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THE IMPACT OF FIXED CONCENTRATIONS SEDATION INFUSIONS ON FLUID OVERLOAD IN CRITICALLY ILL CHILDREN
Adam Sutherland1, Elizabeth Jemmett2, Stephen Playfor2
1Central Manchester University Hospitals NHS Foundation Trust.
Insights
Standardized drug concentrations significantly reduce fluid overload in critically ill children. This approach is particularly beneficial for infants, decreasing fluid administration by over 68% and mitigating risks associated with fluid overload.
Area of Science:
- Pediatric Critical Care Medicine
- Clinical Pharmacy
- Nephrology
Background:
- Fluid overload, defined as 10% at 48 hours, is linked to morbidity in critically ill children, especially infants.
- Contributing factors include fluid resuscitation, acute kidney injury, and intravenous drug administration.
- Traditional weight-based drug infusions can lead to large volumes, complicating fluid management.
Purpose of the Study:
- To evaluate the impact of standardized drug concentrations on fluid overload in a pediatric intensive care unit (PICU).
- To compare fluid volumes administered via standardized concentrations versus traditional weight-based infusions.
Main Methods:
- Prospective documentation of sedation infusion administration in critically ill children.
- Calculation and comparison of infusion volumes (ml/kg/day) for different weight groups using standardized versus weight-based concentrations.
Main Results:
- Overall drug volumes were reduced by 50.3% (5.19 ml/kg to 2.65 ml/kg) with standardized concentrations.
- The greatest volume reduction (68%) was observed in the smallest patients (0-5 kg).
- While midazolam volumes increased in larger patients (>20 kg), the overall fluid burden was not significantly impacted.
Conclusions:
- Weight-based sedation infusions contribute to fluid overload morbidity, particularly in infants.
- Standardized concentrations drastically reduce fluid administration in infants, from 16.7 ml/kg/day to 5.36 ml/kg/day.
- Implementing standardized concentrations is a key strategy to reduce fluid overload and associated complications in pediatric intensive care.
Introduction:
Fluid overload of 10% at 48 hrs (100 ml/kg additional fluid) is strongly associated with morbidity in critically ill children.1 Contributors include fluid resuscitation, acute kidney injury, and administration of intravenous drugs. Acute Kidney Injury has been observed to be more prevalent in infants.2 Drug infusions are historically prepared according to bodyweight to run at large volumes to facilitate end-of-bed calculation and administration. We report the impact of using standardised concentrations on fluid overload in critically ill children in a tertiary general PICU.
Methods:
Administration of sedation infusions was prospectively documented using purposive sampling until a population-representative sample for age and weight was obtained. Infusion volumes were calculated in ml/kg/day for different weight groups - 0-5 kg, 5-20 kg and <20 kg - and compared with equivalent volumes for weight-based infusions.
Results:
33 patients received sedation infusions over a 5 week period. Overall drug volumes were reduced by 50.3%(41.3 to 58.7%) from 5.19 ml/kg to 2.65 ml/kg. Greatest reduction was seen in the smallest patients (total reduction 68% (16.72 ml/kg vs 5.36 ml/kg). Midazolam volumes in patients >20 kg was observed to increase (0.75 ml/kg vs. 0.95 ml/kg) but this did not have an impact on overall fluid burden.
Conclusions:
Weight based sedation infusions may contribute to fluid overload related morbidity, especially in infants. An infant on morphine and midazolam at standard doses (20 mcg/kg/hr and 90 mcg/kg/hr respectively) will receive 16.7 ml/kg/day (33.4% of critical fluid overload at 48 hrs) when using weight-based infusions. Using standard concentrations reduces this volume to 5.36 ml/kg/day (10.7% of critical fluid overload at 48 hrs).
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