An approach to management of dengue infection in the setting of profound or prolonged shock (WHO DHF Grade IV)*^¶

WHO: World Health Organization; DHF: dengue hemorrhagic fever.
* The WHO has established a grading for severity of dengue hemorrhagic fever

• DHF Grade I – Fever, hemorrhagic manifestation (positive tourniquet test), and evidence of plasma leakage.
• DHF Grade II – DHF Grade I plus spontaneous bleeding.
• DHF Grade III – DHF Grade I or DHF Grade II plus circulatory failure.
• DHF Grade IV – DHF Grade III plus profound shock with undetectable blood pressure and pulse.

Dengue shock syndrome consists of DHF Grade III and DHF Grade IV.
¶ Shock refers to normal systolic pressure but rising diastolic pressure with narrowing pulse pressure. Profound shock refers to hypotension and narrow pulse pressure (systolic minus diastolic pressure ≤20 mmHg).
Δ Intravenous crystalloid solutions include normal saline or Ringer's lactate. Colloid solution includes blood products or 10% dextran 40 in normal saline; no other colloid formulations (such as albumin) should be used for management of dengue, and dextran should not be used for initial resuscitation. If 10% dextran 40 in normal saline is not available, crystalloid should be used.
◊ Criteria for clinical improvement include blood pressure rising or normalized, heart rate decreasing, pulse pressure widening, respiratory rate decreasing, skin warm with turgor intact, or sensorium clear.
§ The patient's clinical status (including vital signs, urine output, and hematocrit) should be evaluated prior to each infusion rate adjustment.
¥ Criteria for lack of clinical improvement include blood pressure decreasing, heart rate increasing, pulse pressure narrowing, respiratory rate increasing, skin cool and clammy with diminished turgor, mental confusion, or restlessness.
‡ Additional interventions include dialysis or plasmapheresis; the clinical approach depends on locally available resources and clinical expertise.