Associations of resuscitation fluid load, colloid-to-crystalloid infusion ratio and clinical outcomes in children with dengue shock syndrome

Abstract

Background

Severe respiratory distress and acute kidney injury (AKI) are key factors leading to poor outcomes in patients with dengue shock syndrome (DSS). There is still limited data on how much resuscitated fluid and the specific ratios of intravenous fluid types contribute to the development of severe respiratory distress necessitating mechanical ventilation (MV) and AKI in children with DSS.

Methodology/principal findings

This retrospective study was conducted at a tertiary pediatric hospital in Vietnam between 2013 and 2022. The primary outcomes were the need for MV and renal function within 48 h post-admission. A predictive model for MV was developed based on covariates from the first 24 h of PICU admission. Changes in renal function within 48 h were analyzed using a linear mixed-effects model. A total of 1,278 DSS children with complete clinical and fluid data were included. The predictive performance of MV based on the total intravenous fluid volume administered yielded an AUC of 0.871 (95% CI, 0.836–0.905), while the colloid-to-crystalloid ratio showed an AUC of 0.781 (95% CI, 0.743–0.819) (both P < 0.001). The optimal cut-off point of the cumulative fluid infusion was 181 mL/kg, whereas that of the colloid-to-crystalloid ratio was 1.6. Multivariable analysis identified female patients, severe bleeding, severe transaminitis, excessive fluid resuscitation, and a higher proportion of colloid solutions in the first 24 h as significant predictors of MV in DSS patients. The predictive model for MV demonstrated high accuracy, with a C-statistic of 89%, strong calibration, and low Brier score (0.04). Importantly, a more pronounced decline in glomerular filtration rate was observed in DSS patients who required MV than in those who did not.

Conclusions/significance

This study provides insights into optimizing fluid management protocols, highlighting the importance of monitoring fluid volume and the colloid-to-crystalloid ratio during early resuscitation to improve the clinical outcomes of DSS patients.

Author summary

Dengue shock syndrome (DSS) in children admitted to the pediatric intensive care unit (PICU) has mortality rates ranging from 5% to > 20%, particularly in those with prolonged shock, severe respiratory distress requiring mechanical ventilation (MV), and acute kidney injury (AKI). Although colloidal solutions are commonly used in severe DSS management, excessive use can lead to respiratory failure and AKI, raising concerns regarding optimal fluid strategies. This study analyzed 1,278 children with DSS and found that 13.3% required MV, with a significantly higher mortality rate in the MV group (22.4%) than in the non-MV group (0.1%). Both the total intravenous fluid volume and colloid-to-crystalloid ratio were strong predictors of MV, with optimal cut-offs of 181 mL/kg for fluid volume and a ratio of 1.6. In practice, a cut-off of colloid-to-crystalloid ratio ≥ 1.6 may indicate the need to transition to alternative fluids such as albumin or fresh frozen plasma. Moreover, a marked reduction in the estimated glomerular filtration rate (eGFR) was observed in the MV group, indicating a link between fluid management and renal function. These findings underscore the importance of fluid management in DSS, providing key predictors of MV and AKI to guide treatment and improve the clinical outcomes.