Fluid balance in critically ill children with acute lung injury.

Pubmed ID: 22824936

Pubmed Central ID: PMC3455114

Journal: Critical care medicine

Publication Date: Oct. 1, 2012

Affiliation: Critical Care Division, Department of Anesthesia, Perioperative and Pain Medicine, Children's Hospital Boston, and Department of Anesthesia, Harvard Medical School, Boston, MA 02115, USA. stacey.valentine@childrens.havard.edu

MeSH Terms: Humans, Male, Female, Bayes Theorem, Adolescent, Randomized Controlled Trials as Topic, Infant, Newborn, Child, Retrospective Studies, Fluid Therapy, Water-Electrolyte Balance, Child, Preschool, Infant, Critical Illness, Intensive Care Units, Pediatric, Ventilator-Induced Lung Injury

Grants: HD047349, K23 HL085526, L40 HL110149, T32 HS000063, UL1 RR 025758, UL1 TR000170, UL1 RR025758, K12 HD047349

Authors: Wiedemann HP, Wiedemann HP, Wheeler AP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Valentine SL, Sapru A, Higgerson RA, Spinella PC, Flori HR, Graham DA, Brett M, Convery M, Christie LM, Karamessinis L, Randolph AG, Connors A, Hite D, Schoefeld D, Harabin A, Ringwood N, Oldmixon C, Molay F, Korpak A, Morse R, Ancukiewicz M, Minihan A, Wenzlow G, Garcia JG, Balk R, Emerson S, Shasby M, Sibbald W, Spragg G Corbie-Smith R, Kelley K Leeper J, Slutsky AS, Turnbull B, Vreim C, Gail D, Lew P, Maclawiw M, Hudson L, Steinberg K, Neff M, Maier R, Sims K, Cooper C, Berry-Bell T, Carter G, Andersson L, Toews GB, Bartlett RH, Watts C, Hyzy R, Arnoldi D, Dechert R, Purple M, Silverman H, Shanholtz C, Moore A, Heinrich L, Corral W, Brower R, Thompson D, Fessler H, Murray S, Sculley A, Arroliga AC, Komora J, Haney D, Isabella A, Kern J, Abraham E, McIntyre R, Piedalue F, Welsh C, Douglas I, Wolkin R, Sagel B, Hawkes A, MacIntyre N, Govert J, Fulkerson W, Mallatrat L, Brown L, Everett S, VanDyne E, Knudsen N, Gentile M, Rock P, Carson S, Schuler C, Baker L, Salo V, Bernard G, Rice T, Christman B, Bozeman S, Welsh T, Lanken P, Christie J, Fuchs B, Finkel B, Kaplan S, Gracias V, Hanson CW, Reilly P, Shapiro MB, Burke R, O'Connor E, Wolfe D

Cite As: Valentine SL, Sapru A, Higgerson RA, Spinella PC, Flori HR, Graham DA, Brett M, Convery M, Christie LM, Karamessinis L, Randolph AG, Pediatric Acute Lung Injury and Sepsis Investigator's (PALISI) Network, Acute Respiratory Distress Syndrome Clinical Research Network (ARDSNet). Fluid balance in critically ill children with acute lung injury. Crit Care Med 2012 Oct;40(10):2883-9.

Studies:

Abstract

OBJECTIVES: In the Fluid and Catheter Treatment Trial (NCT00281268), adults with acute lung injury randomized to a conservative vs. liberal fluid management protocol had increased days alive and free of mechanical ventilator support (ventilator-free days). Recruiting sufficient children with acute lung injury into a pediatric trial is challenging. A Bayesian statistical approach relies on the adult trial for the a priori effect estimate, requiring fewer patients. Preparing for a Bayesian pediatric trial mirroring the Fluid and Catheter Treatment Trial, we aimed to: 1) identify an inverse association between fluid balance and ventilator-free days; and 2) determine if fluid balance over time is more similar to adults in the Fluid and Catheter Treatment Trial liberal or conservative arms. DESIGN: Multicentered retrospective cohort study. SETTING: Five pediatric intensive care units. PATIENTS: Mechanically ventilated children (ageā‰„1 month to <18 yrs) with acute lung injury admitted in 2007-2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fluid intake, output, and net fluid balance were collected on days 1-7 in 168 children with acute lung injury (median age 3 yrs, median PaO2/FIO2 138) and weight-adjusted (mL/kg). Using multivariable linear regression to adjust for age, gender, race, admission day illness severity, PaO2/FIO2, and vasopressor use, increasing cumulative fluid balance (mL/kg) on day 3 was associated with fewer ventilator-free days (p=.02). Adjusted for weight, daily fluid balance on days 1-3 and cumulative fluid balance on days 1-7 were higher in these children compared to adults in the Fluid and Catheter Treatment Trial conservative arm (p<.001, each day) and was similar to adults in the liberal arm. CONCLUSIONS: Increasing fluid balance on day 3 in children with acute lung injury at these centers is independently associated with fewer ventilator-free days. Our findings and the similarity of fluid balance patterns in our cohort to adults in the Fluid and Catheter Treatment Trial liberal arm demonstrate the need to determine whether a conservative fluid management strategy improves clinical outcomes in children with acute lung injury and support a Bayesian trial mirroring the Fluid and Catheter Treatment Trial.