A 28-year-old man from Bangalore presents on day 7 of illness with fever that defervesced 2 days ago. He now complains of severe epigastric pain, persistent vomiting, and dizziness on standing. On examination, his blood pressure is 100/68 mmHg (sitting) and 88/62 mmHg (standing), pulse 112/min, and capillary refill time is 2.5 seconds. Platelet count is 45,000/μL, haematocrit has risen from 38% to 44% over 24 hours, and AST is 280 U/L. There is no active bleeding. What is the most appropriate immediate management?

Explanation

## Management of Dengue Shock Syndrome This patient meets criteria for dengue shock syndrome (DSS) — a medical emergency requiring immediate fluid resuscitation. ### Diagnostic Criteria Met **Key Point:** Dengue shock syndrome is defined by: 1. Evidence of plasma leakage (rising haematocrit ≥20% from baseline) 2. Circulatory failure (hypotension, narrow pulse pressure, or signs of poor perfusion) | Finding | Value | Significance | |---------|-------|---------------| | Orthostatic hypotension | 100/68 → 88/62 mmHg | ≥10 mmHg drop in systolic BP | | Pulse | 112/min | Tachycardia | | Capillary refill | 2.5 sec | Prolonged (normal <2 sec) | | Haematocrit rise | 38% → 44% (6% increase) | Plasma leakage | | Platelet count | 45,000/μL | Severe thrombocytopenia | | Fever phase | Day 7 (defervesced day 5) | Critical phase | ### Immediate Management Algorithm ```mermaid flowchart TD A[Dengue Shock Syndrome]:::urgent --> B[Establish IV access]:::action B --> C[Start isotonic crystalloid bolus]:::action C --> D{Haemodynamic response?}:::decision D -->|Good| E[Maintenance fluids + monitoring]:::action D -->|Poor| F[Second bolus + reassess]:::action F --> G{Persistent shock?}:::decision G -->|Yes| H[Vasopressor support in ICU]:::urgent G -->|No| E I[Avoid transfusion unless active bleeding]:::action J[Platelet transfusion only if<br/>platelet count <10K + bleeding<br/>or <20K + procedure]:::action ``` **High-Yield:** The cornerstone of DSS management is **rapid isotonic crystalloid fluid resuscitation**, not blood products. Transfusions are reserved for active bleeding or extreme thrombocytopenia with planned procedures. ### Fluid Resuscitation Protocol **Clinical Pearl:** WHO recommends: 1. **Initial bolus:** 10–20 mL/kg isotonic crystalloid (0.9% NaCl or Ringer's lactate) over 15–30 minutes 2. **Reassess** at 15–30 minutes: - If haemodynamically stable → switch to maintenance fluids - If still hypotensive → repeat bolus 3. **Maintenance:** 5–10 mL/kg/hour, adjusted based on urine output (target 0.5 mL/kg/hour) 4. **Monitoring:** Vital signs, urine output, haematocrit, electrolytes every 2–4 hours during critical phase **Warning:** Avoid over-resuscitation — it increases risk of pulmonary oedema and ascites. Fluid balance should be carefully titrated. ### When to Use Blood Products | Product | Indication | |---------|------------| | Fresh frozen plasma | **Not routinely used** in DSS; only if severe coagulopathy (PT/INR >1.5) + active bleeding | | Platelet transfusion | Platelet count <10,000/μL (spontaneous bleeding risk) OR <20,000/μL before invasive procedure; NOT for thrombocytopenia alone | | Red cell transfusion | Only if Hb <7 g/dL or active haemorrhage | **Mnemonic:** **CRASH** — Crystalloid, Resuscitate, Assess, Shock management, Haemodynamic monitoring ### Why This Patient Needs IV Fluids Now He has orthostatic hypotension (drop >10 mmHg systolic), tachycardia, prolonged capillary refill, and rising haematocrit — all signs of hypovolaemic shock from plasma leakage. Oral rehydration is inadequate; he needs IV crystalloid bolus immediately.