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Impact of protocolized restrictive versus liberal/usual maintenance fluid strategy on fluid overload among
Sujith Mathew John1, Suresh Kumar Angurana2, Jayashree Muralidharan1
1Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
Insights
A restrictive fluid strategy significantly reduced fluid overload in mechanically ventilated children. This approach did not negatively impact short-term clinical outcomes, offering a potential benefit for critically ill pediatric patients.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Nephrology
- Pediatric Hospital Medicine
Background:
- Fluid overload (FO) is a significant concern in critically ill children, linked to adverse clinical outcomes.
- Understanding effective fluid management strategies is crucial for improving care in pediatric intensive care units (PICUs).
Purpose of the Study:
- To evaluate the effectiveness of a protocolized restrictive maintenance fluid strategy in reducing fluid overload in mechanically ventilated children.
- To compare the impact of restrictive versus liberal fluid strategies on clinical outcomes in this patient population.
Main Methods:
- An open-label randomized controlled trial involving hemodynamically stable, mechanically ventilated children in a North Indian tertiary care hospital PICU.
- Patients were randomized into two groups: protocolized restrictive (40-50% of maintenance fluids) and liberal/usual (70-80% of maintenance fluids).
- Primary outcome was the proportion of children with cumulative FO >10% through day 5; secondary outcomes included clinical and safety parameters.
Main Results:
- Significantly fewer children in the restrictive group experienced cumulative FO >10% by day 5 (22% vs. 47%, p=0.003).
- The restrictive group showed lower daily cumulative FO over the first 5 days.
- No significant differences were observed in key secondary outcomes, including ventilator-free days, PICU-free days, and mortality between the groups.
Conclusions:
- A protocolized restrictive maintenance fluid strategy effectively reduces fluid overload in hemodynamically stable, mechanically ventilated children.
- This fluid strategy did not adversely affect short-term clinical outcomes, suggesting its potential utility in pediatric critical care.
Abstract:
Fluid overload (FO) is associated with poor clinical outcomes among critically ill children. The objective of this trial was to assess the impact of a protocolized restrictive maintenance fluid strategy on FO among mechanically ventilated children. This open-label randomized controlled trial was conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital in North India over 13 months (November 2023-November 2024). Hemodynamically stable mechanically ventilated children were randomized to protocolized restrictive (n = 64) (40-50% of maintenance fluids with diuretic infusion if FO% > 10%); and liberal/usual (n = 66) (70-80% of maintenance fluid) groups. The primary outcome was the proportion of children with cumulative FO% > 10% through day 5. Secondary outcomes were daily cumulative FO%; inferior vena cava variability index (∆IVC) and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels at 48 h; safety parameters (requirement of fluid boluses or vasoactive drugs); 28-day ventilator and PICU-free days (VFDs and PFDs), and mortality. Significantly fewer children in the protocolized restrictive group had cumulative FO% > 10% than in the liberal/usual group (22% vs. 47%, p = 0.003). Also, the restrictive group had significantly lower daily cumulative FO% on the first 5 days. ∆IVC and NT-proBNP levels at 48 h, as well as safety parameters, were similar between the two groups. Protocolized restrictive and liberal/usual groups had similar VFDs [20 (8-24) vs. 16 (0-23), p = 0.076], PFDs [16 (3-21) vs. 13 (0-19), p = 0.071], and mortality (14% vs. 24%, p = 0.14).
Conclusion:
A protocolized restrictive maintenance fluid strategy resulted in significantly lower FO among hemodynamically stable, mechanically ventilated children without a measurable impact on short-term clinical outcomes.
What Is Known:
• Fluid overload (FO) is associated with poor clinical outcomes among critically ill mechanically ventilated children.
What Is New:
• Among hemodynamically stable, mechanically ventilated children, a restrictive maintenance fluid strategy may be a useful intervention to limit FO and improve clinical outcomes in LMICs.
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