IV Fluid Management in Dengue with Warning Signs

Initial Fluid Resuscitation

Administer isotonic crystalloid (0.9 % saline or lactated Ringer’s) at 5–7 mL/kg/hour for the first 1–2 hours, then adjust to 3–5 mL/kg/hour or 2–3 mL/kg/hour based on clinical response; the same rates apply to adults and children. 1
Example dosing: a 70‑kg adult receives roughly 350–490 mL/hour; a 20‑kg child receives roughly 100–140 mL/hour. 2
Re‑evaluate vital signs, hematocrit, and urine output every 1–2 hours during the initial phase. 1

If vital signs are stable and urine output is ≥0.5 mL/kg/hour, reduce the infusion to 3–5 mL/kg/hour for the next 2–4 hours. 1
With continued improvement, further reduce the rate to 2–3 mL/kg/hour (or lower) as tolerated. 1
Continue serial hematocrit measurements to gauge plasma leakage and guide ongoing fluid needs. 1

Hemodynamic response: a ≥10 % rise in systolic/mean arterial pressure and a ≥10 % fall in heart rate indicate adequate resuscitation. 2
Urine output targets: >0.5 mL/kg/hour in adults; >1 mL/kg/hour in children. 2
Hematocrit trend: a decreasing hematocrit with stable vitals suggests sufficient plasma volume replacement. 1
Peripheral perfusion: capillary refill ≤2 seconds and warm extremities denote adequate perfusion. 2

Give a 20 mL/kg isotonic crystalloid bolus over 15–20 minutes when shock (hypotension, narrow pulse pressure, cold extremities) develops. 1
Reassess immediately after each bolus for hemodynamic improvement. 1
Up to 60 mL/kg may be administered in the first hour, with mandatory reassessment after each 20 mL/kg increment. 1
If shock remains refractory, consider inotropic support rather than further aggressive fluid loading. 2

Do not use hypotonic fluids (e.g., D5W, 0.45 % saline) because they increase the risk of hyponatremia and provide inadequate resuscitation. 2
Do not rely solely on blood pressure in children; hypotension is a late sign of circulatory compromise. 1
Stop fluid administration immediately if signs of fluid overload appear (pulmonary crackles, hepatomegaly, peripheral edema, increased work of breathing, worsening oxygenation). 2
Do not exceed 60 mL/kg/hour without reassessment; excessive volumes are linked to poorer outcomes. 2

Switch to maintenance when all of the following are met: normal vital signs, adequate urine output (>0.5 mL/kg/hour), decreasing or stable hematocrit, and resolution of warning signs. (Vital signs & urine output – 2; hematocrit – 2; warning‑sign resolution – 1)
Children: use the Holliday‑Segar formula – 100 mL/kg/day for the first 10 kg, 50 mL/kg/day for the next 10 kg, and 25 mL/kg/day for each additional kilogram. 2
Adults: typical maintenance rate is ≈1.5–2 mL/kg/hour of isotonic crystalloid. 2