Assistant Professor of Pediatrics Indiana University School of Medicine and Riley Hospital for Children Indinapolis, IN
Background: Fluid overload, defined as a pathologic positive fluid balance, is common in critically ill children and is associated with increased morbidity and mortality. However, positive fluid balance is often unrecognized, which may lead to fluid overload being overlooked.
Objectives: We aimed to: 1) describe the frequency of fluid status discussion among pediatric patients in the Intensive Care Unit (ICU) and 2) quantify recognition of fluid overload. We hypothesized that < 70% of practitioners address fluid status daily with their ICU patients.
Design/Methods: In this single-center prospective observational study, trained study members observed rounds in the Neonatal ICU (NICU) and Pediatric ICU (PICU) and recorded both objective data and subjective information. We considered fluid status discussed if the team directly discussed the patient’s fluid balance or volume status, and secondary makers of fluid status were considered daily weight or fluid balance, change in fluid, or diuretics. Data were collected on fluids balance, weights, and clinical status. As a pre-specified sub-analysis, we evaluated recognition of fluid status in those more than 10% fluid overloaded.
Results: 191 individual patient rounding encounters were evaluated, including 106 (54%) in the NICU and 85 (46%) in the PICU. Of all rounding encounters, fluid status was explicitly discussed in only 94 (49%) patients, including 45% of NICU patients and 54% of PICU patients. Fluid balance was more likely to be discussed in mechanically ventilated patients, those requiring vasopressors, those with severe acute kidney injury, and those in which a resident physician was presenting.
Secondary markers of fluid status were discussed more frequently: 58% discussed daily weight, 54% discussed daily fluid balance, and 15% either decreased fluid rate or increased diuretic dosage in apparent response to fluid status. Physical examination was infrequently reported on rounds (23%), and markers of fluid overload were rarely mentioned (Figure 1).
In the 46 patients with >10% fluid overload, clinicians recognized fluid overload in only 12 (26%) patients.
Conclusion: Fluid status was infrequently discussed in critically ill patients, and fluid overload was often unrecognized. Opportunities to improve recognition may be population specific, such as improving daily weights in the PICU and reporting physical examination in the NICU. Further studies to better understand fluid overload and explore modifiable practice improvement opportunities are needed.
