Severe Dengue with Persistent Hypotension and Mean Arterial Pressure Below 65 mmHg After Repeated Fluid Boluses
This protocol addresses the patient in severe dengue with decompensated (profound) shock who remains haemodynamically unstable — with a mean arterial pressure below 65 mmHg and signs of reduced perfusion — after a full course of fluid resuscitation boluses.
Clinical scenario
- Severe dengue with decompensated (profound) shock
- Hypotension with signs of reduced perfusion
- Mean arterial pressure (MAP) below 65 mmHg
- Pulse pressure below 10 mmHg
- Raised haematocrit
Previous treatment — insufficient response
This step is reached after repeat bolus therapy failed to achieve restoration of blood pressure, a falling haematocrit, and improved urine output. Prior boluses included fluid resuscitation (crystalloid or colloid) and, where indicated, blood transfusion or packed red blood cells. The failure of those boluses to meet these haemodynamic targets is what escalates to the current protocol.
Next-line approach (partial overview)
When hypotension remains refractory after the third bolus, inotropic support is among the interventions considered to maintain blood pressure. This step also requires structured investigation to identify the underlying cause of persistent shock before further management.
The full protocol — including specific agent selection, investigation criteria, and stepwise decision points — is available via the link below.
References
- Decompensated shock among adults (hypotension + signs of reduced perfusion) mean arterial pressure (MAP) < 65, HCT high
- Table 9. Treatment of profound shock (hypotensive; undetectable pulse and BP)
- Inotropes may be used to support the blood pressure at this stage.
- Refractory hypotension, consider inotropes after 3rd bolus
- Detailed investigation to rule out: 1. cardiogenic shock; 2. septic shock; 3. metabolic cause; 4. organ dysfunction