Standard Therapy versus Plasmalyte in Children with Dengue Shock Syndrome (SPLID trial): a study protocol for an open-labeled randomized control trial

Intravenous fluid resuscitation is the first-line therapy in the management of dengue shock syndrome (DSS), a severe complication of dengue fever characterized by vascular leakage and organ dysfunction. However, the choice of intravenous fluids for resuscitation in DSS remains contentious. Evidence is lacking with regard to standard therapy, like normal saline (NS) and Ringer lactate (RL), versus newer balanced crystalloids like Plasmalyte (PL) for resuscitation of DSS. This study is a three-arm, prospective, open-label, parallel-group randomized clinical trial (RCT) to be conducted at a tertiary care hospital in north India over 36 months. We will recruit 135 children aged 2 months to 18 years, admitted with DSS who fulfill the eligibility criteria as per the WHO classification. The participants will be randomized to receive NS, or RL or PL in a 1:1:1 assignment. The primary outcome is a ≥5 mmol/L increase in serum chloride within 48 h post-randomization. The secondary outcomes include changes in acid-base status, hospital stay, need for colloid bolus, new-onset acute kidney injury (AKI), organ dysfunction, and mortality. AKI and organ dysfunction will be defined as per KDIGO criteria and Pediatric Logistic Organ Dysfunction 2 score (PELOD-2), respectively. Any serious adverse event occurring during the course of the trial will be reported to the ethics committee and the monitoring committee within 24 h. Both intention-to-treat and per-protocol analyses will be conducted. DSS initially requires prompt fluid resuscitation with crystalloids. NS in large volumes may lead to hyperchloremic metabolic acidosis. RL, containing lactate as a buffer, is contraindicated in children with compromised liver function due to their reduced ability to metabolize lactate. PL, a balanced crystalloid, is isotonic with a chloride concentration similar to that of plasma. Thus, the RCT aims to determine the change in serum chloride between standard treatment vs. PL within 48 h of fluid resuscitation and to compare the change in acid-base status, hospital stay, new-onset AKI, organ dysfunction, and mortality in children with DSS. The SPLID trial has been registered prospectively with the Clinical Trial Registry of India (CTRI) registry no. CTRI/2023/11/060213 [Registered on 23/11/2023].