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Medication Use as a Contributor to Fluid Overload in the PICU: A Prospective Observational Study
Journal of Pediatric Intensive Care, 2017
In this prospective observational study, we explored the association of daily fluid intake from medication use with fluid overload in 75 children beginning 24 hours after intubation. The mean percent daily fluid intake from medications was 29% in the overall cohort. Excess intake and inadequate output contributed significantly to fluid overload. In the 28 patients who became ≥10% fluid overloaded, the mean percent daily fluid intake from medications was 34%, but just 23% in the patients who did not. Awareness of volume contribution and maximized concentration of parenteral medications when able may lessen the burden of fluid overload.
Fluid management in hospitalized patients
Comprehensive therapy, 2005
Intravenous fluid administration is critical to the care of hospitalized patients. Despite the lack of a clear consensus on fluid administration, one may use the principles in this article to develop an organized framework for patient care.
Fluid overload in a South African pediatric intensive care unit
Journal of tropical pediatrics, 2014
Fluid resuscitation is integral to resuscitation guidelines and critical care. However, fluid overload (FO) yields increased morbidity. Prospective observational study of Red Cross War Memorial Children's Hospital pediatric intensive care unit admissions (February to March 2013). FO % = (fluid in minus fluid out) [liters]/weight [kg] × 100%. FO ≥ 10%, 28 day mortality. Median [interquartile range (IQR)] age: 9.5 (2.0-39.0) months, median (IQR) admission weight: 7.9 (3.6-13.7) kg. Median (IQR) FO with admission weight: 3.5 (2.1-4.9)%; three patients had FO ≥ 10%. The 28 day mortality was 10% (n = 10). Patients who died had higher mean (IQR) FO using admission weight [4.9 (2.9-9.3)% vs. 3.4 (1.9-4.8)%; p = 0.04]. Low FO ≥ 10% prevalence with 28 day mortality 10%. Higher FO% with admission weight associated with mortality (p = 0.04). We advocate further investigation of FO% as a simple bedside tool.
Fluid Therapy Management in Hospitalized Patients: Results From a Cross-sectional Study
Clinical Therapeutics, 2017
Purpose: Intravenous (IV) fluid therapy is widely used in hospitalized patients. It has been internationally studied in surgical patients, but little attention to date has been dedicated to medical patients within the Italian context. The aims of the present study were to describe the prevalence of fluid therapy and associated factors among Italian patients admitted to medical and surgical units, describe the methods used to manage fluid therapy, and analyze the monitoring of patients by clinical staff. Methods: In this cross-sectional study of 7 hospitals in northern Italy, data on individual and monitoring variables were collected, and their associations with in-hospital fluid therapy were analyzed by using logistic regression analysis. Patients aged Z18 years who were admitted to medical and surgical units were included. Patients who received at least 500 mL of continuous fluids were included in the fluid therapy group. Findings: In total, 785 (median age, 72 years; women, 52%) patients were included in the study, and 293 (37.3%) received fluid therapy. Maintenance was the most frequent reason for prescribing IV fluid therapy (59%). The mean (SD) volume delivered was 1177 (624) mL/d, and the highest volume was infused for replacement therapy (1660 [931] mL/d). The mean volume infused was 19.55 (13) mL/kg/d. The most commonly used fluid solutions were 0.9% sodium chloride (65.7%) and balanced crystalloid without glucose (32.9%). The proportion of patients assessed for urine output (52.6% vs 36.8%; P o 0.001), serum electrolyte concentrations (74.4% vs 65.0%; P ¼ 0.005), and renal function (70.0% vs 58.7%; P ¼ 0.002) was significantly higher in patients who did receive fluid therapy versus those who did not. In contrast, the use of weight and fluid assessments was not significantly different between the 2 groups (P ¼ 0.216 and 0.256, respectively). Patients admitted for gastrointestinal disorders (odds ratio [OR], 3.5 [95% CI, 1.8-7.05) and for fluid/electrolyte imbalances (OR, 3.35 [95% CI, 1.06-10.52) were more likely to receive fluids. However, the likelihood of receiving fluids was lower for patients admitted to a surgical unit (OR, 0.36 [95% CI, 0.22-0.59]) and with cardiovascular diseases (OR, 0.37 [95% CI, 0.17-0.79). Implications: Only one third of the study patients received fluid therapy. Crystalloid fluids, are the fluids of choice for maintaining plasma volume. During fluid therapy, measurement of the serum electrolyte concentrations, renal function, and urine output was largely used while weight and fluid balance were rarely assessed.
Fluid Overload in Critically Ill Children
Frontiers in Pediatrics
Background: A common practice in the management of critically ill patients is fluid resuscitation. An excessive administration of fluids can lead to an imbalance in fluid homeostasis and cause fluid overload (FO). In pediatric critical care patients, FO can lead to a multitude of adverse effects and increased risk of morbidity. Objectives: To review the literature highlighting impact of FO on a multitude of outcomes in critically-ill children, causative vs. associative relationship of FO with critical illness and current pediatric fluid management guidelines. Data Sources: A literature search was conducted using PubMed/Medline and Embase databases from the earliest available date until June 2017. Data Extraction: Two authors independently reviewed the titles and abstracts of all articles which were assessed for inclusion. The manuscripts of studies deemed relevant to the objectives of this review were then retrieved and associated reference lists hand-searched. Data Synthesis: Articles were segregated into various categories namely pathophysiology and sequelae of fluid overload, assessment techniques, epidemiology and fluid management. Each author reviewed the selected articles in categories assigned to them. All authors participated in the final review process. Conclusions: Recent evidence has purported a relationship between mortality and FO, which can be validated by prospective RCTs (randomized controlled trials). The current literature demonstrates that "clinically significant" degree of FO could be below 10%. The lack of a standardized method to assess FB (fluid balance) and a universal definition of FO are issues that need to be addressed. To date, the impact of early goal directed therapy and utility of hemodynamic parameters in predicting fluid responsiveness remains underexplored in pediatric resuscitation.
BMC pediatrics, 2018
Fluid overload (FO) is associated with unfavorable outcomes in critically ill children. Clinicians are encouraged to avoid FO; however, strategies to avoid FO are not well-described in pediatrics. Our aim was to implement a bundle strategy to prevent FO in children with sepsis and pARDS and to compare the outcomes with a historical cohort. A quality improvement initiative, known as preemptive fluid strategy (PFS) was implemented to prevent early FO, in a 12-bed general PICU. Infants on mechanical ventilation (MV) fulfilling pARDS and sepsis criteria were prospectively recruited. For comparison, data from a historical cohort from 2015, with the same inclusion and exclusion criteria, was retrospectively reviewed. The PFS bundle consisted of 1. maintenance of intravenous fluids (MIVF) at 50% of requirements; 2. drug volume reduction; 3. dynamic monitoring of preload markers to determine the need for fluid bolus administration; 4. early use of diuretics; and 5. early initiation of enter...
Frontiers in Pediatrics, 2019
Background: Fluid overload is common in critically ill children and is associated with adverse outcome. Therefore, restricting fluid intake may be beneficial. This study aims to study the feasibility of a randomized controlled trial (RCT) comparing a conservative to a standard, more liberal, strategy of fluid management in mechanically ventilated pediatric patients with acute respiratory tract infection (ARTI).Methods: This is a feasibility study in a single, tertiary referral pediatric intensive care unit (PICU). Twenty-three children receiving mechanical ventilation for ARTI, without ongoing hemodynamic support, admitted to the PICU of the Emma Children's Hospital/Amsterdam UMC between 2016 and 2018 were included. Patients were randomized to a conservative (<70% of normal intake) or standard (>85% of normal intake) fluid strategy, which was kept throughout the period of mechanical ventilation.Results: Primary endpoints were adherence to fluid strategy and safety parameters such as calorie and protein intake. Secondary outcomes were cumulative fluid intake (CFI) and cumulative fluid balance (CFB) on day 3. In the conservative group, in 75% of the mechanical ventilation days patients achieved their target fluid intake. Median [25th−75th percentiles] calorie intake over all mechanical ventilation days was 67.9 [51.5–74.0] kcal/kg/day in the conservative vs. 67.2 [58.0–75.2] kcal/kg/day in the standard group (p = 0.878). Protein intake was 1.6 [1.3–1.8] gr protein/kg in the conservative and 1.5 [1.2–1.7] gr protein/kg in the standard group (p = 0.598). No adverse effects on hemodynamics or electrolyte imbalances were noted. Mean (±SD) CFI on day 3 was 262.3 (±58.9) ml/kg in the conservative group vs. 360.5 (±52.6) ml/kg in the standard fluid group (p < 0.001), which did not result in a lower CFB.Conclusions: A conservative fluid strategy in mechanically ventilated children with ARTI seems feasible, without limiting metabolic needs. However, in our study a conservative fluid strategy surprisingly did not reduce the degree of fluid overload. This study aids the design and sample size calculation of a future larger multicenter RCT, in which we need to redefine the target fluid strategy, possibly by even further fluid restriction and early initiation of active diuresis.Clinical Trial Registration: ClinicalTrials.gov, identifier: {"type":"clinical-trial","attrs":{"text":"NCT02989051","term_id":"NCT02989051"}}NCT02989051.
Ten answers to key questions for fluid management in intensive care
Medicina Intensiva, 2020
This review focuses on fluid management of critically ill patients. The topic is addressed based on 10 single questions with simplified answers that provide clinicians with the basic information needed at the point of care in treating patients in the Intensive Care Unit. The review has didactic purposes and may serve both as an update on fluid management and as an introduction to the subject for novices in critical care. There is an urgent need to increase awareness regarding the potential risks associated with fluid overload. Clinicians should be mindful not only of the indications for administering fluid loads and of the type of fluids administered, but also of the importance to set safety limits. Lastly, it is important to implement proactive strategies seeking to establish negative fluid balance as soon as the clinical conditions are considered to be stable and the risk of deterioration is low.
Acute and Critical Care
Background: Percent fluid overload greater than 5% is associated with increased mortality. The appropriate time for fluid deresuscitation depends on the patient's radiological and clinical findings. This study aimed to assess the applicability of percent fluid overload calculations for evaluating the need for fluid deresuscitation in critically ill patients. Methods: This was a single-center, prospective, observational study of critically ill adult patients requiring intravenous fluid administration. The study's primary outcome was median percent fluid accumulation on the day of fluid deresuscitation or intensive care unit (ICU) discharge, whichever came first. Results: A total of 388 patients was screened between August 1, 2021, and April 30, 2022. Of these, 100 with a mean age of 59.8±16.2 years were included for analysis. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15.4±8.0. Sixty-one patients (61.0%) required fluid deresuscitation during...