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Fluid overload is associated with impaired oxygenation and morbidity in critically ill children*

Arikan, Ayse A. MD; Zappitelli, Michael MD, MSc; Goldstein, Stuart L. MD; Naipaul, Amrita NP; Jefferson, Larry S. MD; Loftis, Laura L. MD

Pediatric Critical Care Medicine: May 2012 - Volume 13 - Issue 3 - p 253–258
doi: 10.1097/PCC.0b013e31822882a3
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Rationale: Fluid overload is common in the critically ill and is thought to contribute to oxygenation failure and mortality. Since increasing disease severity often requires more fluid for resuscitation, it is unclear whether fluid overload is a causative factor in morbidity or is simply an indicator of disease severity.

Objective: Investigate the association between fluid overload and oxygenation while controlling for severity of illness by daily Pediatric Logistic Organ Dysfunction scores.

Design and Setting: Retrospective chart review, tertiary children’s hospital.

Patients and Methods: The oxygenation index, fluid overload percent, and daily Pediatric Logistic Organ Dysfunction scores were obtained in a retrospective chart review of 80 patients (mean age 58.7 ± 73.0 months) with respiratory failure. Univariate and multivariate approaches were used to assess the independent relation between fluid overload percent and duration of stay and ventilation.

Interventions: None.

Main Results: Higher peak fluid overload percent predicted higher peak oxygenation index, independent of age, gender, and Pediatric Logistic Organ Dysfunction (p = .009). Fluid overload percent ≥15% on any given day was also independently associated with that day’s oxygenation index, controlled for age, gender, and Pediatric Logistic Organ Dysfunction (p < .05). Peak fluid overload percent and severe fluid overload percent (≥15%) were both independently associated with longer duration of ventilation (p = .004, p = .01), and pediatric intensive care unit (p = .008, p = .01) and hospital length of stay (p = .02, p = .04), controlled for age, gender, Pediatric Logistic Organ Dysfunction, and in the case of ventilation, respiratory admission.

Conclusion: This is the first study to report that positive fluid balance adversely affected the pediatric intensive care unit course in children who did not receive renal replacement therapy. While timely administration of fluids is lifesaving, positive fluid balance after hemodynamic stabilization may impact organ function and negatively influence important outcomes in critically ill patients.

From the Section of Critical Care Medicine (AAA, AN, LSJ, LLL) and Renal Section (AAA, MZ), Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Nephrology (MZ), Department of Pediatrics, McGill University Health Centre, Montreal, Canada; and The Center for Acute Care Nephrology (SLG), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

*See also p. 348.

Dr. Zappitelli received salary support from the Fondation de Recherche en Santé du Québec, the McGill University Health Centre Research Institute, and the Kidney Research Scientist Core and National Training Program. The remaining authors have not disclosed any potential conflicts of interest.

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©2012The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies