Profile of Fluid Exposure and Recognition of Fluid Overload in Critically Ill Children

Objectives: Fluid overload is common in the PICU and has been associated with increased morbidity and mortality. It remains unclear whether fluid overload is a surrogate marker for severity of illness and need for increased support, an iatrogenic modifiable risk factor, or a sign of oliguria. The proportions of various fluid intake contributing to fluid overload and its recognition have not been adequately examined. We aimed to: 1) describe the types and amounts of fluid exposure in the PICU and 2) identify the clinicians' recognition of fluid overload. Setting: Noncardiac PICU in a quaternary care hospital. Patients: Pediatric patients admitted for more than 24 hours. Design: Prospective observational study over 28 days. Interventions: Data were collected on the amount and type of fluid exposure-resuscitative boluses, blood products, enteral intake, parenteral nutrition (total parenteral nutrition), or modifiable fluids (IV fluids and medications) indexed to the patients' admission body surface area on days 1 and 3. Charts of patients admitted for 3 days who developed 15% fluid overload were reviewed to assess clinicians' recognition of fluid overload. Measurements and Main Results: One hundred two patients were included. Day 1 median fluid exposure was 2,318 mL/m(2)(1,831-3,037 mL/m(2); 1,646 mL/m(2)[1,296-2,086 mL/m(2)] modifiable fluids). Forty-seven patients (46%) received fluid boluses, and 16 (16%) received blood products. Day 3 median fluid exposure was 2,233 mL/m(2)(1,904-2,556 mL/m(2); 750 mL/m(2)[375-1,816 mL/m(2)] modifiable fluids). Of the 54 patients, one patient (1.9%) received a fluid bolus and two (3.7%) received blood products. In our cohort, 47 of 54 (87%) had fluid exposure greater than 1,600 mL/m(2)on day 3. Fluid overload was not recognized by the clinicians in 30% of the patients who developed more than 15% fluid overload. Conclusions: Although resuscitation fluids contributed more to fluid exposure on day 1 compared with day 3, fluid exposure frequently exceeded maintenance requirements on day 3. Fluid overload was not always recognized by PICU practitioners. Further studies to correlate modifiable fluid exposure to fluid overload and explore modifiable practice improvement opportunities are needed.