|Year : 2020 | Volume
| Issue : 4 | Page : 161-162
Fluid administration in critically ill children: Striking a balance!!!!
Sachin S Shah
Director, Pediatric Intensive Care Services, Intensive Care Services, Surya Mother and Child Superspeciality Hospital, Pune, Maharashtra, India
|Date of Submission||19-Jun-2020|
|Date of Acceptance||29-Jun-2020|
|Date of Web Publication||13-Jul-2020|
Dr. Sachin S Shah
Director, Pediatric Intensive Care Services, Surya Mother and Child Superspeciality Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shah SS. Fluid administration in critically ill children: Striking a balance!!!!. J Pediatr Crit Care 2020;7:161-2
Fluid administration is one of the most fundamental interventions in critically ill children. Fluids are administered with an intention to maintain adequate intravascular volume during various phases of critical illness. Administration of “correct” amount of fluids is an art and depends on various factors such as diagnosis, type of shock, severity of illness, age of patient, and underlying cardiac and renal status. Furthermore, the fluid requirements and type of fluids may keep on changing over the course of illness.
A perpetual dilemma in the mind of clinicians is “am I giving less fluids” OR “am I giving more fluids,” and both the scenarios can have deleterious effects on patient outcome.
In this issue, Namitha et al. published a retrospective study on 48-h fluid balance and outcome in 107 mechanically ventilated critically ill children. Children aged 1 month to 12 years ventilated for more than 24 h with 48-h fluid balance were included and were divided into ≤10% and >10% fluid overload (FO) groups. A total of 107 patients (23 in >10% FO and 84 in ≤10% FO groups) were enrolled. The median (interquartile range) age and pediatric risk of mortality III score was similar in both groups (12, 7–36 months vs. 11, 3–32 months; P = 0.37 and 16, 12–20 vs. 15, 12–18; P = 0.71, respectively). In >10% FO group, a higher proportion of patients had acute respiratory distress syndrome (13 [56%] vs. 28 [35%], P = 0.06) and acute kidney injury (AKI) (15 [65%] vs. 37 [44%], P = 0.07), of which a significant number required renal replacement therapy (RRT) (10 [43%] vs. 15 [17%], P = 0.01). More patients had septic shock in >10% FO group (13 [56%] vs. 27 [32%], P = 0.03). There was no significant difference in all-cause pediatric intensive care unit mortality in >10% FO group (13 [57%]) as compared to ≤10% FO group (32 [38%]) (relative risk = 1.2, 95% confidence interval [CI]: 1.0–1.5, P = 0.11 and adjusted hazard ratio = 1.52, 95% CI: 0.78–2.97, P = 0.22). No differences were noted in other outcome variables.
A major limitation of the study is the retrospective nature with resultant biases. Furthermore, the number of children with >10% FO is relatively small, and a larger sample size is needed to demonstrate a clinically significant difference in mortality. Hence, the findings of this study need to be interpreted with caution and in conjunction with other published evidence.
Alobaidi et al. performed a systematic review to see if there a causal association between FO and adverse outcomes such as mortality? A total of 44 studies (7507 children) were included in this systematic review. Of the included studies, 27 (61%) were retrospective cohort studies, 13 (30%) were prospective cohort studies, 3 (7%) were case–control studies, and 1 study (2%) was a secondary analysis of a randomized trial. The clinical case mix and FO definition varied between the studies. FO, however defined, was associated with increased inhospital mortality (17 studies [n = 2853]; odds ratio [OR], 4.34 [95% CI, 3.01–6.26]; I2 = 61%). Nonsurvivors had a higher percentage of FO than survivors (22 studies [n = 2848]; mean difference, −5.62 [95% CI, −7.28–− 3.97]). After adjusting for illness severity, there was a 6% increase in odds of mortality for every 1% increase in percentage of FO (11 studies [n = 3200]; adjusted OR, 1.06 [95% CI, 1.03–1.10]). FO was associated with increased risk for prolonged mechanical ventilation (>48 h) (3 studies [n = 631]; OR, 2.14 [95% CI, 1.25–3.66]) and AKI (7 studies [n = 1833]; OR, 2.36 [95% CI, 1.27–4.38]). All the included studies are observational in nature with majority being retrospective in nature, thus increasing the risk of bias, especially selection and performance bias. Hence, a causal relation cannot be definitely confirmed between FO and mortality. Positive fluid balance could be a marker of disease and severity of illness rather than a pure iatrogenic or preventable problem. Indeed, inadequate resuscitation due to insufficient fluid administration may lead to organ dysfunction, especially in the early phase of illness. Prospective clinical trials evaluating different clinical strategies of fluid management in critically ill children are needed to answer this question.
As of now, clinicians should carefully titrate fluids during resuscitation phase, optimization phase, maintenance phase, and recovery phase of critical illness. The fluid requirements may vary during these various phases, and judicious use of static and dynamic monitoring may help in achieving optimum fluid balance and avoiding FO. Fluids should be prescribed like drugs with careful attention to dose, choice of fluids, duration, and de-escalation of fluids. Fluid therapy should be individualized, and once hemodynamic stability has been achieved, FO should be promptly managed with restriction of nonessential volumes, diuretics, or RRT. It is time for fluid stewardship!!!!
| References|| |
Namitha R, Ramachandran R, Ponnarmeni S, Subramanian M. Retrospective study on 48 hours fluid balance and outcome in mechanically ventilated children. J Ped Crit Care 2020;7:174-178.
Alobaidi R, Morgan C, Basu RK, Stenson E, Featherstone R, Majumdar SR, et al
. Association between fluid balance and outcomes in critically ill children: A systematic review and meta-analysis. JAMA Pediatr 2018;172:257-68.
Malbrain ML, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O, et al
. Principles of fluid management and stewardship in septic shock: It is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care 2018;8:66.