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Post-ICU Admission Fluid Balance and Pediatric Septic Shock Outcomes: A Risk-Stratified Analysis*

Abulebda, Kamal MD1; Cvijanovich, Natalie Z. MD2; Thomas, Neal J. MD3; Allen, Geoffrey L. MD4; Anas, Nick MD5; Bigham, Michael T. MD6; Hall, Mark MD7; Freishtat, Robert J. MD8; Sen, Anita MD9; Meyer, Keith MD10; Checchia, Paul A. MD11; Shanley, Thomas P. MD12; Nowak, Jeffrey MD13; Quasney, Michael MD, PhD12; Weiss, Scott L. MD14; Chopra, Arun MD15; Banschbach, Sharon RN1; Beckman, Eileen RN1; Lindsell, Christopher J. PhD16; Wong, Hector R. MD1,17

doi: 10.1097/CCM.0b013e3182a64607
Pediatric Critical Care

Objective: Observed associations between fluid balance and septic shock outcomes are likely confounded by initial mortality risk. We conducted a risk-stratified analysis of the association between post-ICU admission fluid balance and pediatric septic shock outcomes.

Design: Retrospective analysis of an ongoing multicenter pediatric septic shock clinical and biological database.

Setting: Seventeen PICUs in the United States.

Patients: Three hundred and seventeen children with septic shock.

Interventions: None.

Measurements and Main Results: We stratified subjects into three mortality risk categories (low, intermediate, and high) using a validated biomarker-based stratification tool. Within each category, we assessed three fluid balance variables: total fluid intake/kg/d during the first 24 hours, percent positive fluid balance during the first 24 hours, and cumulative percent positive fluid balance up to 7 days. We used logistic regression to estimate the effect of fluid balance on the odds of 28-day mortality, and on complicated course, which we defined as either death within 28 days or persistence of two or more organ failures at 7 days. There were 40 deaths, and 91 subjects had a complicated course. Increased cumulative percent positive fluid balance was associated with mortality in the low-risk cohort (n = 204; odds ratio, 1.035; 95% CI, 1.004–1.066) but not in the intermediate- and high-risk cohorts. No other associations with mortality were observed. Fluid intake, percent positive fluid balance in the first 24 hours, and cumulative percent positive fluid balance were all associated with increased odds of a complicated course in the low-risk cohort but not in the intermediate- and high-risk cohorts.

Conclusions: When stratified for mortality risk, increased fluid intake and positive fluid balance after ICU admission are associated with worse outcomes in pediatric septic shock patients with a low initial mortality risk but not in patients at moderate or high mortality risk.

1Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH.

2Children’s Hospital and Research Center Oakland, Oakland, CA.

3Penn State Hershey Children’s Hospital, Hershey, PA.

4Children’s Mercy Hospital, Kansas City, MO.

5Children’s Hospital of Orange County, Orange, CA.

6Akron Children’s Hospital, Akron, OH.

7Nationwide Children’s Hospital, Columbus, OH.

8Children’s National Medical Center, Washington, DC.

9Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY.

10Miami Children’s Hospital, Miami, FL.

11Texas Children’s Hospital, Houston, TX.

12CS Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI.

13Children’s Hospital and Clinics of Minnesota, Minneapolis, MN.

14The Children’s Hospital of Philadelphia, Philadelphia, PA.

15St. Christopher’s Hospital for Children, Philadelphia, PA.

16Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH.

17Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.

* See also p. 470.

Supported, in part, by grants RC1HL100474, RO1GM064619, and RO1GM099773 from National Institutes of Health and grant NIH/NCRR 8UL1 TR000077 from an Institutional Clinical and Translational Science Award.

Dr. Abulebda received grant support from National Institutes of Health (NIH). Dr. Cvijanovich is employed by CCCMG and received support for article research from NIH. His institution received grant support from the NIH. Dr. Thomas received grant support from NIH and the FDA (R01 grant) and has Scientific Advisory Board membership with Discovery Labs. Dr. Allen received support for article research from NIH. His institution received grant support from the NIH. Dr. Anas received support for article research from NIH and provided expert testimony and received royalties (past). Dr. Bigham received grant support from NIH. Dr. Hall and Freishtat’s institutions received grant support from the NIH. Dr. Sen received support for article research from NIH, and her institution received grant support from the NIH. Dr. Meyer’s institution received grant support from NIH (specimen collection). Dr. Checchia received grant support from NIH. Dr. Shanley received grant support and support for article research from NIH. He received royalties from Springer and had SPR board and external advisory board memberships. His institution received grant support from the NIH. Dr. Nowak received support for article research from NIH, and his institution received grant support from the NIH. Dr. Quasney received grant support (does not overlap with this project) and support for article research from NIH. His institution received grant support from the NIH. Dr. Chopra received grant support and support for article research from NIH. Ms. Banschbach received grant support from NIH. Ms. Beckman received support for article research from NIH, and her institution received grant support from the NIH. Dr. Lindsell received support for article research from NIH. Dr. Lindsell is named as a coinventor in the PERSEVERE patent application. His institution received grant support from the NIH. Dr. Wong received support for article research from NIH. His institutions received grant support from the NIH. Dr. Wong and the Cincinnati Children’s Hospital Research Foundation have submitted a provisional patent application for PERSEVERE. Dr. Abulebda, Dr. Thomas, Dr. Allen, Dr. Bigham, Dr. Hall, Dr. Freishtat, Dr. Sen, Dr. Meyer, Dr. Checchia, Dr. Shanley, Dr. Quasney, Ms. Beckman, Dr. Lindsell, and Dr. Wong disclosed a patent (CCHMC described in manuscript). Dr. Weiss has disclosed that he does not have any potential conflicts of interest.

For information regarding this article, E-mail: hector.wong@cchmc.org

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins