Self-Reported Management of IV Fluids and Fluid Accumulation in Children With Acute Respiratory Failure
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Published on: March 8, 2024
Amanda B Hassinger1,2, Stacey L Valentine3,4
1Department of Pediatrics, University of Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY.
Insights
Pediatric intensivists recognize fluid overload worsens outcomes in pediatric acute respiratory distress syndrome. They prioritize intake/output monitoring over central venous pressure for fluid management decisions.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Respiratory Medicine
- Fluid Management in Pediatrics
Background:
- Fluid overload is linked to increased morbidity in critically ill children, particularly those with respiratory issues.
- Current clinical practice regarding intravenous fluid management in pediatric acute respiratory distress syndrome (PARDS) is not well-documented.
Purpose of the Study:
- To describe current intravenous fluid management strategies employed by pediatric intensivists in cases of pediatric acute respiratory distress syndrome.
- To assess if recent evidence on fluid overload has influenced clinical practice in PARDS management.
Main Methods:
- A multinational, cross-sectional electronic survey was distributed to pediatric intensivists.
- The survey collected data on fluid management practices, including maintenance fluid, resuscitation, and monitoring methods.
Main Results:
- Most respondents (96%) use the "4-2-1" rule for maintenance IV fluids.
- Normal saline in 10 mL/kg aliquots or fluid challenges is common for resuscitation (77%).
- Intake/output documentation is favored over central venous pressure for guiding fluid management, with a 10% fluid overload threshold for intervention.
Conclusions:
- Pediatric intensivists acknowledge the importance of addressing 10% fluid overload in PARDS.
- Fluid management decisions are primarily based on intake/output data.
- These findings have implications for designing future interventional trials in PARDS.
Objectives:
Observational studies have shown that fluid overload is independently associated with increased morbidity in critically ill children, especially with respiratory pathology. It is unknown if recent evidence has influenced clinical practice. We sought to describe current IV fluid management in pediatric acute respiratory distress syndrome.
Design:
Multinational, cross-sectional electronic survey.
Setting:
Pediatric Acute Lung Injury and Sepsis Investigators Network.
Subjects:
Pediatric intensivists.
Interventions:
None.
Measurements And Main Results:
One-hundred fifty-four respondents (43% response rate) had a median 10 years of experience (Q1-Q3, 4-17.8), in ICUs with a median 24 beds (18-36), where 86% provided extracorporeal membrane oxygenation. For maintenance IV fluid, 96% used the "4-2-1" rule to determine rate, and 59% used dextrose with normal saline for content. For fluid resuscitation, 77% use normal saline in 10 milliliters per kilogram aliquots (42%) or as fluid challenges (37%). Less than 20% of respondents reported resuscitating with 20 mL/kg boluses. Documented intake over output is the favored vital sign to assess (75% vs 57%) and guide fluid management (97% vs 14%) over central venous pressure. The majority of respondents chose 10% fluid overload as the threshold to act in children with pediatric acute respiratory distress syndrome. The majority (77%) agreed that fluid accumulation contributes to worse outcomes in pediatric acute respiratory distress syndrome and should be treated. Ninety-one percent reported conservative fluid management in pediatric acute respiratory distress syndrome is likely to be beneficial or protective.
Conclusions:
Pediatric intensivists agree that acting on 10% fluid overload in children with pediatric acute respiratory distress syndrome is important. Decisions are being made largely using intake and output documentation, not central venous pressure. These findings are important for future pediatric acute respiratory distress syndrome interventional trials.
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