Impact of the Magnitude and Timing of Fluid Overload on Outcomes in Critically Ill Children: A Report From the Multicenter International Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) Study

Selewski, David T.; Gist, Katja M.; Basu, Rajit K.; Goldstein, Stuart L.; Zappitelli, Michael; Soranno, Danielle E.; Mammen, Cherry; Sutherland, Scott M.; Askenazi, David; Ricci, Zaccaria; Akcan-Arikan, Ayse; Gorga, Stephen M; Gillespie, Scott; Woroniecki, Robert

doi:10.1097/ccm.0000000000005791

Cited by 25 publications

(17 citation statements)

References 38 publications

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“…Finally, common to such large epidemiological studies in children in intensive care is the steady attrition due to early intensive care discharge for large proportions of children. In the study by Selewski et al (1), only 40% of children remained in intensive care by day 3 suggesting most children had low illness severity. Furthermore, only 31% received mechanical ventilation.…”

Section: To the Editormentioning

confidence: 97%

“…To the I n an international, multicentre study of over 5,000 children and young adults, Selewski et al (1) report the epidemiology and adverse outcomes associated with thresholds of fluid accumulation in terms of magnitude and timing. They found that thresholds of fluid accumulation of 5% and 10% were associated with important adverse outcomes.…”

Section: E169mentioning

confidence: 99%

“…Pediatric studies will need to identify populations at highest risk of harm if trials of fluid restriction are to be performed. W e appreciate the opportunity to respond to Gelbart et al (1), who astutely pointed out that not all levels of positive fluid balance (FB) are pathologic, and perhaps the associations with outcomes are driven by extremes of pathologic positive FB. Gelbart et al ( 1) also suggest that using defined thresholds may put patients at undue harm because the wrong treatment strategy may be applied.…”

Section: E169mentioning

confidence: 99%

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Fluid Accumulation in Children

Gelbart

Bellomo

2023

Critical Care Medicine

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Section: To the Editormentioning

confidence: 97%

Section: E169mentioning

confidence: 99%

Section: E169mentioning

confidence: 99%

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Fluid Accumulation in Children

Gelbart

Bellomo

2023

Critical Care Medicine

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“…However, uid shifts over the course of disease result in extravascular uid accumulation, consequent hypoxemia, and organ dysfunction(s). (3) Persistence of a positive uid balance (PFB) has been independently associated with poor clinical outcomes among patients with sepsis (4)(5)(6)(7)(8)(9). Complicating matters further, patients may develop sepsis associated acute kidney injury (SA-AKI) and oliguria.…”

Section: Introductionmentioning

confidence: 99%

Revisiting post-ICU admission fluid balance across pediatric sepsis mortality risk strata: A secondary analyses from a prospective observational cohort study.

Atreya

Cvijanovich

Fitzgerald

et al. 2023

Preprint

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Introduction: Post-ICU admission cumulative positive fluid balance (PFB) is associated with increased mortality among critically ill patients. We sought to test whether this risk varied across biomarker-based risk strata upon adjusting for illness severity, presence of severe acute kidney injury (AKI), and use of renal replacement therapy (CRRT) in pediatric septic shock. Design: Ongoing multi-center prospective observational cohort. Setting: Thirteen pediatric ICUs in the United States (2003–2023). Patients: Six hundred and eighty-one children with septic shock. Interventions: None. Measurements and Main Results: Cumulative percent positive fluid balance between day 1–7 (Day 1–7%PFB) was determined. Primary outcome of interest was complicated course defined as death or persistence of ≥ 2 organ dysfunctions by day 7. PERSEVERE-II biomarkers were used to assign mortality probability and categorize patients into high (n = 91), intermediate (n = 134), and low (n = 456) mortality risk strata. Cox proportional hazard regression models with adjustment for PERSEVERE-II mortality probability, presence of sepsis associated acute kidney injury (SA-AKI) on Day 3, and any use of CRRT, demonstrated that time-dependent variable Day 1–7%PFB was independently associated with increased hazard of complicated course in the cohort. Risk stratified analyses revealed that each 10% increase in Day 1–7%PFB was independently associated with increased hazard of complicated course among patients with high mortality risk strata (adj HR of 1.24 (95%CI: 1.08–1.42), p = 0.002), but not among those categorized as intermediate- or low- mortality risk. Conclusions: Our data demonstrate the independent influence of cumulative %PFB on the risk of complicated course. Contrary to our previous report, this risk was largely driven by patients categorized as having a high-mortality risk based on PERSEVERE-II biomarkers. Further research is necessary to determine whether this subset of patients may benefit from targeted deployment of restrictive fluid management or early initiation of de-escalation therapies upon resolution of shock.

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“…Our study uniquely determines the specific impact of phase of illness by evaluating the timing (end of ICU days 1 and 2), in conjunction with FB threshold (5% and 10%), of when the transition occurs from positive FB to FO (5). This adds the element of timing to describe the transition of positive FB to the pathologic state of FO.…”

mentioning

confidence: 99%