Browsing by Subject "Fluid overload"
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Item A Standardized Approach to Reduce Fluid Overload in Critically Ill Children(Wolters Kluwer, 2025-05-01) Hopwood, Andrew J.; Schade Willis, Tina M.; Starr, Michelle C.; Hughes, Katie M.; Malin, Stefan W.; Pediatrics, School of MedicineIntroduction: Fluid overload, the pathologic state of positive fluid balance, is common in the pediatric intensive care unit (PICU) and is independently associated with poor outcomes. Quality improvement-based processes to measure and assess fluid balance in critically ill children are lacking. Methods: The primary aim was to develop and implement a fluid management strategy that includes the standardized measurement and assessment of fluid balance, which is adhered to in at least 50% of all PICU patients. The 4 components of the strategy include (1) creating a fluid balance dashboard that tracks percent cumulative fluid balance over time, (2) documentation of daily weights, (3) fluid balance reporting and discussion incorporated into standardized rounds, and (4) active total intravenous (IV) fluid order. Results: We reviewed 280 patient encounters between May 2023 and April 2024 and achieved the primary aim of at least 50% compliance with the fluid management strategy and maintained this success over time. Achieving the primary aim coincides with implementing daily weights and total IV fluid orders into PICU admission order sets. Conclusions: In this quality improvement project, we develop, implement, and maintain compliance with a fluid management strategy. Future work will involve daily utilization of the fluid balance dashboard and monitoring compliance with total IV fluid orders. Implementing a quality improvement-based fluid management strategy may lead to improved awareness of the fluid status of patients and the prescription of fluid therapy to mitigate the harmful effects of fluid overload.Item Acute Kidney Injury and Fluid Overload in Pediatric Cardiac Surgery(Springer, 2019-12) Carlisle, Michael A.; Soranno, Danielle E.; Basu, Rajit K.; Gist, Katja M.; Pediatrics, School of MedicinePurpose of review: Acute kidney injury (AKI) and fluid overload affect a large number of children undergoing cardiac surgery, and confers an increased risk for adverse complications and outcomes including death. Survivors of AKI suffer long-term sequelae. The purpose of this narrative review is to discuss the short and long-term impact of cardiac surgery associated AKI and fluid overload, currently available tools for diagnosis and risk stratification, existing management strategies, and future management considerations. Recent findings: Improved risk stratification, diagnostic prediction tools and clinically available early markers of tubular injury have the ability to improve AKI-associated outcomes. One of the major challenges in diagnosing AKI is the diagnostic imprecision in serum creatinine, which is impacted by a variety of factors unrelated to renal disease. In addition, many of the pharmacologic interventions for either AKI prevention or treatment have failed to show any benefit, while peritoneal dialysis catheters, either for passive drainage or prophylactic dialysis may be able to mitigate the detrimental effects of fluid overload. Summary: Until novel risk stratification and diagnostics tools are integrated into routine practice, supportive care will continue to be the mainstay of therapy for those affected by AKI and fluid overload after pediatric cardiac surgery. A viable series of preventative measures can be taken to mitigate the risk and severity of AKI and fluid overload following cardiac surgery, and improve care.Item Adherence to Daily Weights and Total Fluid Orders in the Pediatric Intensive Care Unit(Wolters Kluwer, 2018-10-10) Ahearn, Marshall A.; Soranno, Danielle E.; Stidham, Timothy; Lusk, Jennifer; Gist, Katja M.; Pediatrics, School of MedicineBackground: Fluid is central to the resuscitation of critically ill children. However, many pay limited attention to continued fluid accumulation. Fluid overload (FO) is associated with significant morbidity and mortality. The Volume Status Awareness Program (VSAP) is a multi-phase quality improvement initiative aimed at reducing iatrogenic FO. For baseline data, the authors examined a retrospective cohort of patients admitted to the pediatric intensive care unit. Methods: Cohort included diuretic-naive patients admitted to the pediatric intensive care unit at a tertiary care children's hospital in 2014. Furosemide-exposure was used to indicate provider-perceived FO. Variables included daily weight and total fluid (TF) orders, and their timing, frequency, and adherence. Implementation of VSAP phase 1 (bundle of interventions to promote consistent use of patient weights) occurred in June 2017. Results: Forty-nine patients met criteria. Five (10%) had daily weight orders, and 41 (84%) had TF orders-although 7 of these orders followed furosemide administration. Adherence to TF orders was good with 32 (78%) patients exceeding TF limits by < 10%. Thirty (63%) had > 5% FO by day 1, and 22 (51%) had > 10% cumulative FO by day 3. Following phase 1 of the VSAP, the frequency of daily weight orders increased from 6% to 88%. Conclusions: In our institution, use of fluid monitoring tools is both inconsistent and infrequent. Early data from the VSAP project suggests simple interventions can modify ordering and monitoring practice, but future improvement cycles are necessary to determine if these changes are successful in reducing iatrogenic FO.Item Continuous Kidney Replacement Therapy and Survival in Children and Young Adults: Findings From the Multinational WE-ROCK Collaborative(Elsevier, 2024) Starr, Michelle C.; Gist, Katja M.; Zang, Huaiyu; Ollberding, Nicholas J.; Balani, Shanthi; Cappoli, Andrea; Ciccia, Eileen; Joseph, Catherine; Kakajiwala, Aadil; Kessel, Aaron; Muff-Luett, Melissa; Santiago Lozano, María J.; Pinto, Matthew; Reynaud, Stephanie; Solomon, Sonia; Slagle, Cara; Srivastava, Rachana; Shih, Weiwen V.; Webb, Tennille; Menon, Shina; Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) Collaborative; Pediatrics, School of MedicineRationale & objective: There are limited studies describing the epidemiology and outcomes in children and young adults receiving continuous kidney replacement therapy (CKRT). We aimed to describe associations between patient characteristics, CKRT prescription, and survival. Study design: Retrospective multicenter cohort study. Setting & participants: 980 patients aged from birth to 25 years who received CKRT between 2015 and 2021 at 1 of 32 centers in 7 countries participating in WE-ROCK (Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Diseases). Exposure: CKRT for acute kidney injury or volume overload. Outcomes: Death before intensive care unit (ICU) discharge. Analytical approach: Descriptive statistics. Results: Median age was 8.8 years (IQR, 1.6-15.0), and median weight was 26.8 (IQR, 11.6-55.0) kg. CKRT was initiated a median of 2 (IQR, 1-6) days after ICU admission and lasted a median of 6 (IQR, 3-14) days. The most common CKRT modality was continuous venovenous hemodiafiltration. Citrate anticoagulation was used in 62%, and the internal jugular vein was the most common catheter placement location (66%). 629 participants (64.1%) survived at least until ICU discharge. CKRT dose, filter type, and anticoagulation were similar in those who did and did not survive to ICU discharge. There were apparent practice variations by institutional ICU size. Limitations: Retrospective design; limited representation from centers outside the United States. Conclusions: In this study of children and young adults receiving CKRT, approximately two thirds survived at least until ICU discharge. Although variations in dialysis mode and dose, catheter size and location, and anticoagulation were observed, survival was not detected to be associated with these parameters. Plain-language summary: In this large contemporary epidemiological study of children and young adults receiving continuous kidney replacement therapy in the intensive care unit, we observed that two thirds of patients survived at least until ICU discharge. However, patients with comorbidities appeared to have worse outcomes. Compared with previously published reports on continuous kidney replacement therapy practice, we observed greater use of continuous venovenous hemodiafiltration with regional citrate anticoagulation.Item Early Cumulative Fluid Balance and Outcomes in Pediatric Allogeneic Hematopoietic Cell Transplant Recipients With Acute Respiratory Failure: A Multicenter Study(Frontiers Media, 2021-07-20) Sallee, Colin J.; Smith, Lincoln S.; Rowan, Courtney M.; Heckbert, Susan R.; Angelo, Joseph R.; Daniel, Megan C.; Gertz, Shira J.; Hsing, Deyin D.; Mahadeo, Kris M.; McArthur, Jennifer A.; Fitzgerald, Julie C.; Pediatrics, School of MedicineObjectives: To evaluate the associations between early cumulative fluid balance (CFB) and outcomes among critically ill pediatric allogeneic hematopoietic cell transplant (HCT) recipients with acute respiratory failure, and determine if these associations vary by treatment with renal replacement therapy (RRT). Methods: We performed a secondary analysis of a multicenter retrospective cohort of patients (1mo - 21yrs) post-allogeneic HCT with acute respiratory failure treated with invasive mechanical ventilation (IMV) from 2009 to 2014. Fluid intake and output were measured daily for the first week of IMV (day 0 = day of intubation). The exposure, day 3 CFB (CFB from day 0 through day 3 of IMV), was calculated using the equation [Fluid in - Fluid out] (liters)/[PICU admission weight] (kg)*100. We measured the association between day 3 CFB and PICU mortality with logistic regression, and the rate of extubation at 28 and 60 days with competing risk regression (PICU mortality = competing risk). Results: 198 patients were included in the study. Mean % CFB for the cohort was positive on day 0 of IMV, and increased further on days 1-7 of IMV. For each 1% increase in day 3 CFB, the odds of PICU mortality were 3% higher (adjusted odds ratio (aOR) 1.03, 95% CI 1.00-1.07), and the rate of extubation was 3% lower at 28 days (adjusted subdistribution hazard ratio (aSHR) 0.97, 95% CI 0.95-0.98) and 3% lower at 60 days (aSHR 0.97, 95% CI 0.95-0.98). When day 3 CFB was dichotomized, 161 (81%) had positive and 37 (19%) had negative day 3 CFB. Positive day 3 CFB was associated with higher PICU mortality (aOR 3.42, 95% CI 1.48-7.87) and a lower rate of extubation at 28 days (aSHR 0.30, 95% CI 0.18-0.48) and 60 days (aSHR 0.30, 95% 0.19-0.48). On stratified analysis, the association between positive day 3 CFB and PICU mortality was significantly stronger in those not treated with RRT (no RRT: aOR 9.11, 95% CI 2.29-36.22; RRT: aOR 1.40, 95% CI 0.42-4.74). Conclusions: Among critically ill pediatric allogeneic HCT recipients with acute respiratory failure, positive and increasing early CFB were independently associated with adverse outcomes.Item Fluid Overload in Pediatric Acute Respiratory Distress Syndrome after Allogeneic Hematopoietic Cell Transplantation(Thieme, 2022-10-11) Sallee, Colin J.; Fitzgerald, Julie C.; Smith, Lincoln S.; Angelo, Joseph R.; Daniel, Megan C.; Gertz, Shira J.; Hsing, Deyin D.; Mahadeo, Kris M.; McArthur, Jennifer A.; Rowan, Courtney M.; Pediatric Acute Lung Injury Sepsis Investigators (PALISI) Network; Pediatrics, School of MedicineThe aim of the study is to examine the relationship between fluid overload (FO) and severity of respiratory dysfunction in children posthematopoietic cell transplantation (HCT) with pediatric acute respiratory distress syndrome (PARDS). This investigation was a secondary analysis of a multicenter retrospective cohort of children (1month to 21 years) postallogeneic HCT with PARDS receiving invasive mechanical ventilation (IMV) from 2009 to 2014. Daily FO % (FO%) and daily oxygenation index (OI) were calculated for each patient up to the first week of IMV (day 0 = intubation). Linear mixed-effect regression was employed to examine whether FO% and OI were associated on any day during the study period. In total, 158 patients were included. Severe PARDS represented 63% of the cohort and had higher mortality (78 vs. 42%, p <0.001), fewer ventilator free days at 28 (0 [IQR: 0-0] vs. 14 [IQR: 0-23], p <0.001), and 60 days (0 [IQR: 0-27] v. 45 [IQR: 0-55], p <0.001) relative to nonsevere PARDS. Increasing FO% was strongly associated with higher OI ( p <0.001). For children with 10% FO, OI was higher by nearly 5 points (adjusted β , 4.6, 95% CI: [2.9, 6.3]). In subgroup analyses, the association between FO% and OI was strongest among severe PARDS ( p <0.001) and during the first 3 days elapsed from intubation ( p <0.001). FO% was associated with lower PaO 2 /FiO 2 (adjusted β , -1.92, 95% CI: [-3.11, -0.73], p = 0.002), but not mean airway pressure ( p = 0.746). In a multicenter cohort of children post-HCT with PARDS, FO was independently associated with oxygenation impairment. The associations were strongest among children with severe PARDS and early in the course of IMV.Item Prolonged acute kidney injury exacerbates lung inflammation at 7 days post‐acute kidney injury(Wiley, 2014-07-22) Andres-Hernando, Ana; Altmann, Christopher; Bhargava, Rhea; Okamura, Kayo; Bacalja, Jasna; Hunter, Brandi; Ahuja, Nilesh; Soranno, Danielle; Faubel, Sarah; Pediatrics, School of MedicinePatients with acute kidney injury (AKI) have increased mortality; data suggest that the duration, not just severity, of AKI predicts increased mortality. Animal models suggest that AKI is a multisystem disease that deleteriously affects the lungs, heart, brain, intestine, and liver; notably, these effects have only been examined within 48 h, and longer term effects are unknown. In this study, we examined the longer term systemic effects of AKI, with a focus on lung injury. Mice were studied 7 days after an episode of ischemic AKI (22 min of renal pedicle clamping and then reperfusion) and numerous derangements were present including (1) lung inflammation; (2) increased serum proinflammatory cytokines; (3) liver injury; and (4) increased muscle catabolism. Since fluid overload may cause respiratory complications post-AKI and fluid management is a critical component of post-AKI care, we investigated various fluid administration strategies in the development of lung inflammation post-AKI. Four different fluid strategies were tested - 100, 500, 1000, or 2000 μL of saline administered subcutaneously daily for 7 days. Interestingly, at 7 days post-AKI, the 1000 and 2000 μL fluid groups had less severe AKI and less severe lung inflammation versus the 100 and 500 μL groups. In summary, our data demonstrate that appropriate fluid management after an episode of ischemic AKI led to both (1) faster recovery of kidney function and (2) significantly reduced lung inflammation, consistent with the notion that interventions to shorten AKI duration have the potential to reduce complications and improve patient outcomes.Item Revisiting Post-ICU Admission Fluid Balance Across Pediatric Sepsis Mortality Risk Strata: A Secondary Analysis of a Prospective Observational Cohort Study(Wolters Kluwer, 2024-01-16) Atreya, Mihir R.; Cvijanovich, Natalie Z.; Fitzgerald, Julie C.; Weiss, Scott L.; Bigham, Michael T.; Jain, Parag N.; Abulebda, Kamal; Lutfi, Riad; Nowak, Jeffrey; Thomas, Neal J.; Baines, Torrey; Quasney, Michael; Haileselassie, Bereketeab; Sahay, Rashmi; Zhang, Bin; Alder, Matthew N.; Stanski, Natalja L.; Goldstein, Stuart L.; Pediatrics, School of MedicineOBJECTIVES: Post-ICU admission cumulative positive fluid balance (PFB) is associated with increased mortality among critically ill patients. We sought to test whether this risk varied across biomarker-based risk strata upon adjusting for illness severity, presence of severe acute kidney injury (acute kidney injury), and use of continuous renal replacement therapy (CRRT) in pediatric septic shock. DESIGN: Ongoing multicenter prospective observational cohort. SETTING: Thirteen PICUs in the United States (2003–2023). PATIENTS: Six hundred and eighty-one children with septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cumulative percent PFB between days 1 and 7 (days 1–7 %PFB) was determined. Primary outcome of interest was complicated course defined as death or persistence of greater than or equal to two organ dysfunctions by day 7. Pediatric Sepsis Biomarker Risk Model (PERSEVERE)-II biomarkers were used to assign mortality probability and categorize patients into high mortality (n = 91), intermediate mortality (n = 134), and low mortality (n = 456) risk strata. Cox proportional hazard regression models with adjustment for PERSEVERE-II mortality probability, presence of sepsis-associated acute kidney injury on day 3, and use of CRRT, demonstrated that time-dependent variable days 1–7%PFB was independently associated with an increased hazard of complicated course. Risk-stratified analyses revealed that each 10% increase in days 1–7 %PFB was associated with increased hazard of complicated course only among patients with high mortality risk strata (adjusted hazard ratio 1.24 (95% CI, 1.08–1.43), p = 0.003). However, this association was not causally mediated by PERSEVERE-II biomarkers. CONCLUSIONS: Our data demonstrate the influence of cumulative %PFB on the risk of complicated course in pediatric septic shock. Contrary to our previous report, this risk was largely driven by patients categorized as having a high mortality risk based on PERSEVERE-II biomarkers. Incorporation of such prognostic enrichment tools in randomized trials of restrictive fluid management or early initiation of de-escalation strategies may inform targeted application of such interventions among at-risk patients.