A 5-year-old girl from Bangalore presents on day 5 of fever with abdominal pain, persistent vomiting, and lethargy. Her blood pressure is 95/60 mmHg (normal for age: 105/70), pulse 110/min, and capillary refill 2.5 seconds. Platelet count is 45,000/μL, haematocrit 48% (baseline 40%), and AST 280 U/L. Chest X-ray shows a small right-sided pleural effusion. What is the most appropriate immediate intervention?

Explanation

## Clinical Diagnosis: Dengue Shock Syndrome (DSS) ### Recognition of Shock in This Child | Finding | Significance | |---------|-------------| | **BP 95/60** | Below normal for age (systolic <90th percentile); narrow pulse pressure | | **Pulse 110/min** | Tachycardia (compensatory) | | **Capillary refill 2.5 sec** | Delayed (normal <2 sec); sign of poor perfusion | | **Haematocrit 48%** | Rise from baseline 40% (8% increase); indicates plasma leakage | | **Pleural effusion** | Confirms plasma leakage | | **Day 5 fever + warning signs** | Classic DSS presentation (critical phase, days 3–7) | **Key Point:** This child meets criteria for **dengue shock syndrome (DSS)**: evidence of plasma leakage (rising haematocrit, pleural effusion, hypotension, narrow pulse pressure) with haemodynamic compromise. ### Management of DSS ```mermaid flowchart TD A[Dengue Shock Syndrome]:::urgent --> B[Establish IV access]:::action B --> C[Isotonic crystalloid bolus: 20 mL/kg over 15 min]:::action C --> D{Response to fluids?}:::decision D -->|Yes: BP restored, perfusion improved| E[Continue maintenance + deficit replacement]:::action D -->|No: Persistent shock| F[Repeat bolus, then infusion]:::action F --> G[Consider vasopressor if unresponsive]:::urgent E --> H[Monitor haematocrit, urine output, vital signs]:::action H --> I[Platelet transfusion only if <20,000 or bleeding]:::action ``` ### High-Yield: **Fluid resuscitation in DSS:** - **First-line:** Isotonic crystalloid (normal saline or Ringer's lactate) at **20 mL/kg bolus over 15 minutes** - **Goal:** Restore systolic BP to >90th percentile for age, narrow pulse pressure, improve perfusion - **Reassess:** If shock persists after first bolus, repeat once; if still unresponsive, add vasopressor (dopamine 5–10 μg/kg/min) - **Avoid:** Over-resuscitation (increases plasma leakage and pulmonary oedema) ### Clinical Pearl: **Platelet transfusion is NOT first-line in DSS.** Transfuse only if: - Platelet count <20,000/μL (risk of spontaneous bleeding), OR - Platelet count <50,000/μL with active bleeding In this case, platelets are 45,000/μL without bleeding — transfusion is deferred until haemodynamics are restored. ### Warning: ~~Fresh frozen plasma~~ is not indicated for DSS unless there is evidence of disseminated intravascular coagulation (DIC) with coagulopathy and bleeding. Routine FFP transfusion worsens fluid overload. [cite:Park 26e Ch 10; WHO Dengue Guidelines 2009]