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Post-ICU admission fluid balance and pediatric septic shock outcomes: a risk-stratified analysis
Kamal Abulebda1, Natalie Z Cvijanovich, Neal J Thomas
11Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH. 2Children's Hospital and Research Center Oakland, Oakland, CA. 3Penn State Hershey Children's Hospital, Hershey, PA. 4Children's Mercy Hospital, Kansas City, MO. 5Children's Hospital of Orange County, Orange, CA. 6Akron Children's Hospital, Akron, OH. 7Nationwide Children's Hospital, Columbus, OH. 8Children's National Medical Center, Washington, DC. 9Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY. 10Miami Children's Hospital, Miami, FL. 11Texas Children's Hospital, Houston, TX. 12CS Mott Children's Hospital at the University of Michigan, Ann Arbor, MI. 13Children's Hospital and Clinics of Minnesota, Minneapolis, MN. 14The Children's Hospital of Philadelphia, Philadelphia, PA. 15St. Christopher's Hospital for Children, Philadelphia, PA. 16Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH. 17Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
Insights
Fluid overload in pediatric septic shock is linked to worse outcomes, but only in low-risk patients. This finding highlights the importance of risk stratification when managing fluid balance in children with septic shock.
Area of Science:
- Pediatric critical care medicine
- Septic shock research
- Fluid management in critical illness
Background:
- Fluid balance is crucial in managing pediatric septic shock.
- Previous studies suggest associations between fluid balance and outcomes, but may be confounded by initial mortality risk.
- Risk stratification is essential for accurate assessment of fluid balance impact.
Purpose of the Study:
- To conduct a risk-stratified analysis of fluid balance and outcomes in pediatric septic shock.
- To investigate the association between post-ICU admission fluid balance and pediatric septic shock outcomes stratified by initial mortality risk.
Main Methods:
- Retrospective analysis of a multicenter pediatric septic shock database.
- Inclusion of 317 children with septic shock across 17 PICUs.
- Stratification into low, intermediate, and high mortality risk categories using a validated biomarker-based tool.
Main Results:
- Increased cumulative positive fluid balance was associated with mortality in the low-risk cohort (OR, 1.035; 95% CI, 1.004-1.066).
- No significant association between fluid balance and mortality was observed in intermediate or high-risk cohorts.
- Fluid intake and positive fluid balance were linked to increased odds of a complicated course in the low-risk cohort only.
Conclusions:
- In pediatric septic shock, increased fluid intake and positive fluid balance post-ICU admission are associated with worse outcomes specifically in patients with low initial mortality risk.
- These associations were not observed in patients with moderate or high initial mortality risk.
- Risk stratification is critical for understanding the impact of fluid management on pediatric septic shock outcomes.
Objective:
Observed associations between fluid balance and septic shock outcomes are likely confounded by initial mortality risk. We conducted a risk-stratified analysis of the association between post-ICU admission fluid balance and pediatric septic shock outcomes.
Design:
Retrospective analysis of an ongoing multicenter pediatric septic shock clinical and biological database.
Setting:
Seventeen PICUs in the United States.
Patients:
Three hundred and seventeen children with septic shock.
Interventions:
None.
Measurements And Main Results:
We stratified subjects into three mortality risk categories (low, intermediate, and high) using a validated biomarker-based stratification tool. Within each category, we assessed three fluid balance variables: total fluid intake/kg/d during the first 24 hours, percent positive fluid balance during the first 24 hours, and cumulative percent positive fluid balance up to 7 days. We used logistic regression to estimate the effect of fluid balance on the odds of 28-day mortality, and on complicated course, which we defined as either death within 28 days or persistence of two or more organ failures at 7 days. There were 40 deaths, and 91 subjects had a complicated course. Increased cumulative percent positive fluid balance was associated with mortality in the low-risk cohort (n = 204; odds ratio, 1.035; 95% CI, 1.004-1.066) but not in the intermediate- and high-risk cohorts. No other associations with mortality were observed. Fluid intake, percent positive fluid balance in the first 24 hours, and cumulative percent positive fluid balance were all associated with increased odds of a complicated course in the low-risk cohort but not in the intermediate- and high-risk cohorts.
Conclusions:
When stratified for mortality risk, increased fluid intake and positive fluid balance after ICU admission are associated with worse outcomes in pediatric septic shock patients with a low initial mortality risk but not in patients at moderate or high mortality risk.
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