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Nonresuscitation Fluid Accumulation and Outcomes After Pediatric Cardiac Surgery: Single-Center Retrospective Cohort
Matthew R Hudkins1,2, Laura Miller-Smith1, Patrick D Evers3
1Division of Pediatric Critical Care, Department of Pediatrics, Oregon Health and Science University, Portland, OR.
Insights
Fluid creep, or excess IV fluids, is common after pediatric cardiac surgery and linked to worse outcomes. Reducing this "fluid creep" may improve patient recovery and reduce mortality.
Area of Science:
- Pediatric Cardiac Surgery
- Intensive Care Medicine
- Fluid Management
Background:
- Postoperative fluid overload (FO) is a significant risk for patients after congenital cardiac surgery, associated with adverse outcomes.
- Fluid creep, defined as nonresuscitation intravenous fluid administration exceeding maintenance requirements, is a recognized contributor to FO in general pediatric intensive care units (PICUs) but remains understudied in cardiac surgery patients.
Purpose of the Study:
- To characterize fluid administration patterns in pediatric patients following congenital cardiac surgery.
- To quantify the incidence and impact of fluid creep in this specific population.
- To investigate the association between fluid creep, fluid overload, and patient outcomes, including mortality and length of stay.
Main Methods:
- Retrospective, observational cohort study conducted in a single-center mixed-medical and cardiac PICU.
- Analysis of data from 1,459 postoperative encounters of 1,224 unique patients admitted after cardiac surgery between January 2010 and December 2020.
- Quantification of fluid creep and its association with fluid overload, mortality, mechanical ventilation duration, and PICU length of stay, with adjustments for relevant covariates.
Main Results:
- Fluid creep was prevalent, occurring on 56% of patient days, with total fluid intake exceeding maintenance requirements on 67% of days.
- Patients with fluid overload exhibited higher total nonresuscitation fluid intake and greater fluid creep, particularly within the first 5 postoperative days.
- Each 10 mL/kg of fluid creep in the first 24 hours postoperatively was associated with a 26% increased odds of developing FO and a 17% increased odds of mortality, independent of other risk factors.
Conclusions:
- Fluid creep is a common and potentially under-recognized issue in the postoperative care of pediatric congenital cardiac surgery patients.
- Early postoperative fluid creep is significantly associated with increased odds of fluid overload, mortality, prolonged mechanical ventilation, and extended PICU stays.
- Targeting and reducing fluid creep presents a potential modifiable strategy to improve clinical outcomes in this high-risk patient population.
Objectives:
Postoperative patients after congenital cardiac surgery are at high risk of fluid overload (FO), which is known to be associated with poor outcomes. "Fluid creep," or nonresuscitation IV fluid in excess of maintenance requirement, is recognized as a modifiable factor associated with FO in the general PICU population, but has not been studied in congenital cardiac surgery patients. Our objective was to characterize fluid administration after congenital cardiac surgery, quantify fluid creep, and the association between fluid creep, FO, and outcome.
Design:
Retrospective, observational cohort study.
Setting:
Single-center urban mixed-medical and cardiac PICU.
Patients:
Patients admitted to the PICU after cardiac surgery between January 2010 and December 2020.
Interventions:
None.
Measurements And Main Results:
There were 1,459 postoperative encounters with 1,224 unique patients. Total fluid intake was greater than maintenance requirements on 3,103 of 4,661 patient days (67%), with fluid creep present on 2,624 patient days (56%). Total nonresuscitation intake was higher in patients with FO (defined as cumulative fluid balance 10% above body weight) versus those without. Fluid creep was higher among patients with FO than those without for each of the first 5 days postoperatively. Each 10 mL/kg of fluid creep in the first 24 hours postoperatively was associated with 26% greater odds of developing FO (odds ratio [OR] 1.26; 95% CI, 1.17-1.35) and 17% greater odds of mortality (OR 1.17; 95% CI, 1.05-1.30) after adjusting for risk of mortality based on surgical procedure, age, and day 1 resuscitation volume. Increasing fluid creep in the first 24 hours postoperatively was associated with increased postoperative duration of mechanical ventilation and PICU length of stay.
Conclusions:
Fluid creep is present on most postoperative days for pediatric congenital cardiac surgery patients, and fluid creep is associated with higher-risk procedures. Fluid creep early in the postoperative PICU stay is associated with greater odds of FO, mortality, length of mechanical ventilation, and PICU length of stay. Fluid creep may be under-recognized in this population and thus present a modifiable target for intervention.
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