Rational Fluid Management in DHF

Budhi Santoso, MD
Senior Medical Advisor CIBG PT Otsuka Indonesia

The management of DHF is entirely symptomatic and supportive and is directed towards replacement of
plasma losses for the period of 24-48 hours. Survival depends on early clinical recognition and frequent
monitoring of patients for pathophysiologic changes. Early volume replacement when haematocrit rises
can significantly prevent shock and/or modify disease severity (1). Studies reveal a reduction in plasma
volume of more than 20% in severe cases. The evidence that supports the existence of plasma leakage
includes findings of pleural effusion and ascites by examination or radiography, haemoconcentration,
hypoproteinaemia and serous effusion (at post mortem) (2). In general, parenteral fluid therapy can be
classified into three categories: Resuscitation, Repair and Maintenance. Since, severe electrolyte and
acid-base disorders rarely complicate DHF, repair fluid therapy is seldom administered for DHF patients.

1. Resuscitation (Volume Replacement)

In shock cases (grade 3 4) satisfactory results have been obtained with the following regimen (1) :
a) Immediately and rapidly replace plasma losses with isotonic salt solution and plasma or plasma
expander (in cases of profound shock).
b) Continue to replace further plasma losses to maintain effective circulation for the period of 24-48 hours.
c) Correct metabolic and electrolyte disturbance (metabolic acidosis, hyponatremia, hypoglycemia or
hypocalcemia).
d) Give blood transfusion in cases of significant bleeding.
Therefore, we conducting table regarding guidelines or studies stated volume replacement in DHF, as
below:
No
Statement
Author/Publication
GUIDELINES Clinical and Laboratory
1 Monitor treatment and recovery IV resuscitation therapy (3) :
Guidelines for Dengue Fever and
Acetated=Ringers or 5% glucose (I PSS) at a rate of 10-20 ml/kg of

body weight per hour (or as fast as possible).

If shock persists after 20-30 ml/kg of body weight add a plasma expander
at the rate of 10-20 ml/kg per hour.
If shock persist significant internal bleeding should be suspected
Continuation of intravenous therapy should be adjusted according to
hematocrit and the rate should be reduced to 10 ml/kg per hour.
In general there is no need to continue the therapy beyond 48 hours.
Type of fluid in volume replacement in DHF (4) :
Crystalloid:
5% dextrose in lactated Ringers solution (5% D/RL)
5% dextrose in Acetated Ringers solution (5% D/RA)
5% dextrose in half strength normal saline solution (5% D/1/2/NSS)
5% dextrose in normal saline solution (5% D/NSS)
Colloid:
Dextran 40, - Plasma Expander
Because patients have loss of plasma (through increased vascular
permeability into the serous spaces) they must be given isotonic solutions
and plasma expanders, such as Acetated Ringers or lactated ringer,
plasma protein fraction, and Dextran 40 (5) .
In the critical stage, immediate volume replacement with isotonic solution
such as normal saline (NSS), 5% D/NSS, Ringers lactate solution (RLS)
or Acetated Ringers Solution (ARS), at a rate of 10-20 ml/kg/h in 12 hours, should be administered until circulation improves and an
adequate urinary output is obtained (6).
The result of studies from various places (Bangkok, Thailand, 2000) on
the use of corticosteroid in treating DSS showed no benefit either in the
fatality rate or any reduction in the volume of fluid therapy or duration of
therapy. Solution for volume replacement: 5% D in NSS, 5% D in 1/2
NSS, Lactated Ringer or Acetated Ringers, Plasma expander,

Dengue Haemorrhagic Fever/Dengue

Shock Syndrome for Health Care
Providers

Prevention and Control of Dengue and

DHF: Comprehensive Guidelines; WHO,
Regional Publication, SEARO, no. 29; New
Delhi;

P Amin*, Sweety Bhandare**, Ajay

Srivastava*** . *Consultant BHIMS, **Resident,
Cook Country Hosp. Chicago. ***Resident,
Bombay Hosp. Mumbai

Faculty of Tropical Medicine, Mahidol

University. All rights reserved. Webmaster :

tmwww@mahidol.ac.th
WHO/SEARO Home WHO Regional
Office for South-East Asia 2009 All rights
reserved

Dextran 40 (7) .

Acetated Ringer's Solution is often used for fluid resuscitation

after a blood loss due to trauma, surgery, or a burn injury, as well as
hypovolemic shock due to severe dehydration and dengue
hemorrhagic fever. It is used because the byproducts of acetate
metabolism counteract acidosis, a chemical imbalance that occurs with
acute fluid loss, such as occurring in diarrhoea. The metabolism of
acetate is mainly in muscle and 2.5 to 4 times faster than lactate
(see lactated Ringer's solution) (8) .
Acetated Ringers solution is a slightly hypotonic infusion fluid
(osmolality 270 mosmol/kg) that has inspired the belief that the fluid
causes a shift of water volume to the intracellular space. In conclusion,
infusion of Acetated Ringers solution does not promote cellular
swelling as a result of the excretion of urine that is low in sodium.(9) .

Acetated Ringers ** is another isotonic solution often used for

replacement therapy (10).

Otsuka Indonesia, Asering Brochure,

reprinted 2010.

** Asering is branded name of

acetated ringers marketed in
Indonesia by PT. Otsuka
Rapid Water and Slow Sodium Excretion of
Acetated Ringers Solution
Dehydrates Cells; Robert G. Hahn,
MD PhD, and Dan Drobin, MD PhD
Sder Hospital, S-118 83
Stockholm, Sweden
Osuka Pharmaceuticals. Ringer Acetate
Solution in Clinical Practice. MediMedia
Com; 1-5, 1999.

2. Supportive Therapy (Maintenance)

Given the widespread availability of isotonic infusion solutions, they are commonly given also to patients
with grade 1 and 2 DHF, simply to satisfy the comfort level of the attending physicians that in leakage
conditions isotonic solutions would be preferred although there are no strong reasons, except in mild
hyponatremia. Maintenance fluid therapy can be viewed as an important supportive therapy for
hospitalized patients. Unlike resuscitation fluid therapy where the goal is to restore hemodynamic
derangement, maintenance therapy is aimed at maintaining homeostasis in patients who have insufficient
oral intake of fluid. Practically, resuscitation infuse still widely given as a maintenance therapy with lower
speed (20 30 gtt/minute). Whenever, they could not meet daily requirement, such below table:

Ideally, goal of maintenance fluid therapy can be summarized as follow:

1. Fulfills daily physiological requirements for homeostasis. Restore quickly the depleted fluid electrolyte
content of intracellular compartment
2. Prevents electrolyte & acid base disorders
3. Supports primary therapy of patients illness
4. Enzymatic process & protein synthesis
5. Facilitates recovery
What are the features of a good maintenance solution ? (11)
1. Practical, easy and safe to administer
2. In addition to basic electrolytes (Na+,K+,Cl-) also contains microminerals (Mg++,Ca++,P) which are
required for cellular metabolism
3. The presence of value added zinc helps to promote tissue healing
4. Contains high quality amino acids (BCAA enriched, high in EAA) to promote protein synthesis
5. Glucose to maintain euglycemia, prevent ketosis, and protein-sparing effects. One of possible
candidates to fulfill the above criteria is Aminofluid. Compositions of Aminofluid and other maintenance
solution (KAEN3B) and Ringers lactate are shown below:

Composition

Aminofluid

KAEN3B

Ringers lactate

ASPEN guideline(2)

Water
2000
2000
2000
30-40 ml/kg/day
+
Na
70
100
260
1-2 mEq/kg/day
K+
40
40
8
1-2 mEq/kg*/day
Cl70
100
218
As needed
Mg++
10
8-20 mEq/day
Ca++
10
10-15 mEq/day
P
20
20-40 mEq/day
Zn
10 mol
2.5-5 g
Amino Acid
AA 60 g
0.8 g/kg/day
Glucose
150 g
54 g
* basic requirement for K+ homeostasis 20-30 mEq/daily (10); basal amino acid requirement in nonstressed patients;
protein-sparing effect

Maintenance IV fluid therapy can be considered to substitute the oral intake of water and nutrients. Its
place in grade 1 and 2 must be encouraged when oral intake is severely impaired by nausea, anorexia
and vomiting. The rationale of new generation maintenance solution as supportive fluid therapy in grade 1
& 2 DHF is based on the following:
1. Although patients feel thirsty due to probable hypertonic dehydration, they might not be able to
consume enough water and nutrient owing to abdominal discomfort/pain, hepatomegaly
2. Elevated levels of cytokines, such as interferons (IFNs), interleukin-2 (IL-2), IL-8, and tumor necrosis
factor alpha, have been reported in DHF (12) One of their pleiotropic effects is delaying gastric emptying
3. Patients might experience loss of appetite because of dry mouth (dehydration), malaise and fatigue
besides other systemic symptoms(13) . Therefore, once body fluid homeostasis is restored, systemic
symptoms might be alleviated and further progression to more severe illness is prevented.

3. Conclusion
3.1. When hemodynamic patients is not stable (DBD gr III and IV) Asering for replacement therapyseems
superior compare to LR or NS
3.2. If hemodynamic still stable (DBD gr I and II) and patients could intake adequate orally give hypotonic
solution which meet daily requirement and It has evolved from simply giving water and electrolyte in
simple container to practical and complete composition in advanced dual-chamber formulation.
3.3. Most important goal of maintenance therapy is to correct homeostasis, improve sense of well-being,
combat fatigue, increase appetite and finally faster recovery.
3.4. Aminofluid already designed for advance maintenance fluid therapy today

References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Dengue/DHF Management of Dengue Epidemic (SEA/DEN/1): Medical and Laboratory Services and Standard Case
Management of DEN/DHF/DSS During Epidemics; 2009.
WHO publication on Dengue Hemorrhagic Fever, chapter 3th, page:24-33.
Caribean Epidemiology Center; GUIDELINES: Clinical and Laboratory Guidelines for Dengue Fever and Dengue
Haemorrhagic Fever/Dengue Shock Syndrome for Health Care Providers, 2009.
Prevention and Control of Dengue and DHF: Comprehensive Guidelines; WHO, Regional Publication, SEARO, no. 29;
New Delhi
Amin, P, et all; Dengue, DHF, DSS; Bombay Hospital Journal; 43003, July 2001.
Faculty of Tropical Medicine, Mahidol University; Knowledge on Dengue.
WHO/SEARO Home WHO Regional Office for South-East Asia 2009 All rights reserved
Otsuka Indonesia, Asering Brochure, reprinted 2010.
Hahn, G Robert; Drobin Dan; Rapid Water and Slow Sodium Excretion of Acetated Ringers Solution Dehydrates Cells;
Sder Hospital, S-118 83 Stockholm, Sweden
Osuka Pharmaceuticals. Ringer Acetate Solution in Clinical Practice. Medi Media Com; 1-5, 1999
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Associated with Plasma Leakage in Dengue Hemorrhagic Fever J Virol. 2007 February; 81(4): 15921600.
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