Adverse Outcomes due to Aggressive Fluid Resuscitation in Children: A Prospective Observational Study

Abstract

Fluid management has a major impact on the duration, severity, and outcome of critically ill children. The aim of this study was to examine the relationship between cumulative fluid overload (CFO) with mortality and morbidity in critically ill children. This was a prospective observational study wherein children (1 month–16 years) who were critically ill (with shock requiring inotropes and/or mechanically ventilated) were enrolled. CFO was defined as the sum of daily fluid balances. Daily fluid balance was calculated as a difference between fluid intake (oral and intravenous) and output (urine output, discharge from nasogastric tube) in 24 hours. Percentage of fluid overload (FO) (PFO) was calculated as the ratio of CFO with weight at admission in kilogram. The CFO and PFO at 24, 48, 72 hours and at 7 days or end of PICU stay were calculated. A total of 291 children (244 survivors and 47 non-survivors; 47% males) were included in the final analysis. A higher mortality was observed in children with higher PFO (>20% FO: 45.8% mortality vs. 14.5% < 10% FO, p < 0.01) and CFO (10.97 ± 6.4 mL/kg in survivors vs. 13.95 ± 9.6 mL/kg in non-survivors; p = 0.022) at 72 hours. A 1% increase in fluid overload was associated with 6% and 4% increase in mortality at 72 hours and 7 days, respectively. Similarly, the impact of every 1% increase in fluid overload on both ventilation (yes/no) and acute kidney injury (AKI; yes/no) were found to be significant for both parameters at 72 hours, but only AKI had significant correlation on seventh day. In the multivariate stepwise Cox's proportional hazard model for PICU stay and hospital stay, 3% (p < 0.05) and 2% (p > 0.05) increase were found for every 1% increase in fluid overload, respectively. Oxygenation index is also associated with fluid overload with the adjusted model estimated 0.27 units (95% confidence interval: 0.18–0.36) increase per 1% increase in fluid overload. FO was associated with increased mortality and morbidity in critically ill children.

Keywords

critically ill - intensive care units - pediatric - critical care - fluid - therapy

• References

• 1 Brandstrup B, Tønnesen H, Beier-Holgersen R. , et al; Danish Study Group on Perioperative Fluid Therapy. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003; 238 (05) 641-648
• 2 Schuller D, Mitchell JP, Calandrino FS, Schuster DP. Fluid balance during pulmonary edema. Is fluid gain a marker or a cause of poor outcome?. Chest 1991; 100 (04) 1068-1075
• 3 Foland JA, Fortenberry JD, Warshaw BL. , et al. Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 2004; 32 (08) 1771-1776
• 4 Sakr Y, Vincent JL, Reinhart K. , et al; Sepsis Occurence in Acutely Ill Patients Investigators. High tidal volume and positive fluid balance are associated with worse outcome in acute lung injury. Chest 2005; 128 (05) 3098-3108
• 5 Goldstein SL, Somers MJ, Baum MA. , et al. Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 2005; 67 (02) 653-658
• 6 Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. PediatrCrit Care Med 2015; 16 (05) 428-439
• 7 Kidney Disease. Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group.KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Inte Suppl 2012; 2: 8-9
• 8 Zhang Z. Univariate description and bivariate statistical inference: the first step delving into data. Ann Transl Med 2016; 4 (05) 91
• 9 Zhang Z. Model building strategy for logistic regression: purposeful selection. Ann Transl Med 2016; 4 (06) 111
• 10 Arikan AA, Zappitelli M, Goldstein SL, Naipaul A, Jefferson LS, Loftis LL. Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med 2012; 13 (03) 253-258
• 11 Murphy CV, Schramm GE, Doherty JA. , et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest 2009; 136 (01) 102-109
• 12 Trachsel D, McCrindle BW, Nakagawa S, Bohn D. Oxygenation index predicts outcome in children with acute hypoxemic respiratory failure. Am J Respir Crit Care Med 2005; 172 (02) 206-211
• 13 Erickson S, Schibler A, Numa A. , et al; Paediatric Study Group; Australian and New Zealand Intensive Care Society. Acute lung injury in pediatric intensive care in Australia and New Zealand: a prospective, multicenter, observational study. Pediatr Crit Care Med 2007; 8 (04) 317-323
• 14 Subhedar NV, Tan AT, Sweeney EM, Shaw NJ. A comparison of indices of respiratory failure in ventilated preterm infants. Arch Dis Child Fetal Neonatal Ed 2000; 83 (02) F97-F100
• 15 Payen D, de Pont AC, Sakr Y, Spies C, Reinhart K, Vincent JL. ; Sepsis Occurrence in Acutely Ill Patients (SOAP) Investigators. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 2008; 12 (03) R74