2 Sep 2025

Hemorrhagic Dengue with Shock

History of Present Illness

  • Mr. R, a 32-year-old male, presented with high-grade fever for 5 days, associated with severe retro-orbital headache, myalgia, and generalized body ache. On Day 4 of fever: developed abdominal pain, nausea, and persistent vomiting. On Day 5 morning: he noticed bleeding gums and a few petechiae on both legs.
  • On arrival to ER: fever had subsided (defervescence phase) but patient complained of dizziness, abdominal pain, and reduced urine output.

Past Medical History

  • Hypertension × 3 years – controlled with Amlodipine 5 mg once daily.
  • Mechanism: Amlodipine is a calcium channel blocker (DHP type) → causes vasodilation of arterioles → lowers systemic vascular resistance → reduces BP.
  • No diabetes, CKD, ischemic heart disease, asthma, or bleeding disorders.
  • No known drug allergies.
  • No anticoagulant or NSAID use.

On Examination (ICU Admission, Day 1 Critical Phase)

  • General: Anxious, restless, cold extremities, petechial rash on both legs.
  • Vitals:
    • Temp: Afebrile
    • HR: 128/min (tachycardia)
    • BP: 90/70 mmHg (narrow pulse pressure = 20 mmHg)
    • RR: 30/min (tachypnea)
    • SpO₂: 95% on room air
  • Systemic Exam:
    • CVS: Tachycardia, weak pulse
    • RS: Clear, no crepitations
    • Abdomen: Tender hepatomegaly, ascites (shifting dullness + confirmed on USG)
    • CNS: Conscious, oriented

Investigations on Admission (Day 1)

TestResultInterpretation
Hb 14 g/dLNormal
HCT 49% (baseline 38%) ↑ Hemoconcentration → plasma leakage
WBC 3,200/µL Leukopenia, typical of viral infection
Platelets 36,000/µL Severe thrombocytopenia
AST/ALT
AST 480
ALT 300		Dengue hepatitis (AST > ALT)
Creatinine1.1 mg/dL Borderline, watch renal perfusion
Na/K Na 132
K 3.3		Mild hyponatremia, hypokalemia (vomiting + fluid shifts)
INR 1.5 Mild coagulopathy
ABG pH 7.32, HCO₃ 18Metabolic acidosis due to hypo perfusion
USG Abdomen Mild ascites, GB wall edema Plasma leak evidence
CXR Normal lungsNo effusion initially

Initial ICU Management (Day 1)

  1. Airway/Breathing: Oxygen by nasal cannula 3 L/min → maintain SpO₂ >94%.
  2. Circulation:
    • IV access (2 large bore + central line).
    • Started Ringer Lactate at 7 mL/kg/hr (≈ 350 mL/hr for 50 kg).
    • Why RL? Balanced crystalloids preferred over NS (less hyperchloremic acidosis).
    • Why 7 mL/kg/hr? WHO recommends 5–7 mL/kg/hr during plasma leakage phase.
  3. Foley catheter: Strict urine monitoring → goal >0.5 mL/kg/hr.
  4. Investigations ordered: CBC & HCT q6h, ABG q12h, daily LFT/RFT.
  5. Drugs avoided: NSAIDs, IM injections, steroids.
  6. Transfusion policy explained: No prophylactic platelet transfusion unless <10k with bleeding or <20k with major risk/procedure.

Day 2 – Shock Worsening

  • Overnight Events: Patient restless, hypotensive.
  • Vitals: HR 142, BP 80/60 (PP 20), urine 15 mL/hr, SpO₂ 92%.
  • Labs: HCT 55% (still rising → ongoing plasma leak), Platelets 24k, Lactate 3.4.
  • CXR: New bilateral pleural effusion.
  • Management:
    • NS bolus 10 mL/kg over 1 hr (fluid responsive).
    • Still hypotensive → Dextran 40 10 mL/kg over 1 hr (colloid for refractory shock).
    • Started Noradrenaline 0.1 µg/kg/min (MAP target >65 mmHg).
    • Corrected hypokalemia with IV KCl.
    • No platelet transfusion (only mucosal bleed, stable Hb).
  • Rationale: Shock due to plasma leakage, not bleeding → fluids + vasopressors more important.

Day 3 – Stabilization Phase

  • Vitals: HR 110, BP 102/74, Urine output 40 mL/hr, extremities warm.
  • Labs: HCT ↓ 46% (improving), Platelets 22k, Cr 1.0, Na 134.
  • CXR: Stable pleural effusion, no pulmonary edema.
  • Management:
    • Reduced fluids → 5 mL/kg/hr (maintenance).
    • Noradrenaline tapered gradually.
    • Nutrition: Started NG tube feeding (100 mL every 3 hr).
    • Prophylaxis: IV pantoprazole for stress ulcer, DVT stockings (no LMWH because of thrombocytopenia).
    • Physiotherapy: Chest & limb exercises.
    • Monitoring: CBC & HCT q12h.

Day 4 – Recovery Phase

  • Vitals: HR 98, BP 110/76, urine 2 mL/kg/hr (polyuric).
  • Labs: HCT 42% (normalizing), Platelets 28k (rising), Cr 0.9, AST/ALT trending down.
  • Clinical: More alert, less abdominal pain.
  • Management:
    • Reduced IV fluids → 2 mL/kg/hr (avoid overload during reabsorption).
    • Noradrenaline stopped.
    • Switched to oral hydration + soft diet.
    • Monitoring for pulmonary edema → daily lung auscultation + bedside USG.

Day 5 – Transfer Ready

  • Vitals: HR 92, BP 112/78, SpO₂ 98% RA, afebrile, tolerating diet.
  • Labs: HCT 38% (normal), Platelets 52k, LFT/RFT improving, CXR effusion resolving.
  • Management:
    • IV fluids stopped completely → oral hydration only.
    • Mobilized out of bed.
    • CBC once daily in ward.
    • No platelet transfusion.
    • Handover to ward with advice for discharge once platelets >100k and clinically stable.

Summary of Pathophysiology Across ICU Stay

  • Day 1 & 2: Plasma leakage → hemoconcentration, shock.
  • Day 3: Stabilization → fluids carefully titrated, vasopressors tapered.
  • Day 4: Recovery → reabsorption phase, risk of pulmonary edema.
  • Day 5: Recovery complete → safe transfer

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