Identifying Opportunities for Fluid Balance Optimization in Critically Ill Children.

Area of Science:

• Pediatric Critical Care Medicine
• Nephrology
• Fluid Management

Background:

• Fluid overload (FO) is a significant complication in Pediatric Intensive Care Units (PICUs), linked to increased morbidity and mortality.
• Accurate fluid balance (FB) reporting and management are challenging due to unique institutional needs, barriers, and limitations.

Purpose of the Study:

• To investigate the prevalence of positive cumulative fluid balance (CFB) within the initial days of PICU admission.
• To identify site-specific drivers of positive CFB, barriers to accurate FB recording, and opportunities for improvement.

Main Methods:

• A concurrent mixed methods study combining retrospective observational data and prospective interviews/surveys across four tertiary pediatric ICUs.
• Fluid balance data extracted from electronic health records using a federated data collection framework.
• Primary outcome: %CFB on PICU days 1 and 2, calculated as (total intake - total output) / PICU admission weight.

Main Results:

• Day 2 CFB >5% ranged from 39% to 54% (p=0.03) and >10% from 16% to 25% (p=0.04) across sites.
• Significant inter-site variations observed in urine output recording and fluid administration protocols (p<0.001).
• While discussion frequency of FB goals varied, reported barriers and improvement opportunities were similar across sites.

Conclusions:

• Positive fluid balance is prevalent in PICU patients, with significant variability in its proportion across different ICUs.
• Effective management of FO requires targeting the unique drivers of positive fluid balance at each individual pediatric intensive care unit.