Fluid therapy in mechanically ventilated critically ill children: the sodium, chloride and water burden of fluid creep

Abstract

Background: Fluid therapy is a cornerstone of pediatric intensive care medicine. We aimed at quantifying the load of water, sodium and chloride due to different fluid indications in our pediatric intensive care unit (PICU). We were particularly interested in the role of fluid creep, i.e. fluid administered mainly as the vehicle for drugs, and the association between sodium load and water balance. Methods: Critically ill children aged ≤3 years and invasively ventilated for ≥48 h between 2016 and 2019 in a single tertiary center PICU were retrospectively enrolled. Need for renal replacement therapy, plasmapheresis or parenteral nutrition constituted exclusion criteria. Quantity, quality and indication of fluids administered intravenously or enterally, urinary output and fluid balance were recorded for the first 48 h following intubation. Concentrations of sodium and chloride provided by the manufacturers were used to compute the electrolyte load. Results: Forty-three patients (median 7 months (IQR 3-15)) were enrolled. Patients received 1004 ± 284 ml of water daily (153 ± 36 ml/kg/day), mainly due to enteral (39%), creep (34%) and maintenance (24%) fluids. Patients received 14.4 ± 4.8 mEq/kg/day of sodium and 13.6 ± 4.7 mEq/kg/day of chloride, respectively. The majority of sodium and chloride derived from fluid creep (56 and 58%). Daily fluid balance was 417 ± 221 ml (64 ± 30 ml/kg/day) and was associated with total sodium intake (r 2 = 0.49, p < 0.001). Conclusions: Critically ill children are exposed, especially in the acute phase, to extremely high loads of water, sodium and chloride, possibly contributing to edema development. Fluid creep is quantitatively the most relevant fluid in the PICU and future research efforts should address this topic in order to reduce the inadvertent water and electrolyte burden and improve the quality of care of critically ill children.

Management and outcomes of acute post-streptococcal glomerulonephritis in children

“…Patients who present with generalized edema due to acute kidney injury or acute glomerulonephritis due to APSGN may benefit from sodium restriction[ 20 ]. A sodium-restricted diet between 1 and 2 mEq/kg·d is recommended for the reduction of edema and positive natriuresis[ 21 ]. Patients who are compliant with Na + restriction will have self-limiting fluid restriction[ 21 ].…”

“…A sodium-restricted diet between 1 and 2 mEq/kg·d is recommended for the reduction of edema and positive natriuresis[ 21 ]. Patients who are compliant with Na + restriction will have self-limiting fluid restriction[ 21 ]. However, patients with severe edema may be treated with fluid restriction to two-thirds of maintenance or half or less of urine output once a brisk diuresis is achieved[ 21 , 22 ].…”

“…Patients who are compliant with Na + restriction will have self-limiting fluid restriction[ 21 ]. However, patients with severe edema may be treated with fluid restriction to two-thirds of maintenance or half or less of urine output once a brisk diuresis is achieved[ 21 , 22 ]. Patients who are on fluid restriction should have close monitoring of fluid input and output, serum electrolytes, and vital signs[ 21 ].…”

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

“…Restricting the amount of fluids is a daily clinical challenge, particularly in critically ill children undergoing invasive mechanical ventilation. Specifically, because the administration of fluid is necessary to provide hemodynamic support and to ensure appropriate caloric/protein intake while at the same time it functions as a vehicle for drug delivery (fluid creep) ( 5 , 6 ). As a result, a positive (cumulative) fluid balance and the formation of edema are very common in these children ( 3 , 4 , 7 , 8 ).…”

A burden of fluid, sodium, and chloride due to intravenous fluid therapy in patients with respiratory support: a post-hoc analysis of a multicenter cohort study

“…The prevalence of fluids administered as drug diluents and for the maintenance of catheter patency, so-called fluid creep, has recently been investigated [ 2 – 4 , 20 , 21 ]. Fluid creep is also associated with the burden of fluid, sodium, and chloride.…”