 hours
- If the patient does not improve clinically check ABCS and HCT.
- When HCT rises give colloid 10 ml/kg over one hour. Then if the patient does not improve give blood as below.
- If HCT falls, think concealed hemorrhage and give Blood transfusion(Whole fresh blood 10 ml/kg or packed cell 5 ml/kg over 1 hour)
- When the patient improves after giving colloid or blood step down fluid therapy as a chart within 24 to 48 hours.
- If patient deteriorate and progress to profound shock follow the treatment protocol for DHF Grade IV.
Management of fluid in decompensated shock
- Preferably this group of the patient needs to manage in HDU/ICU setting
- Oxygen should be started immediately
- The bolus 10-20 ml/kg crystalloids should be given within 15-30 min
- If the vital signs and Hct improved, the fluid can be reduced from 10 ml/kg/hr to 6 ml/kg/hr for 2 hours, then from 6 to 3 ml/kg/hr for 2-4 hrs and then 3 to 1.5 ml/kg/hr for another 2-4 hrs. Fluid should be discontinued after 24-48 hrs
- If there is no clinical improvement after 1st bolus crystalloids, 2nd bolus should be given within another 15-30 minutes and check Hct.
- When the Hct is raising the fluid should be changed to colloid at (10-20 ml/kg/hr).
- If Hct is reduced, then suspect concealed bleeding and blood transfusion should be started immediately at 10 ml/kg whole blood or packed RBC at 5 ml/kg.
- In the case of refractory hypotension, look for ABCS and IV inotropes with crystalloids as per requirement is to be continued.
Management of fluid overload in Dengue patient
Detection of fluid overload in patients
- Early signs and symptoms include
– puffy eyelids
– distended abdomen (Ascites)
– tachypnoea, mild dyspnoea
- Late signs and symptoms include
All of the above, along with
– moderate to severe respiratory distress
– shortness of breath and wheezing (not due to asthma) which are also an early sign of interstitial pulmonary edema and crepitations
– restlessness/agitation and confusion are signs of hypoxia and impending respiratory failure
Management of fluid overload
- Review the total intravenous fluid therapy and clinical course, and check and correct for ABCS (Box 14).
- All hypotonic solutions should be stopped.
- In the early stage of fluid overload,
- switch from crystalloid solutions as bolus fluids. Dextran 40 is effective as 10 ml/kg bolus infusions, but the dose is restricted to 30 ml/kg/day because of its renal effects.
- In the late stage of fluid overload or those with frank pulmonary edema,
- Furosemide may be administered if the patient has stable vital signs.
- If they are in shock, together with fluid overload 10 ml/kg/h of colloid (Dextran) should be given. When the blood pressure is stable, usually within 10 to 30 minutes of infusion, administer IV 1 mg/kg/dose of Furosemide and continue with Dextran infusion until completion. Intravenous fluid should be reduced to as low as 1 ml/kg/h until discontinuation when hematocrit decreases to baseline or below with clinical improvement
- The following points should be noted:
– These patients should have a urinary bladder catheter to monitor hourly urine output
– Furosemide should be administered during Dextran infusion because the hyper-oncotic nature of Dextran will maintain the intravascular volume while furosemide depletes in the intravascular compartment.
– After administration of Furosemide, the vital signs should be monitored every 15 minutes for one hour to note its effects.
DENGUE FLUID MANAGEMENT GUIDELINE
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