Profile of Fluid Exposure and Recognition of Fluid Overload in Critically Ill Children

Abstract

Objectives: Fluid overload is common in the PICU and has been associated with increased morbidity and mortality. It remains unclear whether fluid overload is a surrogate marker for severity of illness and need for increased support, an iatrogenic modifiable risk factor, or a sign of oliguria. The proportions of various fluid intake contributing to fluid overload and its recognition have not been adequately examined. We aimed to: 1) describe the types and amounts of fluid exposure in the PICU and 2) identify the clinicians’ recognition of fluid overload. Setting: Noncardiac PICU in a quaternary care hospital. Patients: Pediatric patients admitted for more than 24 hours. Design: Prospective observational study over 28 days. Interventions: Data were collected on the amount and type of fluid exposure—resuscitative boluses, blood products, enteral intake, parenteral nutrition (total parenteral nutrition), or modifiable fluids (IV fluids and medications) indexed to the patients’ admission body surface area on days 1 and 3. Charts of patients admitted for 3 days who developed 15% fluid overload were reviewed to assess clinicians’ recognition of fluid overload. Measurements and Main Results: One hundred two patients were included. Day 1 median fluid exposure was 2,318 mL/m2 (1,831–3,037 mL/m2; 1,646 mL/m2 [1,296–2,086 mL/m2] modifiable fluids). Forty-seven patients (46%) received fluid boluses, and 16 (16%) received blood products. Day 3 median fluid exposure was 2,233 mL/m2 (1,904–2,556 mL/m2; 750 mL/m2 [375–1,816 mL/m2] modifiable fluids). Of the 54 patients, one patient (1.9%) received a fluid bolus and two (3.7%) received blood products. In our cohort, 47 of 54 (87%) had fluid exposure greater than 1,600 mL/m2 on day 3. Fluid overload was not recognized by the clinicians in 30% of the patients who developed more than 15% fluid overload. Conclusions: Although resuscitation fluids contributed more to fluid exposure on day 1 compared with day 3, fluid exposure frequently exceeded maintenance requirements on day 3. Fluid overload was not always recognized by PICU practitioners. Further studies to correlate modifiable fluid exposure to fluid overload and explore modifiable practice improvement opportunities are needed.

Association Between Hyponatremia and Maintenance Intravenous Solutions in Critically Ill Children: A Retrospective Observational Study

“…The median length of hospital stay of all the included patients was 17 days (IQR 9-34). The group receiving hypotonic solutions had a longer stay (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38) than the group receiving isotonic solutions (14 days IQR 8-30) (p = 0.000). The use of hypotonic solutions was associated with 8 more days of total hospital stay (difference in means 8, 95% CI 2.67, 13.3, p = 0.001) (Figure 2A).…”

Non-resuscitation fluid in excess of hydration requirements is associated with higher mortality in critically ill children

“…Pediatric studies, although smaller in size, have demonstrated a similar trend in the volume burden associated with maintenance fluids. 14,15 Maintenance fluids are primarily used to prevent dehydration and to provide a source of glucose to prevent starvation ketosis. However, our data demonstrate that maintenance fluids are frequently given to patients with fluid in excess of hydration requirements and this practice may represent iatrogenic harm.…”

“…Studies in children have also demonstrated that a large fluid burden may result from non-resuscitation fluids, especially maintenance fluids. 14,15 Recently, Al-Lawati et al 15 demonstrated that fluid exposure frequently exceeded hydration requirements on day 3 of pediatric intensive care unit (PICU) admission. However, the degree to which non-resuscitation fluid in excess of hydration requirements impacts clinical outcomes has not been previously studied.…”

Early restrictive fluid resuscitation has no clinical advantage in experimental severe pediatric acute respiratory distress syndrome

“…Remarkably, the sheep receiving fluid boluses had a higher need of vasopressor support, indicating only a temporary effect of fluid resuscitation. Nevertheless, this study does not report on fluid maintenance therapy, which also significantly impacts hemodynamic response and fluid accumulation (14,15). Indeed, a recent clinical study shows that the timing of peak fluid overload is an important indicator of adverse outcome (8).…”

“…Besides fluid loading during the resuscitation phase, ongoing intravenous fluid administration during the maintenance phase strongly contributes to fluid overload (14,15). As such, early fluid restriction in both resuscitation practice and in the maintenance phase of (P)ARDS may prove beneficial.…”