Related Experiment Video

Updated: Jul 23, 2025

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Published on: January 16, 2019

Revisiting post-ICU admission fluid balance across pediatric sepsis mortality risk strata: A secondary analyses from

Mihir R Atreya¹, Natalie Z Cvijanovich², Julie C Fitzgerald³

¹Cincinnati Children's Hospital Medical Center.

Research Square

|July 18, 2023

Insights

Positive fluid balance in pediatric septic shock patients is linked to worse outcomes, especially in those with high mortality risk identified by PERSEVERE-II biomarkers. This suggests a need for tailored fluid management strategies in high-risk pediatric septic shock cases.

Area of Science:

Pediatric critical care medicine
Fluid management in critical illness
Septic shock pathophysiology

Background:

Cumulative positive fluid balance (PFB) post-ICU admission is a known mortality risk factor in critically ill patients.
The influence of PFB on outcomes may vary based on patient risk stratification.
Understanding these variations is crucial for optimizing treatment in pediatric septic shock.

Approach:

A multi-center prospective observational cohort study was conducted across 13 pediatric ICUs.
Six hundred and eighty-one children with septic shock were analyzed.
Cox proportional hazard regression models were used to assess the association between Day 1-7%PFB and complicated course, adjusting for illness severity, AKI, and CRRT.

Key Points:

Post-ICU admission cumulative positive fluid balance (Day 1-7%PFB) was independently associated with an increased hazard of complicated course in pediatric septic shock.
This association was significant only in patients categorized as high-mortality risk based on PERSEVERE-II biomarkers (adj HR 1.24, p=0.002).
No significant association was found in intermediate or low-mortality risk strata.

Conclusions:

Cumulative positive fluid balance independently influences the risk of a complicated course in pediatric septic shock.
The heightened risk associated with PFB is primarily driven by high-mortality risk patients.
Further research should explore targeted fluid management or de-escalation therapies for this high-risk subset.

Read full analysis

Abstract

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.

Keywords:

Acute Kidney Injury Biomarkers Critical illness Fluid Overload Positive Fluid Balance Post-ICU Admission Fluid Balance Sepsis Septic Shock

More Related Videos

Cecal Ligation Puncture Procedure

Cecal Ligation Puncture Procedure

Published on: May 7, 2011

Bedside Ultrasound for Guiding Fluid Removal in Patients with Pulmonary Edema: The Reverse-FALLS Protocol

Bedside Ultrasound for Guiding Fluid Removal in Patients with Pulmonary Edema: The Reverse-FALLS Protocol

Published on: July 28, 2018

Related Concept Videos

Acute Kidney Injury VI: Nursing Management

Acute Kidney Injury VI: Nursing Management

Acute Kidney Injury (AKI) results in an inability to maintain fluid, electrolyte, and acid-base balance. Effective nursing management is critical in improving patient outcomes and includes comprehensive patient assessment and targeted interventions.Comprehensive Patient AssessmentA detailed history collection is essential, focusing on any recent infections, nephrotoxic medication use, or chronic conditions such as hypertension and diabetes that may contribute to AKI. During the physical...

Acute Kidney Injury V: Interprofessional Care

Acute Kidney Injury V: Interprofessional Care

Acute Kidney Injury (AKI) requires a collaborative healthcare approach to restore renal function and prevent complications. Essential management strategies involve monitoring fluid and electrolyte balance, adjusting medications, initiating dialysis when necessary, and providing nutritional support.Fluid and Electrolyte ManagementFluid Monitoring: Regularly monitoring body weight, central venous pressure, and urine output helps detect fluid imbalances early. Patient intake and output are...

Cardiomyopathy VII: Pre and Post Operative Nursing Management

Cardiomyopathy VII: Pre and Post Operative Nursing Management

Patients with hypertrophic cardiomyopathy (HCM) and left ventricular outflow tract (LVOT) obstruction who remain symptomatic despite optimal medical therapy may undergo a septal myectomy (Morrow procedure). This procedure involves excising a portion of the hypertrophied septum below the aortic valve using a heart-lung machine to improve blood flow through the LVOT. Effective preoperative and postoperative nursing management ensures successful patient outcomes, minimizes complications, and...

Acute Kidney Injury I: Introduction

Acute Kidney Injury I: Introduction

Introduction:Acute Kidney Injury (AKI) describes a swift decrease in kidney function occurring over hours to days, characterized by the kidneys' failure to remove waste products from the bloodstream. This leads to dangerous complications like metabolic acidosis, fluid overload, and electrolyte imbalances, such as hyperkalemia, which can cause life-threatening arrhythmias. AKI is common in both hospital and outpatient settings, often triggered by dehydration, sepsis, or exposure to nephrotoxic...

Acute Kidney Injury IV: Diagnostic Studies and Prevention

Acute Kidney Injury IV: Diagnostic Studies and Prevention

Accurate diagnosis and effective prevention are critical in managing Acute Kidney Injury (AKI), which is linked to high mortality rates ranging from 10% to 80%. Timely recognition of at-risk patients and careful monitoring can significantly reduce the likelihood of kidney damage.Diagnostic Assessments:The diagnostic process starts with a comprehensive medical history to identify prerenal, intrarenal, and postrenal causes.Prerenal causes, such as dehydration, hypotension, or blood loss, should...

Chronic Kidney Disease IV: Nursing Management

Chronic Kidney Disease IV: Nursing Management

Nursing management is essential for preventing complications, maintaining stability, and improving patients' quality of life in chronic kidney disease (CKD). By using a structured approach, nurses help slow CKD progression and support effective patient care.1. Comprehensive patient assessmentEffective management begins with nurses reviewing the patient’s medical history, and identifying key risk factors like diabetes, hypertension, and nephrotoxic drug use. Nurses assess signs of...

Articles linked to this work by shared authors, journal, and citation graph.

PPARγ Variant rs10865710 and Mortality in Pediatric Septic Shock Stratified by Corticosteroid Exposure.

Critical care explorations·2026

Mitigating Excessive Mitochondrial Fission Through the Development of a Selective Macrocyclic Inhibitor Targeting Fis1/Mid51 Signaling.

Journal of medicinal chemistry·2026

External Validation, Molecular Signatures, and Therapeutic Relevance of Pediatric Sepsis-Associated Acute Kidney Injury Subphenotypes.

Critical care medicine·2026

Ventilator management on extracorporeal membrane oxygenation: considerations for open lung strategy.

Current opinion in pediatrics·2026

Proposing Entrustable Professional Activities for Pediatric Critical Care Ultrasound: A Modified Delphi Consensus Approach.

Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies·2026

Neutrophil dysregulation differentiates pediatric septic shock biomarker-based mortality-risk strata: insights from weighted gene co-expression network and transcriptomic analyses.

Frontiers in immunology·2025

See all related articles