Management of “fluid- overload”

in Severe Dengue
Kiki MK Samsi
UKK-Infeksi dan Pediatrik Tropik
..how is fluid overload happens ?
Increase volume
volume replacement
replacement

Increased Hydrostatic
pressure

Decreased Oncotic Intertitial

Intertitial edema
Intertitial edema
edema
pressure
Why fluid overload in severe dengue is a concern ???
… it makes more difficult in :

Differential diagnosis

Management
When are fluid overload happens?
How to recognized fluid overload
in severe dengue ???
Early clinical features of fluid overload are:

1. Rapid breathing;
2. suprasternal in-drawing and intercostal recession (in children);
3. respiratory distress, difficulty in breathing;
4. wheezing, crepitations;
5. large pleural effusions;
6. tense ascites, persistent abdominal discomfort/pain/tenderness (this should
not be interpreted as warning signs of shock);
7. increased jugular venous pressure (JVP).

Late clinical features are:

1. pulmonary oedema (cough with pink or frothy sputum, wheezing and crepitations, cyanosis) - this
may be mistaken as pulmonary haemorrhage;
2. irreversible shock (heart failure, often in combination with ongoing hypovolaemia).
Additional investigations are:

1. blood gas and lactate analysis;

2. the chest X-ray which shows cardiomegaly, pleural effusion, upward displacement of the diaphragm
by the ascites and varying degrees of “bat’s wings” appearance ± Kerley B lines, suggestive of fluid
overload and pulmonary oedema;
3. ECG to exclude ischaemic changes and arrhythmia;
4. echocardiogram for assessment of left ventricular function and left ventricular end- diastolic
diameters (LVEDD) and regional wall dyskinesia that may suggest underlying ischaemic heart disease.
The LVEDD is a reliable measure of the filling volume of the left ventricle and is increased in
hypervolaemia. Other indirect measures of the intravascular compartment status are the sizes of
internal jugular vein and inferior vena cava;
5. cardiac enzymes.
How to deal with fluid overload in
severe dengue ??
Action plan:
1. Oxygen therapy should be given immediately.
2. The further action plan for the treatment of fluid overload is dependent on:
1. the patient’s haemodynamic stability,
2. intravascular volume status
3. the timing of this event with respect to the timeline of the critical phase.
 Fluid Overload

Strong pulses with warm extremities are positive indications to stop (if ≥ 48 hours of plasma leakage) intravenous fluids.
1. If the patient has difficulty in breathing because of excessive third space fluid accumulation, it is all the more imperative

to stop fluid therapy.

2. Small doses of furosemide 0.1−0.5 mg/kg/dose twice or thrice daily or a continuous infusion of

furosemide 0.1 mg/kg/hour may be indicated for patients who are out of the critical phase.

3. Monitor serum potassium and correct the ensuing hypokalaemia.

4. A high creatinine level suggests that the kidneys may only respond to higher doses of furosemide.

5. Watch out for hypertension and treat during the recovery phase otherwise hypertensive encephalopathy may occur.

6. Respiratory support may be indicated depending on the severity of respiratory distress.

7. Recognizing when to decrease or stop intravenous fluids is crucial to preventing fluid overload
 Fluid Overload

patient has stable haemodynamic status Patients who remain in shock

 Fluid Overload

ASSESMENT
The patient has stable haemodynamic status but is still within the critical phase, < 48 hours of
plasma leakage.

ACTION PLAN
1. Reduce the intravenous fluid accordingly or change to a colloid solution at 1–2 ml/kg/hour
and reduce accordingly.
2. Avoid diuretics during the plasma leakage phase because they may precipitate intravascular
volume depletion.
 Fluid Overload

patient has stable haemodynamic status Patients who remain in shock

with elevated haematocrit levels with low or normal haematocrit

 Fluid Overload

ASSESMENT
Patients who remain in shock with elevated haematocrit levels but show excessive fluid
accumulation are likely to have received rapid infusions of crystalloid or hypotonic
solutions or blood products.

ACTION PLAN
1. Reduce the intravenous fluid accordingly or change to a colloid solution at 1–2
ml/kg/hour and reduce accordingly.
2. Avoid diuretics during the plasma leakage phase because they may precipitate
intravascular volume depletion.
 Fluid Overload

Patients who remain in shock with low or normal haematocrit levels but have excessive
fluid accumulation, are most likely to have severe occult bleeding

1. If the BP is low, a dopamine infusion should be started.

2. Further infusion of large volumes of intravenous fluids will lead to a poor outcome.
3. Careful transfusion of FWB, at least 10 ml/kg, should be initiated as soon as possible
at a rate titrated to a clinical response, blood gases and lactate.
4. Respiratory support may be required
Patients who remain in shock with
low or normal haematocrit levels
but have excessive fluid
accumulation, are most likely to
have severe occult bleeding

Careful transfusion of FWB, at least 10 ml/kg,

should be initiated as soon as possible at a rate titrated
to a clinical response, blood gases and lactate.
ASSESMENT
Patients with both intravascular and extravascular fluid overload remain in shock with metabolic
acidosis because the severe bleeding has been replaced with non-fresh whole blood.

ACTION PLAN
1. A combination of FWB or fresh packed red cells transfusion and careful colloid infusion
may help the patient out of the plasma leakage phase with minimal worsening of the
respiratory condition.
2. Dopamine should be commenced for hypotension and the patient should be
monitored carefully for respiratory failure.
 Fluid Overload

Ultra Sonography in Prolong/Recurrent DSS

• Inferior Vena Cava (IVC) Collapse
• Right Ventricle Volume vs Left Ventricle Volume (RV vs RL)
• Cardiac Contractility

kiki mk samsi
IVC collapse + + -
Volume RV vs LV RV < LV RV > LV RV > LV
Cardiac Contractility normal poor normal
Assesment Hypovolemia Cadiac Problems Volume Overload
(fluid responsive)

More Fluid Less Fluid Less Fluid

+ and / or
Inotropic Diuretik

kiki mk samsi
 Preventing excessive fluid overload
1. DO NOT GIVE excessive and/or too rapid intravenous fluids during the critical phase;
2. AVOID incorrect use of hypotonic crystalloid solutions e.g. 0.45% sodium chloride solutions;
3. AVOID inappropriate use of large volumes of intravenous fluids in patients with unrecognized severe
bleeding;
4. AVOID inappropriate transfusion of fresh-frozen plasma, platelet concentrates and cryoprecipitates;
5. AVOID prolonged intravenous fluid therapy, i.e., continuation of intravenous fluids after plasma leakage
has resolved (> 48 hours from the start of plasma leakage);
6. AWARE for the present of co-morbid conditions such as congenital or ischaemic heart disease, heart
failure, chronic lung and renal diseases.
Terima kasih