Treating Dengue haemorrhagic fever with fixed flat rate of fluid and intermittent fluid boluses: Insights from a specialized dengue treatment centre

Abstract

Background: Dengue, a devastating public health problem has clinical entities dengue fever (DF) and dengue haemorrhagic fever (DHF) differentiated by plasma leaking in latter. Most guidelines have introduced a total fluid volume [maintenance with added 5% (50 ml/kg body weight up to maximum of 50 kg)] given over 48 hours as standard fluid quota (SFQ) needed for leaking phase replacement in DHF. Accordingly DHF is managed with ascending and descending fluid rates which are titrated to clinical parameters and duration of leaking. Centre for Clinical Management of Dengue and Dengue haemorrhagic fever (CCMDDHF) Sri Lanka treated DHF, using a fixed flat rate (FFR) of fluid 1.5 ml/kg/hour [Oral fluid 1 ml, intravenous (IV) fluid 0.5 ml] and intermittent fluid boluses (IFB) staying within SFQ as an alternative fluid regimen. When unable to take orally (sleep at night, vomiting), a total IV fluid rate of 1.2 ml/kg/hour was given. Fluid management was aimed to maintain pulse pressure 30 mmHg, urine output 0.5 ml/kg/hour and avoid unexplained tachycardia throughout. Boluses were crystalloid (Normal Saline) or colloid (Dextran40), 10 ml/kg/hour over one hour (full bolus-FB) or 5 ml/kg over 30 minutes (half bolus-HB). Methods and materials: Observational study of 400 consecutive serologically proven DHF patients treated during leaking phase from January 2017 at CCMDDHF. All patients had routine serial limited ultrasound scan of chest and abdomen, when platelets dropped below 150,000 looking for gradual fluid accumulation to confirm DHF. Patient treatment record data was extracted and entered to an Excel database and descriptive analysis done using R software. Results: 83.8% (335/400) needed ≤85% of SFQ (mean 83.75%, 95% CI 79.8-87). 36.3% (145/400) required IFB. 12% (48/400) received FFR with single crystalloid bolus (FB/HB). 75.7% (303/400) received FFR and single crystalloid bolus. 10% (40/400) received crystalloid and colloid boluses. 3.3% (13/400) received FFR with single colloid HB. 01% (4/400) received colloid FB. 74.2% (297/400) required no crystalloid boluses. 80.5% (322/400) required no colloid boluses. All patients were discharged with complete recovery with 0.0% Case Fatality Rate (CFR). Conclusion: Once diagnosed objectively and early, DHF could be managed with FFR of fluid and IFB with zero CFR.