Implementation of preemptive fluid strategy as a bundle to prevent fluid overload in children with acute respiratory distress syndrome and sepsis

Abstract

BackgroundFluid overload (FO) is associated with unfavorable outcomes in critically ill children. Clinicians are encouraged to avoid FO; however, strategies to avoid FO are not well-described in pediatrics. Our aim was to implement a bundle strategy to prevent FO in children with sepsis and pARDS and to compare the outcomes with a historical cohort.MethodsA quality improvement initiative, known as preemptive fluid strategy (PFS) was implemented to prevent early FO, in a 12-bed general PICU. Infants on mechanical ventilation (MV) fulfilling pARDS and sepsis criteria were prospectively recruited. For comparison, data from a historical cohort from 2015, with the same inclusion and exclusion criteria, was retrospectively reviewed. The PFS bundle consisted of 1. maintenance of intravenous fluids (MIVF) at 50% of requirements; 2. drug volume reduction; 3. dynamic monitoring of preload markers to determine the need for fluid bolus administration; 4. early use of diuretics; and 5. early initiation of enteral feeds. The historical cohort treatment, the standard fluid strategy (SFS), were based on physician preferences. Peak fluid overload (PFO) was the primary outcome. PFO was defined as the highest FO during the first 72 h. FO was calculated as (cumulative fluid input – cumulative output)/kg*100. Fluid input/output were registered every 12 h for 72 h.ResultsThirty-seven patients were included in the PFS group (54% male, 6 mo (IQR 2,11)) and 39 with SFS (64%male, 3 mo (IQR1,7)). PFO was lower in PFS (6.31% [IQR4.4–10]) compared to SFS (12% [IQR8.4–15.8]). FO was lower in PFS compared to CFS as early as 12 h after admission [2.4(1.4,3.7) v/s 4.3(1.5,5.5), p < 0.01] and maintained during the study. These differences were due to less fluid input (MIVF and fluid boluses). There were no differences in the renal function test. PRBC requirements were lower during the first 24 h in the PFS (5%) compared to SFS (28%, p < 0.05). MV duration was 81 h (58,98) in PFS and 118 h (85154) in SFS(p < 0.05). PICU LOS in PFS was 5 (4, 7) and in SFS was 8 (6, 10) days.ConclusionImplementation of a bundle to prevent FO in children on MV with pARDS and sepsis resulted in less PFO. We observed a decrease in MV duration and PICU LOS. Future studies are needed to address if PFS might have a positive impact on health outcomes.Electronic supplementary materialThe online version of this article (10.1186/s12887-018-1188-6) contains supplementary material, which is available to authorized users.

Intravenous Fluid Prescription Practices in Critically Ill Children: A Shift in Focus from Natremia to Chloremia?

“…27 Fluid creep has previously been observed in critically ill infants and children 4 ; however, little emphasis has been placed on the significance of its contribution given the current research focus on restrictive resuscitation and maintenance fluid strategies. 28,29 The majority of patients in this study developed hyperchloremia within the first 72 hours of PICU admission. Hyperchloremia and HCMA have not been well studied in the general PICU population.…”

Less Is More?—A Feasibility Study of Fluid Strategy in Critically Ill Children With Acute Respiratory Tract Infection

“…Although we cannot draw conclusions of the effect of these specific fluid strategies for other patient populations based on this study, it could be hypothesized that patients with sepsis or severe acute respiratory distress syndrome and therefore more risk of capillary leak and/or AKI, will show a different response in terms of fluid balance upon use of similar fluid strategies. A recent implementation study in children with acute respiratory distress syndrome or sepsis has shown that the combination of fluid restriction, drug volume reduction, dynamic monitoring of preload markers to determine the need for fluid bolus administration, early use of diuretics and early initiation of enteral feeds decreased fluid overload and mechanical ventilation duration (28). However, this study was a retrospective cohort and a future RCT in the future might provide more robust evidence.…”

Impact of fluid overload and infection on respiratory adverse event development during induction therapy for childhood acute myeloid leukemia

“…FO is an iatrogenic and modifiable risk factor, yet the construct of FO is not included in the NCI CTCAE versions 4.0 or 5.0. Furthermore, FO is not consistently described in the pediatric literature, with definitions typically relating to daily fluid balance, percent weight change from baseline, and physical exam findings. At initial presentation, pediatric acute leukemia patients have historically received hyperhydration in an effort to prevent hyperuricemia‐induced renal injury and leukostasis complications, a practice that may place patients at risk for iatrogenic FO, pulmonary edema, and preventable respiratory AEs.…”

“…Lung ultrasound is an inexpensive, low risk, highly accessible method shown to be effective in quantifying extravascular lung volume in patients at risk for pulmonary edema. 45,46 Conservative, net-neutral, fluid balance strategies have been successful in a number of pediatric patient populations, including stem cell transplant recipients, 35 ARDS patients, 34,43 and post-resuscitation sepsis patients. 34,43 In a meta-analysis of 11 randomized trials incorporating conservative versus standard/liberal fluid strategies in the post-resuscitative care of adults and children with ARDS, sepsis, or systemic inflammatory response syndrome, a conservative strategy was associated with increased ventilator-free days and decreased ICU stay.…”

“…45,46 Conservative, net-neutral, fluid balance strategies have been successful in a number of pediatric patient populations, including stem cell transplant recipients, 35 ARDS patients, 34,43 and post-resuscitation sepsis patients. 34,43 In a meta-analysis of 11 randomized trials incorporating conservative versus standard/liberal fluid strategies in the post-resuscitative care of adults and children with ARDS, sepsis, or systemic inflammatory response syndrome, a conservative strategy was associated with increased ventilator-free days and decreased ICU stay. 34 The Fluid and Catheter Treatment Trial (FACTT), a multicenter randomized controlled trial that compared use of liberal versus conservative fluid management in patients with ARDS, showed a conservative fluid balance significantly improved survival and ventilator-free days.…”