, et al
Fluid accumulation in critically ill children
Crit Care Med.
; doi:

Investigators from the University of Alberta, Edmonton, Canada, and Children’s Healthcare of Atlanta, GA, conducted a retrospective study to assess the association of fluid overload with adverse outcomes in critically ill children. Study participants were patients 1 month to 17 years old admitted to 1 of 3 pediatric ICUs (PICUs) in the province of Alberta, Canada, in 2015. Data on these children were abstracted from “eCritical Alberta,” a bedside clinical information system used by the PICUs, and included age, weight, diagnoses, surgeries, laboratory data, use of mechanical ventilation, hourly fluid intake and output from all sources, and disposition (discharge from PICU or death). Severity of illness at PICU admission was classified using the pediatric index of mortality 3 (PIM3) score calculated for each participant. Fluid overload percentage (FO%) was determined daily during the first 10 days of the PICU stay for a study patient as (fluid intake – fluid output)/weight. Several measures of FO% were calculated, including daily cumulative FO% and peak FO% (maximal cumulative FO%, measured both continuously and categorically as > 5%, > 10%, > 15%, and > 20%).

The primary study outcome was PICU mortality. Secondary outcomes included major adverse kidney events (MAKE), a composite index that included death from any cause, need for renal replacement therapy or persistent serum creatinine that was > 2-fold the value on admission, duration of mechanical ventilation, and length of PICU stay. Multivariate regression was used to assess the association between markers of fluid overload and these outcomes after controlling for confounders.

Data were analyzed on 1,017 children with a median age of 24 months; 42.4% were treated with mechanical ventilation, and 22.5% received vasoactive support. Peak FO% was > 5% in 56.4% of study participants and > 20% in 9.1%. A total of 32 children (3.1%) died during their PICU stay. After adjusting for confounders, PICU mortality was independently associated with peak FO% (P = .001); every 1% increase in FO% was associated with a 5% greater odds of death (odds ratio [OR] 1.05; 95% CI, 1.02, 1.09). The risk of PICU mortality in children with >20% peak FO% was almost 3-fold higher than in those with lower peak FO% (OR 2.97; 95% CI, 1.11, 7.97). There were 53 patients who developed MAKE. The risk of MAKE was 3-fold higher in children with peak FO% > 15% than in those with less fluid overload (OR 3.11; 95% CI, 1.46, 6.65). Among survivors, peak FO% also was significantly associated with longer duration of mechanical ventilation and longer PICU stay.

The authors conclude that fluid overload in children admitted to a PICU was associated with an increased risk for mortality and morbidity.

Dr Bratton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use...

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