Monitoring Of Fluid Balance Research Articles

2412. Our Experience With IV Fosfomycin

BackgroundAntimicrobial resistance in Gram-negative organism is a global problem. There is an increased interest in Fosfomycin due to its attractive PK/PD properties. The present study aimed to examine the effectiveness and safety of IV Fosfomycin which has been recently licensed in India.MethodsWe retrospectively studied patients who received IV Fosfomycin from January 2017 to February 2018. Patients with proven or suspected sepsis given IV Fosfomycin were included in the study. Clinical, microbiological outcome, and adverse reactions were noted.Results27 patients received IV fosfomycin. Of these 6 were excluded from the study because 2 had SIRS due to non-infective etiology, 1 had an organism with Fosfomycin resistance and 3 had incomplete clinical records. 7 patients received empirical and 14 received directed treatment. The most frequent isolate was carbapenem-resistant Klebsiella pneumoniae found in 8 patients. 1 patient received monotherapy while 20 received combination therapy. 9 patients were clinically cured. 1 showed clinical improvement, 8 worsened on treatment due to adverse drug reactions and 3 patients died while on treatment. Microbiological cure was seen in 6 patients. 3 had persistently positive cultures. 1 patient with bacteremic UTI due to Klebsiella pneumoniae received IV fosfomycin for 14 days and relapsed after 1 week of stopping treatment with the same organism showing fosfomycin resistance. 16 patients developed adverse drug reactions. The most common adverse drug reaction was diarrhea in 13, among them 1 had C. difficile colitis. Other adverse reactions like hypernatremia and hypokalemia were observed in 7 and 10 patients, respectively. Electrolyte imbalance were seen in patients aged >50 and those who received a higher dose than was appropriate for the creatinine clearance. 2 patients developed noncardiogenic pulmonary edema within 72 hours of starting fosfomycin and 1 developed torsades de pointes with QT prolongation due to hypokalemia ConclusionFosfomycin appears to be a useful addition to the treatment armamentarium. Although adverse events have not been considered significant in most reviews, they are highly significant in our experience. We recommend careful monitoring of fluid and electrolyte balance in patients receiving IV fosfomycinDisclosures All authors: No reported disclosures.

Hipervolemia Pada Pasien Congestive Heart Failure (CHF)

Background: Congestive Heart Failure (CHF) is a condition in which the heart is unable to pump blood normally, causing disturbed venous return pressure to cause edema. The problem that arises is hypervolemia or intracellular fluid resuscitation to the interstitial that causes edema so that can be arranged nursing intervention one of them is giving diuretic and monitor fluid balance. Describes nursing care performed in Congestive Heart Failure (CHF) patients with hypervolemia. Method: This study uses data analysis method that is conducting the nursing process of two patients Congestive Heart Failure (CHF) who suffered from Hypervolemia disorder and then compared with case study journal as well as other sources. Result: After nursing action in both patients the Hipervolemia problem is equally partially resolved by fluid restriction nursing interventions, and the administration of diuretics. Conclusion: In providing nursing care to patients with Congestive Heart Failure (CHF) should pay attention to fluid restriction and appropriate diuretic administration to reduce edema.

Human Body Water Composition Measurement:Methods and Clinical Application

Being the largest single component of the human body,water is essential for life. Disease can lead to salt and water imbalance, and it is particularly important to measure the content and distribution of water in body. The current body water measurement methods are still not mature,and it's even hard to measure extracellular and intracellular water. Isotope dilution method(ID),bioelectrical impedance analysis(BIA),skinfold thickness measurement,and resonant cavity perturbation(RCP)are the commonly used methods for measuring human body water composition. This paper analyzes the advantages and disadvantages of these methods and concludes that all these four methods can be used to measure total body water;more specifically,ID and BIA can measure extracellular water and intracellular water,whereas BIA is more suitable for clinical applications such as monitoring of fluid balance,guiding of fluid management,assessment of lymphedema and nutritional risk,and management of obesity. Body water measurement will play more important roles in diagnosis,prevention,treatment,and prognosis of diseases.

355. Maternal and neonatal seizures secondary to severe hyponatraemia from acute intrapartum water intoxication

Introduction We wish to highlight how unregulated intrapartum water ingestion can result in significant maternal and neonatal morbidity. Early symptoms can be non-specific or confused with common pregnancy complications such as pre-eclampsia. We present a case of maternal and neonatal seizures secondary to severe hyponatremia following water intoxication. We will discuss the challenges in identifying high risk patients and their subsequent management. Case presentation A healthy primiparous women presented at term in spontaneous labour. She developed a generalized seizure followed a short period of acute confusion and disorientation intrapartum. She was mildly hypertensive without proteinuria. Magnesium sulphate was given and an emergency caesarean section performed. Following delivery the neonate developed seizures. Cord blood gases were normal. Maternal and fetal bloods showed severe hyponatraemia. Their biochemical and hormonal profile was otherwise normal. Brain and renal imaging were normal. Both required intensive care treatment. Fluid excess was calculated and they were fluid restricted accordingly. Supplementary hypertonic saline was given. Both made a full neurological recovery. Collateral history revealed that the mother drank up to 4 litres of water following advice to remain well hydrated following severe hyperemesis during the first and second trimester. Discussion Identifying antenatal risk factors for hyponatraemia, strict fluid balance monitoring and renal function testing in labour may identify at risk women and reduce the incidence of seizures and associated morbidity secondary to water intoxication.

261An Audit of Fluid Balance Monitoring in Patients Admitted due to an Exacerbation of Congestive Heart Failure

261An Audit of Fluid Balance Monitoring in Patients Admitted due to an Exacerbation of Congestive Heart Failure

Postoperative Bedside Critical Care of Thoracic Surgery Patients.

Postoperative Bedside Critical Care of Thoracic Surgery Patients.

Transitional care post TAVI: A pilot initiative focused on bridging gaps and improving outcomes

Interventions focused on ensuring safe transitions for patients from hospital to home can assist in providing continuity of care, preventing readmissions, and reducing duplication of services. Patients undergoing a Transcatheter Aortic Valve Implantation (TAVI) procedure are often frail, elderly, and have multiple co-morbidities. A pilot initiative evaluating transitional care strategies through telephone follow up was implemented in a tertiary centre with the aim to identify gaps and intervene, preventing re-admission and improving patient outcomes. TAVI patients or caregivers were contacted at 3 days and 30 days post discharge by an Advanced Practice Nurse (APN). Telephone follow up centered on best practices for transitional care. Outcomes revealed fluid balance monitoring, medication management, and feelings of anxiety and depression post TAVI were the most frequent areas requiring intervention. Findings from this initiative reinforce the need to establish consistent processes that support elderly patient populations during potentially vulnerable points in the care trajectory.

A comparison of compliance in the estimation of body fluid status using daily fluid balance charting and body weight changes during continuous renal replacement therapy

Abstract Background The risk of fluid overload and mortality is increased in patients with severe acute kidney injury. Charting of daily fluid balance is a key component of fluid assessment but not without problems affecting accuracy. The introduction of electronic bed scales has made routine patient-weighing easier and focused attention on monitoring fluid-related weight changes. Objectives This paper investigated the frequency of compliance in weighing patients daily using electronic bed scales and evaluated the relationship between calculated fluid balance and body weight changes in patients receiving continuous renal replacement therapy (CRRT). Methods A prospective cohort interventional observation study was conducted in a tertiary ICU between June 2015 and February 2016. All patients who required CRRT, >18 years with an admission >24 hours were enrolled. Each patient was able to be weighed daily using electronic bed scales. At the same time daily fluid balances were calculated using paper-based charting. Trends in compliance of recording body weight changes with daily charting of fluid balances was observed until patient no longer required CRRT. Daily differences were compared using Pearson correlation and Bland-Altman analysis. Results A total of 61 patients were recruited. Four hundred and three days of CRRT was recorded with 286 days (71%) accompanied by a measured body weight. One hundred and eighty-one paired comparisons between body weight change and corresponding fluid balance was obtained from 39 patients (64%). Correlation between changes in body weight with fluid balance was weak (r = 0.34, p Conclusion Change in body weight offers an alternative to charting inputs and outputs in monitoring fluid balance. A physical representation of fluid status is provided rather than a calculated value. Lack of compliance in weighing of patients on two consecutive days was shown to reduce utility as a routine monitoring practice. The relationship between fluid balance and changes in body weight was not strong.

Case report: patient with Weil’s disease, chest pain, hepatitis b, hepatorenal syndrome, and electrolyte imbalance

A 48-years-old man was hospitalized due to febrile for 5 days accompanied by headache and left chest pain radiating into the back. Pain calf, abdominal pain and tea color urine has occured since 1 week before admission. Physical examination revealed temperature 38.5° C, conjungtival suffusion, jaundice sclera, irregularheart sound, hepatomegaly, gastrocnemius tenderness, Faine score 23. Laboratory tests showed leukocytosis, thrombocytopenia, elevated transaminase enzyme, ureum 181 mg/dl, creatinine 4.3 mg/dl, albumin 2.4 g/dl, sodium 110 mmol/L, potassium 2.3 mmol/L, reactive HbsAg, CKMB 68.06 ng/ml, increased HBV-DNA, negative IgM anti Leptospira. MAT demonstrated 4 positive serovar. Electrocardiography revealed AF rapid ventrikel response. Chest x-ray showed cardiomegaly. Abdominal ultrasound revealed hepatomegaly with chronic parenchimal liver disease, renal insuficiency. Fibroscan showed severe fibrosis. Patient was diagnosed with Weil’s disease and hepatorenal syndrome as complication. Patient was given clavulanate amoxicillin injections. This patient was not dialysis, only fluid balance monitoring and checked ureum-creatinine per 3 days, and there was improvement of ureum-creatinine. Hepatorenal syndrome in Weil’s disease contributed to electrolyte imbalance. In addition, chronic hepatitis B on this patient was treated with tenofovir.

Aciclovir-induced acute kidney injury in patients with 'suspected viral encephalitis' encountered on a liaison neurology service.

Patients with 'suspected viral encephalitis' are frequently empirically treated with intravenous aciclovir. Increasing urea and creatinine are 'common', but rapidly progressive renal failure is reported to be 'very rare'. To describe the clinical course and outcome of cases of aciclovir-induced acute kidney injury (AKI) encountered by the Liaison Neurology Service at AMNCH and to highlight the importance of surveillance and urgent treatment of this iatrogenic complication. Retrospectively and prospectively collected data from the Liaison Neurology Service at AMNCH on patients who received IV aciclovir for suspected viral encephalitis and developed AKI were analysed. Aciclovir-induced AKI was defined by a consultant nephrologist in all cases as a rise in serum creatinine of > 26μmol/L in 48h or by ≥ 1.5 times the baseline value. Renal function, haematocrit, and fluid balance were monitored following AKI onset. Data from 10 patients were analysed. Median time to AKI onset was 3.5days (range: 1-6days). Aciclovir was stopped or the dose adjusted. All patients recovered with IV normal saline, aiming for a urine output > 100-150ml/h. The interval between first rise in creatinine and return to normal levels varied between 5 and 19days. Liaison neurologists and general physicians need to be aware that aciclovir may cause AKI attributed to distal intra-tubular crystal nephropathy. Daily fluid balance and renal function monitoring are essential because AKI may arise even with intensive pre-hydration. Prognosis is good if identified early and actively treated.

Association of Total Fluid Intake and Output with Duration of Hospital Stay in Patients with Acute Pancreatitis.

Background/Aims The aim of this study was to evaluate the association of fluid balance with outcomes in patients hospitalized with acute pancreatitis (AP). Methods This was a retrospective study of patients hospitalized between May 2008 and June 2016 with AP and a clinical order for strict recording of intake and output. Data collected included various types of fluid intake and output at 24 and 48 hours after admission. The primary outcome was length of stay (LOS). Analysis was performed using single-variable and multivariable negative binomial regression models. Results Of 1256 patients hospitalized for AP during the study period, only 71 patients (5.6%) had a clinical order for strict recording of intake and output. Increased urine output was associated with a decreased LOS at 24 and 48 hours in univariable analysis. An increasingly positive fluid balance (total intake minus urine output) at 24 hours was associated with a longer LOS in multivariable analysis. Conclusions Few patients hospitalized for AP had a documented order for strict monitoring of fluid intake and output, despite the importance of monitoring fluid balance in these patients. Our study suggests an association between urine output and fluid balance with LOS in AP.

Prevention of acute kidney injury through accurate fluid balance monitoring.

Acute kidney injury (AKI) is associated with increased patient morbidity, mortality and an extended hospital stay. The financial burden to the National Health Service is high and it can affect up to one in five inpatients. Optimal fluid balance management is essential for the prevention of AKI and this can be particularly challenging in the patient with trauma. Our aim was to reduce the rate of AKI in patients with traumatic injuries in the regional trauma centre.We developed new fluid balance charts and documented how well these were completed. The number of AKI alerts per month was calculated on our pathology system. Scenario training was delivered at handover meetings and an e-learning tool was designed at three levels: healthcare assistants; nurses; and medical staff, dietetics and pharmacists. Educational posters were placed in clinical areas and patient information leaflets produced. Junior doctors were regularly informed of AKI rates on the ward.The number of AKI alerts on our trauma ward declined from 50 in January 2016 to 19 in November 2016. The mean monthly rate of AKI fell 33% following the invention (P<0.001). Completion of fluid balance charts improved; 6 hourly urine output documentation increased from 36% to 68% and running 1 hourly output increased from 80% to 96%. Calculation of total daily fluid balance rose from 12% to 72%, before decreasing to 32%. This highlighted the need for continued encouragement.Improved fluid balance monitoring led to a reduction in the prevalence of AKI in patients admitted to this trauma centre.

Renal Support for Acute Kidney Injury in the Developing World

There is wide variation in the management of acute kidney injury (AKI) and the practice of renal replacement therapy (RRT) around the world. Clinicians in developing countries face additional challenges due to limited resources, reduced availability of trained staff and equipment, cultural and socioeconomic aspects, and administrative and governmental barriers. In this article, we report the consensus recommendations from the 18th Acute Dialysis Quality Initiative conference in Hyderabad, India. We provide the minimal requirements for provision of acute RRT in developing countries, including patient selection, choice of RRT modality and monitoring, transition, and termination of acute RRT. We also discuss areas of uncertainty and propose themes for future research. These recommendations can serve as a foundation for clinicians to implement renal support for AKI in low resource settings.

Nosocomial Clostridium difficile Infection among Patients Over 90 Years Old

Aim: Ageing population trends indicate that the median life expectancy in Japan is increasing. Clostridium difficile infection (CDI) can be a fatal nosocomial infection among the geriatric population. We examined clinical outcome and risk factors associated with death due to CDI among patients >90 years old. Methods: This retrospective observational study was performed to demonstrate the clinical characteristics of Patients >90 years who developed CDI between April 2010 and March 2015 at Tama-Hokubu Medical Center (a 344-bed community tertiary care hospital; average age of inpatients: 72 years). Diagnosis of CDI was confirmed via an enzyme-linked immunosorbent assay using stool sample. Multivariate analysis was performed to determine the independent risk factors associated with death. Results: Twenty-nine patients with CDI confirmed were identified. The mean age was 93 (90–100) years and 37.9% were women. Patients presented with hypertension (37.9%) and diabetes (33%) as underlying diseases, and 93.1% were admitted from long-term care facilities. The median period from admission to onset of CDI was 14 (2– 73) days. The average episodes of diarrhea was 3.96 (1 to 10) times per day. The overall 90-day mortality rate was 34.5%. Multivariate analysis revealed that arrhythmia followed by onset of CDI (Odds Ratio, 8.0; 95% Confidence Interval, 1.37–46.8; P=0.021) was an independent risk factor associated with death. Conclusions: Arrhythmia followed by onset of CDI is a risk factor for death. Strict clinical management, including continuous monitoring of electrolyte and fluid balance and careful observation of patients >90 years old is crucial.

Assessing and documenting fluid balance.

Concerns about inadequate patient hydration and suboptimal monitoring of fluid balance have been documented in recent reports. The Fluid Balance Improvement Project at Central Manchester University Hospitals NHS Foundation Trust was undertaken to identify risk factors influencing hydration and to implement a revised process to manage these risks, resulting in the development of a hydration pathway. This new approach to monitoring patient hydration, together with staff education and support, has resulted in improved compliance with fluid balance monitoring standards, as well as significant improvements in identifying patients at risk of dehydration, and an increase in patients with acute kidney injury commencing appropriate fluid balance monitoring.

Tolvaptan use during hyperhydration in paediatric intracranial lymphoma with SIADH.

SummaryAn 11-year-old boy developed severe syndrome of inappropriate antidiuretic hormone secretion (SIADH) after diagnosis of an intracranial B-cell lymphoma. His sodium levels dropped to 118–120 mmol/L despite 70% fluid restriction. For chemotherapy, he required hyperhydration, which posed a challenge because of severe hyponatraemia. Tolvaptan is an oral, highly selective arginine vasopressin V2-receptor antagonist, which has been licensed in adults for the management of SIADH and has been used in treating paediatric heart failure. Tolvaptan gradually increased sodium levels and allowed liberalisation of fluid intake and hyperhydration. Tolvaptan had profound effects on urinary output in our patient with increases up to 8 mL/kg/h and required close monitoring of fluid balance, frequent sodium measurements and adjustments to intake. After hyperhydration, tolvaptan was stopped, and the lymphoma went into remission with reversal of SIADH. We report one of the first uses of tolvaptan in a child with SIADH, and it was an effective and safe treatment to manage severe SIADH when fluid restriction was not possible or effective. However, meticulous monitoring of fluid balance and sodium levels and adjustments of fluid intake are required to prevent rapid sodium changes.Learning points:Tolvaptan can be used in paediatric patients with SIADH to allow hyperhydration during chemotherapy.Tolvaptan has profound effects on urinary output and meticulous monitoring of fluid balance and sodium levels is therefore warranted.Tolvaptan was well tolerated without significant side effects.

Abstract PR017

Background: Jehovah’s Witnesses (JWs) do not accept blood transfusions of whole blood, although they may accept some blood plasma fractions at their own discretion. Members can specify which allowable fractions and treatments they will personally accept. Though some JWp may accept Normovolemic Hemodilution (NHD) if blood is attached to a return line that is connected to their body, our patient declined that alternative so we proposed Hypervolemic hemodilution (HHD). HHD means infusing extra fluid into the patient. Their circulating blood volume is thus increased, therefore they can afford to lose quite a lot more blood during surgery than they would otherwise. Case Report: 54y-o female, 60kg, with no comorbidity was scheduled to undergo total abdominal hysterectomy. She presented a Hb level of 12g/dl. Her baseline HR was 80 bpm, BP 120/70mmHg and SaO2 99% on room air. Anesthesia was induced with etomidate, fentanyl, cisatracurium, and maintained with sevoflurane, remifentanyle, cisatracurium. After induction we administered slowly 500cc Voluven and 1000cc Physiologic Serum. CAM 1´5-3 needed to keep controlled hypotension with a mean BP of 50-60mmHg. 60minutes after induction when HR was 70bpm, mean BP 55mmHg and SaO2 99%, the patient suffered a sudden ST segment depression in II,III,AVF (2mm) and tachycardia 105bpm. We suspected subendocardial injury caused by a decrease in the Hb level so we proceed to administer diuretics and decreased the CAM of sevofluorane. Results: 30minutes later, with 500ml diuresis and mean BP of 60mmHg, ST segment recovered normality. No increase of CPK & TroponineI were found and the patient had no chest pain after surgery. The patient presented a subendocardial injury due to intraoperative bleeding which was solved with hemoconcentration and decreasing the CAM of sevofluorane with no necessity of nitroglicerine or vasoactive drugs. Conclusions: HHD is an important technique that helps to avoid the need for homologous blood transfusions in JWs patients. We have to take into account the side effects of both hemodilution and hypervolemia: hemodiluting a patient risks acute anemia and hipoxemia. Hypervolemia risks pulmonary and cerebral edema, hyponatremia and congestive heart failure; therefore some relative contraindications for HHD are coronary and cerebral vascular disease, myocardial disfunction, hypertension and coagulopathy. Strict monitoring of fluid balance, diuresis, EKG, Sa02 and invasive blood pressure are mandatory.

Fluid Overload Is Associated With Late Poor Outcomes in Neonates Following Cardiac Surgery.

Acute kidney injury is a severe complication of cardiac surgery associated with increased morbidity and mortality; yet, acute kidney injury classification for neonates remains challenging. We characterized patterns of postoperative fluid overload as a surrogate marker for acute kidney injury and as a risk factor of poor postoperative outcomes in neonates undergoing cardiac surgery. Retrospective cohort study. Single, congenital heart center destination program. Four hundred thirty-five neonates undergoing cardiac surgery with cardiopulmonary bypass from January 2006 through December 2010. None. Demographics, diagnosis, and perioperative clinical variables were collected, including daily weights and serum creatinine levels. A composite poor clinical outcome (death, need for renal replacement therapy or extracorporeal life support within 30 postoperative days) was considered the primary outcome measure. Twenty-one neonates (5%) had a composite poor outcome with 7 (2%) requiring renal replacement therapy, 8 (2%) requiring extracorporeal life support, and 14 (3%) dying between 3 and 30 days post surgery. Neonates with a composite poor outcome had significantly higher maximum fluid overload (> 20%) and were slower to diurese. A receiver-operating characteristic curve determined that fluid overload greater than or equal to 16% and serum creatinine greater than or equal to 0.9 on postoperative day 3 were the optimal cutoffs for significant discrimination on the primary outcome (area under the curve = 0.71 and 0.76, respectively). In multivariable analysis, fluid overload greater than or equal to 16% (adjusted odds ratio = 3.7) and serum creatinine adjusted odds ratio 0.9 (adjusted odds ratio = 6.6) on postoperative day 3 remained an independent risk factor for poor outcome. Fluid overload greater than or equal 16% was also significantly associated with cardiac arrest requiring cardiopulmonary resuscitation, prolonged ICU stay, and chest reexploration. This study highlights the importance of monitoring fluid balance in the neonatal cardiac surgical population and suggests that daily fluid overload, a readily available, noninvasive marker of renal function, may be a sensitive and specific predictor of adverse outcomes.

Fluid Balance Monitoring Accuracy in Intensive Care Units

Introduction: Fluid balance monitoring is a part of the scope of nurses’ practice. The incorrect calculation of fluid balance means that every patient management decision was influenced by inaccurate fluid balance information. Therefore, nurses working in ICUs are responsible and accountable for the accurate recording and calculation of fluid balance when caring for critically ill patients. The aim of the work to examine the accuracy of fluid balance monitoring in critical care units and determine the factors affecting fluid balance monitoring in critical care units. The study design was a descriptive research design. Setting, This study was carried out in two general intensive care units (ICUs) at a selected Hospital in Alexandria- Egypt. Subjects, fluid balance related records for 100 critical care patient and 60 critical care nurses was drawn from the previously mentioned ICUs. Data collection instrument; the tool of this study was “Fluid balance monitoring accuracy in ICUs” This tool combined two parts: “Fluid balance monitoring audit” and “Fluid balance monitoring questionnaire”. Results; 65% of fluid balance recorded in patients’ folders were accurate and 35% were inaccurate. The level of nurses’ knowledge regarding fluid balance monitoring in ICUs was moderately adequate (61.67%) and 71% of nurses had favorable perception regarding fluid balance monitoring in ICUs Inaccuracy of the measuring equipment / continuous intravenous infusions, time management (100%), workload (91.67%) and lack of skills/ training (33.33%) were factors affecting fluid balance monitoring as reported by nurses. Conclusion: Two thirds of the recorded fluid balance was accurate and the inaccurate fluid balance recorded was fluctuating between positive and negative balance. Nurses reported that inaccuracy of the measuring equipment / continuous intravenous infusions, time management, workload, and lack of skills/ training are factors affecting fluid balance monitoring in ICU. Recommendations: For accuracy of fluid balance monitoring in ICU, increase awareness and in-service education should be conducted to improve nurses’ knowledge. Novice nurses should be trained adequately

Vascular leakage in dengue--clinical spectrum and influence of parenteral fluid therapy.

Clinical management of dengue relies on careful monitoring of fluid balance combined with judicious intravenous (IV) fluid therapy. However, in patients with significant vascular leakage, IV fluids may aggravate serosal fluid accumulation and result in respiratory distress. Trained physicians followed suspected dengue cases prospectively at seven hospitals across Asia and Latin America, using a comprehensive case report form that included daily clinical assessment and detailed documentation of parenteral fluid therapy. Applying Cox regression, we evaluated risk factors for the development of shock or respiratory distress with fluid accumulation. Most confirmed dengue patients (1524/1734, 88%) never experienced dengue shock syndrome (DSS). Among those with DSS, 176/210 (84%) had fluid accumulation, and in the majority (83%), this was detectable clinically. Among all cases with clinically detectable fluid accumulation, 179/447 (40%) were diagnosed with shock or respiratory distress. The risk for respiratory distress with fluid accumulation increased significantly as the infused volume over the preceding 24 h increased (hazard ratio 1.18 per 10 ml/kg increase; P < 0.001). Longer duration of IV therapy, use of a fluid bolus in the preceding 24 h, female gender and poor nutrition also constituted independent risk factors. Shock and respiratory distress are relatively rare manifestations of dengue, but some evidence of fluid accumulation is seen in around 50% of cases. IV fluids play a crucial role in management, but they must be administered with caution. Clinically and/or radiologically detectable fluid accumulations have potential as intermediate severity endpoints for therapeutic intervention trials and/or pathogenesis studies.