Plasma leakage peaks in the critical phase around defervescence (days 3-7). Guide crystalloid by haematocrit, capillary refill, lactate and urine output; step fluids down quickly; avoid prophylactic platelets; and recognise reabsorption-phase overload.
At the bedside
Timed steps- 1
Know the timeline
PhaseFebrile (days 1-3), critical (around defervescence, 24-48 h of leakage), recovery (reabsorption; fluid overload risk).
- 2
Admit
Warning signsAbdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver > 2 cm, rising haematocrit with falling platelets.
- 3
Fluids
Warning signsCrystalloid 5-7 mL/kg/h for 1-2 h, then 3-5 mL/kg/h for 2-4 h, then 2-3 mL/kg/h, adjusted to haematocrit and clinical response.
- 4
5-10 mL/kg/h
Compensated shockCrystalloid 5-10 mL/kg over 1 h; if improving, step down to 5-7, 3-5, 2-3 mL/kg/h over 24-48 h.
- 5
Bolus
Hypotensive shock20 mL/kg crystalloid over 15-30 min; repeat; if haematocrit falls with persistent shock, suspect occult bleeding and transfuse blood. Guide with capillary refill time and lactate.
- 6
Only for bleeding
PlateletsProphylactic platelet transfusion does not reduce bleeding (Lye 2017); transfuse for significant bleeding or procedures.
- 7
Harmful
AvoidNSAIDs and aspirin, IM injections, steroids, immunoglobulins; minimise invasive procedures.
Crystalloid step-down in compensated dengue shock (adult)
| Step | Rate | Duration |
|---|---|---|
| Initial | 5-10 mL/kg/h | 1 h |
| If improving | 5-7 mL/kg/h | 1-2 h |
| Then | 3-5 mL/kg/h | 2-4 h |
| Then | 2-3 mL/kg/h | 2-4 h, then stop by 24-48 h |
Reassess at each step: vital signs, CRT, haematocrit, urine output (target ~0.5 mL/kg/h). If not improving, check haematocrit: rising → more crystalloid/colloid; falling → bleeding, transfuse.
Calculators for this topic
References
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Dengue with shock
Step 1 of ~5
Decision: Hypotensive?
Based on World Health Organization. Educational use; follow local protocol.
Evidence
- WHO 2009 dengue guideline: phase-based fluid protocols.
- WHO 2025 arboviral guideline: crystalloids over colloids; CRT and lactate to guide fluids; against NSAIDs, steroids and immunoglobulins.
- Lye 2017: prophylactic platelets did not reduce bleeding and caused more adverse events.
🇮🇳 India notes
- India reports hundreds of thousands of dengue cases yearly; platelet transfusion demand driven by counts is a major waste of blood products.
References
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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.