Reducing NICU ventilator days by preventing fluid overload with the CAN-U-P-LOTS standardized bundle

Fluid overload in critically ill neonates and infants is associated with higher ventilation days, prolonged length of stay, and mortality.

This quality improvement study enrolled infants admitted to Children's of Alabama NICU (excluding those with tracheostomies, severe congenital kidney or heart disease, DNR status, or severe genetic conditions). We compared 7 months of pre-intervention data (211 neonates) with 7 months of post-implementation data (218 neonates). Bundle implementation for at least 5 days occurred for sepsis, spontaneous intestinal perforation, necrotizing enterocolitis, acute kidney injury, positive fluid balance >10%, hypotension, and major surgeries. The primary hypothesis was that the unit-wide ventilator-free days would increase after bundle implementation.

We found special cause variation with an increase in the percentage of ventilator-free and oxygen-free days coinciding with bundle introduction. The ventilator-free days were higher in the post-era compared to the pre-era (5592/8335 (67%) vs. (3732/6619) (56%); p < 0.001). Oxygen-free days and NICU length of stay showed similar findings.

Implementation of a fluid overload prevention bundle was associated with increased ventilator-free days, oxygen-free days, and shortened NICU duration. Additional studies are needed to better understand these associations and externally validate our hypothesis in other populations.

Fluid overload leads to poor clinical outcomes, including the need for ventilatory support. Prolonged ventilation has a deleterious effect on the lungs due to barotrauma and leads to complications (i.e., pneumonia), longer length of stay, and increased costs. After consensus from a multi-disciplinary team, we implemented a strategy using the CAN-U-P-LOTS bundle designed to prevent fluid overload in critically ill infants. We showed an increase in the number of ventilator-free days, oxygen-free days, and shorter length of stay. Studies are needed to validate our single-center study.