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

Abstract

BACKGROUND: Large volumes of non-resuscitation fluids are often administered to critically ill children. We hypothesize that excess maintenance fluid is a significant contributor to non-resuscitation fluid and that non-resuscitation fluid administered beyond hydration requirements is associated with worse clinical outcomes in critically ill children. METHODS: We evaluated all patients admitted to two large urban pediatric intensive care units (PICU) between January 2010-August 2016 and January 2010-August 2018, respectively, who survived and remained in the hospital for at least 3 days following PICU admission. The primary outcome was in-hospital mortality. Association of excess fluid with outcomes was adjusted for confounders (age, Pediatric Risk of Mortality III score, study site, day 3 acute kidney injury, PICU era, resuscitation volume, and volume output) using multivariable regression. RESULTS: We evaluated 14,483 patients; 52% received non-resuscitation fluid in excess of hydration requirements. Nonresuscitation fluid in excess of hydration requirements was associated with higher in-hospital mortality after adjustment for confounders (adjusted odds ratio 1.01 per 10 mL/kg in excess fluid, 95% confidence interval: 1.002-1.02). CONCLUSIONS: Non-resuscitation fluid in excess of hydration requirements is associated with increased mortality in critically ill children. Excess maintenance fluid is a modifiable contributor to this fluid volume. Strategies to reduce excess maintenance fluids warrant further study.

Variability in Clinician Awareness of Intravenous Fluid Administration in Critical Illness: A Prospective Cohort Study

“…The most common reason for admission was respiratory failure or distress (76/259, 29%) and postoperative monitoring and support (64/259, 25%). The median PICU day on which providers estimated fluid administration was 8 (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20).…”

“…Previous studies have demonstrated that patients often receive fluids well beyond estimated hydration needs, but due to their retrospective design, have failed to identify whether clinicians actively prescribed more fluids than needed. 8,9,[22][23][24] Taken together, these data suggest that clinicians are generally unaware of how much fluid has been prescribed to their patients and further study into modifying prescribing behavior may impact care to patients at the bedside. Clinician accuracy varied by clinician role in the PICU in this study.…”

“…7 Consequently, prescribing behavior of IV fluids is variable, and more than half of critically ill children receive fluids beyond hydration needs. 8 9 10 11 12 13…”

“…and more than half of critically ill children receive fluids beyond hydration needs. [8][9][10][11][12][13] Pediatric intensive care clinicians recognize the negative consequences of fluid overload, 13 but they fail to address fluid overload in more than one in three critically ill children. 9 In existing retrospective studies, it is difficult to discern if failure to change care when fluid overload is present is due to active medical decision-making or passive underrecognition of the amount of fluid patients are receiving day to day.…”

Multiple Organ Dysfunction Interactions in Critically Ill Children

“…Another high-risk organ dysfunction interaction in our cohort, respiratory and renal dysfunction, has been described in critically ill children, particularly in the context of fluid overload. Existing literature has linked fluid overload with respiratory failure (particularly in the form of increased ventilator days) and mortality ( 21 , 22 ).…”