| Abstract |
Background
In recent years, fluid therapy in critically ill children attracts much of scientific interest, yet many questions remain to be answered. Much attention has been paid to fluids beyond resuscitation setting, that seem to constitute a great proportion of daily administered fluid volume and affect patients’ outcomes. Data in paediatric population is limited. Choice of the optimal solution is still under investigation, although balanced solutions gain ground in the field of intensive care. International guidelines are rapidly updated to ameliorate the provided fluid therapy and eliminate possible complications. Fluid overload and Acute Kidney Injury (AKI) are two of the most common complications in PICU, that result in higher morbidity and mortality. The lack of definite AKI treatment highlights the need for early precaution and intervention, using novel biomarkers to identify patients in high risk of AKI.
Objective
This study aimed to map out detailed data about all sources of administered fluids, including composition and fluid volume 24 hours prior PICU admission and for the first three days in PICU. In addition, it intented to assess fluid balance and fluid overload (FO%) during the 3rd and 7th day in PICU and investigate subsequent correlations with renal function markers and outcomes.
Methods
This is a retrospective cohort study conducted in our tertiary Pediatric Intensive Care Unit at the University Hospital of Heraklion, Greece from January 2017 to August 2023. One hundred patients met the inclusion criteria, and all data were de-identified. Demographic, clinical, laboratory data and therapeutic interventions were collected. All sources of fluid input were measured 24 hours before PICU admission and for the first 3 days in PICU, including composition and fluid volume. Fluid output, daily and cumulative fluid balance and the amount of fluid overload FO% were calculated for the first 3 days in PICU and 7th day when available. Information about AKI, Renal Angina Index and modified Renal Angina Index were included in the study, as well as disease severity scores and outcomes. Results
Maintenance fluids and fluid creep constituted the vast majority of total fluid intake. Large amounts of administered fluid creep (p=0.05) and blood products (p=0.037), especially during the 1st day in PICU, were associated with higher mortality rates. In the resuscitation setting, balanced fluids were more often administered in patients who survived, compared to patients with poor outcomes, who mostly received NaCl 0,9%. Cumulative fluid balance, fluid overload (FO%) during the 3rd and 7th day in PICU and RAI and mRAI scores (p=0.005) were higher in non-survivors compared to survivors. Infection (p=0.028) or shock (p=0.011) during admission were associated with an RAI score > 8. A high proportion of 5% glucose solutions enriched with electrolytes as maintenance fluids during the first 3 days in PICU was correlated with an abnormal RAI score (p<0.001) and mortality (2nd day, p<0.001). Strong predictors of an abnormal RAI (8-40) were high FO% (AUC 0.92) and lactate (AUC 0.77), younger age, and low creatinine clearance (p<0.001).
Conclusions
High cumulative fluid balance and FO% during the 3rd and 7th days in PICU and large amounts of fluid creep are correlated with higher mortality rates. Compared with balanced fluids, high proportions of NaCl 0,9% or dextrose 5% might be correlated with poor outcomes. Infection or shock is correlated with an RAI score >8, while hyperlactatemia is a strong predictor for an abnormal RAI score.
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