Early fluid accumulation in children with shock and ICU mortality: a matched case–control study

Abstract

The presence, severity and duration of early fluid are associated with increased ICU mortality in children admitted to the pediatric ICU in shock states.

Fluid resuscitation of shock in children: what, whence and whither?

“…This volume will certainly have the potential to impact on fluid overload in the PICU, especially if current ACCM-PALS guidelines are followed (see above, 20-200 mL/kg in the first hour of assessment). Thus while the findings of Bhaskar et al [3]-and for that matter all recent PICU fluid studies [12][13][14][15]-are interesting, they are not conclusive. What is needed now, as Bhaskar et al [3] suggest, are RCTs that better assess the impact of early fluid accumulation on outcome.…”

“…As a pediatric critical care community we have often blamed inadequate fluid resuscitation for this finding, a consequence of failing to follow guidelines recommending aggressive fluid resuscitation, which we have seen as ''acute medicine's great triumph for children'' [2]. In an article recently published in Intensive Care Medicine Bhaskar et al [3] bring to our attention the problem of early fluid accumulation in children treated for shock and its association with pediatric intensive care unit (PICU) mortality. As a concept, intolerable excess of fluid and tissue storage by inundation, is not new-Walter Cannon introduced it at the same time as he defined homeostasis [4]-but it is worth reviewing the current article in the context of where we have come from and where we should be going with fluid management.…”

“…Intensive Care Med (2015) 41:1457-1459 DOI 10.1007/s00134-015-3905-z EDITORIAL As shown in a developed world setting by Bhaskar et al [3], in those patients who survive to PICU admission, ongoing enthusiastic fluid resuscitation, along with maintenance fluid administration, leads to fluid overload, which in some cases is massive and potentially harmful. The authors examined, retrospectively, 114 children admitted to their PICU with a variety of shock states and found that early fluid overload (EFO, defined as fluid accumulation of at least 10 % of admission body weight during the initial 3 days of admission) was associated with mortality, even controlling for severity of illness.…”

“…One major limitation of the report by Bhaskar et al [3], which is shared with other PICU studies (Table 1), is the failure to take into account all of the fluid administered to the child, starting with resuscitation in the pre-PICU phase of care. This volume will certainly have the potential to impact on fluid overload in the PICU, especially if current ACCM-PALS guidelines are followed (see above, 20-200 mL/kg in the first hour of assessment).…”

Focus on paediatrics

“…However, recruitment to RCTs may be improved by using pulse oximetry to fractional inspired oxygen ratio as an index of severity [16]. Second, intravenous fluid resuscitation and responsiveness [17,18]; and there may soon be data from the Canadian SQUEEZE (septic shock reversal is quicker in pediatric patients randomized to an early goal directed fluid-sparing strategy versus usual care) and the UK FiSh (Fluids in Shock) studies [19]. Last, non-invasive ventilation [20]; and their may soon be data from the FIRST-line Support for Assistance in Breathing in Children (FIRST-ABC) feasibility study.…”