Pan American Health Organization · 1st edition, 2026 · 144 pages
Evidence-based ICU management protocols for severe dengue shock, hemorrhage, and organ failure in adults and children.
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2026
- Audience
- Intensivists, ICU nurses, emergency physicians, pediatricians, infectious disease specialists, obstetrician-gynecologists managing severe dengue cases
- Evidence
- GRADE methodology; 17 recommendations (4 strong, 13 conditional) based on systematic reviews, network meta-analyses, and randomized controlled trials; certainty of evidence ranges from high to very low depending on outcome
- Reviewed
- 14 Oct 2026 · GMJ
What this guideline says
GMJ summary
These are the first ICU-specific clinical guidelines for severe dengue management, published by PAHO using GRADE methodology. They provide 17 evidence-based recommendations and 5 good clinical practice statements covering fluid resuscitation, vasoactive agents, blood product use, and hemodynamic monitoring in critically ill dengue patients.
Key recommendations include using crystalloid solutions (preferably Ringer’s lactate) rather than colloids for resuscitation; norepinephrine as first-line vasopressor in adults (epinephrine in children); restrictive fluid strategies (5–10 ml/kg) in patients with comorbidities; and against prophylactic platelet transfusion in non-bleeding patients despite thrombocytopenia below 10,000/mm³. Dynamic measures, serum lactate, and capillary refill time are recommended to guide resuscitation.
The guidelines were developed by a multidisciplinary panel from PAHO’s International Task Force on Arboviral Diseases, the Pan American and Iberian Federation of Critical Medicine, CDC, and the Pedro Kourí Institute, targeting intensivists, emergency physicians, and ICU nurses managing the 13+ million dengue cases reported in the Americas in 2024, the largest epidemic to date.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Use crystalloid solutions (Ringer's lactate preferred) rather than colloids for fluid resuscitation in severe dengue shock
- Use restrictive fluid strategy (5–10 ml/kg) instead of standard 20 ml/kg in patients with heart failure, liver cirrhosis, chronic renal failure, pregnancy, neonates, or frail elderly
- First-line vasopressor: norepinephrine in adults; epinephrine (max 0.1 µg/kg/min) in pediatric patients with persistent shock despite fluids
- Add vasopressin when norepinephrine reaches 0.25–0.5 µg/kg/min in adults; add norepinephrine to epinephrine in children with persistent shock
- Do NOT give prophylactic platelet transfusion for thrombocytopenia <10,000/mm³ without active bleeding
- Use tranexamic acid in severe dengue with shock and active bleeding due to coagulopathy
- Guide resuscitation with serum lactate (measure hourly during initial resuscitation), capillary refill time, and dynamic measures rather than static parameters alone
- Add dobutamine in adults (milrinone in children) for demonstrated cardiac dysfunction despite adequate volume status
First-line vasoactive agents by patient population
Table extracted from the guideline
| Population | First-line agent | Maximum dose | Second-line addition | Third-line consideration |
|---|---|---|---|---|
| Adults with shock | Norepinephrine | 0.2 µg/kg/min | Vasopressin (fixed 0.03 U/min) | Epinephrine |
| Children with shock | Epinephrine | 0.3 µg/kg/min | Norepinephrine | Vasopressin |
| Adults with cardiac dysfunction | Norepinephrine + dobutamine | — | — | — |
| Children with cardiac dysfunction | Epinephrine + milrinone (or dobutamine) | — | — | — |
Source: Pan American Health Organization, Guidelines for the management of severe dengue in intensive care units. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- First-ever ICU-specific guidelines for severe dengue; previous PAHO guidelines (2022) addressed early management but not intensive care unit protocols
- Introduces restrictive fluid strategy (5–10 ml/kg) for high-risk populations versus previous standard 20 ml/kg approach
- Strong recommendation against prophylactic platelet transfusion for thrombocytopenia <10,000/mm³ without bleeding
- Adds specific pediatric vasopressor protocols with epinephrine as first-line (distinct from adult norepinephrine pathway)
- Incorporates point-of-care ultrasound (POCUS) and dynamic hemodynamic monitoring as adjunct resuscitation tools
From the guideline
Verbatim
“The use of crystalloid solutions (preferably balanced crystalloid solutions, such as Ringer's lactate) rather than colloids is recommended to initiate or continue resuscitation with intravenous fluids in patients with severe dengue with shock.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As WHO consultant on health and migration, I recognize these guidelines address a critical gap for Georgia, where dengue is not endemic but imported cases through international travel and labor migration from endemic regions demand ICU preparedness. The recommendation I would stress to Georgian intensivists is the restrictive fluid strategy (5–10 ml/kg) for patients with comorbidities—heart failure, cirrhosis, renal disease—which are prevalent in our aging population and among returned labor migrants with chronic conditions. One realistic implementation caveat: vasopressin availability remains inconsistent in Georgian regional hospitals, and the fixed-dose requirement (0.03 U/min, not titrated) differs from our usual vasoactive protocols, necessitating procurement planning and staff training before the next travel season brings potential imported cases to our ICUs.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 14 Oct 2026
Applicability
Georgia and the South Caucasus
These guidelines are directly applicable to Georgia and the South Caucasus, where dengue is not endemic but imported cases occur through international travel and migration. Georgian ICUs managing returning travelers or migrants from dengue-endemic regions (Southeast Asia, Latin America, Africa) will benefit from standardized protocols for severe cases. The recommendations on fluid management, vasopressor use, and hemorrhage control align with existing Georgian critical care capacity, though implementation will require training on dengue-specific pathophysiology (plasma leakage phase, capillary permeability). National programmes should integrate these protocols into infectious disease and intensive care training curricula, ensure availability of balanced crystalloids (Ringer’s lactate) and vasopressin in tertiary centers, and establish referral pathways for suspected severe arboviral disease from primary care to ICU-equipped facilities.
Questions this guideline answers
Quick answers
What is the preferred intravenous fluid for severe dengue shock resuscitation?
Crystalloid solutions, preferably balanced crystalloids such as Ringer's lactate, are recommended over colloids. Colloids (dextran, starch, gelatins) may increase serious adverse events like infusion reactions without additional mortality benefit. Isotonic crystalloids should be used in sufficient volume to maintain effective circulation during plasma leakage, with dosage adjusted by age, weight, and clinical status.
Should I give prophylactic platelets to a dengue patient with platelet count below 10,000/mm³ but no bleeding?
No. Prophylactic platelet transfusion is NOT suggested for severe dengue patients without active bleeding, regardless of platelet count. The evidence shows no benefit on mortality, major bleeding, or organ failure, with risk of transfusion-transmitted infections and fluid overload. Platelets are indicated only for active bleeding or before surgical procedures where blood loss is anticipated (maintain >50,000/mm³ for cesarean, >100,000/mm³ for neurosurgery).
What is the first-line vasopressor in pediatric severe dengue shock?
Epinephrine is suggested as the first-line vasoactive agent in pediatric patients with severe dengue shock and persistent hypoperfusion or hypotension despite fluid resuscitation (40–60 ml/kg). Maximum dose is 0.3 µg/kg/min. If shock persists, add norepinephrine rather than increasing epinephrine dose. This differs from adults, where norepinephrine is first-line.
How should I monitor resuscitation effectiveness in severe dengue?
Use serum lactate measurement (hourly during initial resuscitation, looking for downward trend), capillary refill time, and dynamic measures (systolic volume variation, pulse pressure variation, echocardiography) rather than static parameters alone. Mean arterial pressure, urine output, level of consciousness, and point-of-care ultrasound (POCUS) are recommended adjuncts. In children, assess skin mottling (correlates with lactate), shock indexes (HR/DAP <2; HR/SBP <1), and central venous saturation before invasive approaches.
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- Issuer
- Pan American Health Organization
- Type
- Guidelines and Technical Manuals
- Edition
- 1st edition, 2026
- Status
- Current
- Published
- 2026-09-22
- Languages
- English, Spanish
- Scope
- Intensive care unit management of severe dengue in adults, children, pregnant women, and patients with comorbidities (heart failure, liver cirrhosis, chronic renal failure); covers shock, hemorrhage, organ failure
- Audience
- Intensivists, ICU nurses, emergency physicians, pediatricians, infectious disease specialists, obstetrician-gynecologists managing severe dengue cases
- Pages
- 144
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-13048-3 (PDF)
- Evidence
- GRADE methodology; 17 recommendations (4 strong, 13 conditional) based on systematic reviews, network meta-analyses, and randomized controlled trials; certainty of evidence ranges from high to very low depending on outcome
- Next review
- Not specified; update when new evidence modifies recommendations
- Record history
- Created 14 Oct 2026 · updated 14 Oct 2026 · next check Apr 2027
Pan American Health Organization. Guidelines for the management of severe dengue in intensive care units. Washington, D.C.: PAHO; 2026. 144 p. ISBN 978-92-75-13048-3. Available from: https://doi.org/10.37774/9789275130483GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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