Current Practice of Fluid Maintenance and Replacement Therapy in Mechanically Ventilated Critically Ill Children: A European Survey

Abstract

Appropriate fluid management in mechanically ventilated critically ill children remains an important challenge and topic of active discussion in pediatric intensive care medicine. An increasing number of studies show an association between a positive fluid balance or fluid overload and adverse outcomes. However, to date, no international consensus regarding fluid management or removal strategies exists. The aim of this study was to obtain more insight into the current clinical practice of fluid therapy in mechanically ventilated critically ill children. On behalf of the section of cardiovascular dynamics of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) we conducted an anonymous survey among pediatric intensive care unit (PICU) specialists in Europe regarding fluid overload and management. A total of 107 study participants responded to the survey. The vast majority of respondents considers fluid overload to be a common phenomenon in mechanically ventilated children and believes this complication is associated with adverse outcomes, such as mortality and duration of respiratory support. Yet, only 75% of the respondents administers a lower volume of fluids (reduction of 20% of normal intake) to mechanically ventilated critically ill children on admission. During PICU stay, a cumulative fluid balance of more than 5% is considered to be an indication to reduce fluid intake and start diuretic treatment in most respondents. Next to fluid balance calculation, the occurrence of peripheral and/or pulmonary edema (as assessed including by chest radiograph and lung ultrasound) was considered an important clinical sign of fluid overload entailing further therapeutic action. In conclusion, fluid overload in mechanically ventilated critically ill children is considered an important problem among PICU specialists, but there is great heterogeneity in the current clinical practice to avoid this complication. We identify a great need for further prospective and randomized investigation of the effects of (restrictive) fluid strategies in the PICU.

A Clinical Score for Quantifying Edema in Mechanically Ventilated Children With Congenital Heart Disease in Intensive Care

“…A retrospective study, of 85 children post-cardiac surgery, reported a relationship between fluid accumulation, edema, and duration of MV (21); however, edema was measured by a radiologist’s assessment of chest wall thickness rather than by clinical assessment of the patient. Pediatric intensivists consider edema to be an important factor in fluid management (22) despite a lack of clinical tools to quantify it.…”

Fluid Overload in Pediatric Univentricular Patients Undergoing Fontan Completion

“…There is no consensus about the initiation of restrictive fluid management after both adult and pediatric cardiac surgery because there have been no randomized controlled trials [16]. In critically ill pediatric patients, randomized clinical trials do not exist [17][18][19]. The above-discussed measures in preventing FO need to be validated in well-designed prospective studies.…”

Evaluating fluid overload in critically ill children

“…This makes fluid overload one of the most frequent complications encountered in the pediatric intensive care unit (PICU). In a recent survey by the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) virtually all of the 107 participating PICU clinicians considered fluid overload to be a major unmet medical health problem [5]. Recently, the Australian and New Zealand Intensive Care Society Paediatric Study Group considered studies focused on restrictive fluid therapy even a top research priority [6].…”