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Bem RA, Lemson J. Evaluating fluid overload in critically ill children. Curr Opin Pediatr 2024; 36:266-273. [PMID: 38655808 DOI: 10.1097/mop.0000000000001347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW To review the evaluation and management of fluid overload in critically ill children. RECENT FINDINGS Emerging evidence associates fluid overload, i.e. having a positive cumulative fluid balance, with adverse outcome in critically ill children. This is most likely the result of impaired organ function due to increased extravascular water content. The combination of a number of parameters, including physical, laboratory and radiographic markers, may aid the clinician in monitoring and quantifying fluid status, but all have important limitations, in particular to discriminate between intra- and extravascular water volume. Current guidelines advocate a restrictive fluid management, initiated early during the disease course, but are hampered by the lack of high quality evidence. SUMMARY Recent advances in early evaluation of fluid status and (tailored) restrictive fluid management in critically ill children may decrease complications of fluid overload, potentially improving outcome. Further clinical trials are necessary to provide the clinician with solid recommendations.
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Affiliation(s)
- Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam Academic Medical Centers, location University of Amsterdam, Amsterdam
| | - Joris Lemson
- Department of Intensive Care, Radboud university medical center, Nijmegen, The Netherlands
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Ingelse SA, IJland MM, van Loon LM, Bem RA, van Woensel JBM, Lemson J. Early restrictive fluid resuscitation has no clinical advantage in experimental severe pediatric acute respiratory distress syndrome. Am J Physiol Lung Cell Mol Physiol 2021; 320:L1126-L1136. [PMID: 33826416 DOI: 10.1152/ajplung.00613.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Intravenous fluids are widely used to treat circulatory deterioration in pediatric acute respiratory distress syndrome (PARDS). However, the accumulation of fluids in the first days of PARDS is associated with adverse outcome. As such, early fluid restriction may prove beneficial, yet the effects of such a fluid strategy on the cardiopulmonary physiology in PARDS are unclear. In this study, we compared the effect of a restrictive with a liberal fluid strategy on a hemodynamic response and the formation of pulmonary edema in an animal model of PARDS. Sixteen mechanically ventilated lambs (2-6 wk) received oleic acid infusion to induce PARDS and were randomized to a restrictive or liberal fluid strategy during a 6-h period of mechanical ventilation. Transpulmonary thermodilution determined extravascular lung water (EVLW) and cardiac output (CO). Postmortem lung wet-to-dry weight ratios were obtained by gravimetry. Restricting fluids significantly reduced fluid intake but increased the use of vasopressors among animals with PARDS. Arterial blood pressure was similar between groups, yet CO declined significantly in animals receiving restrictive fluids (P = 0.005). There was no difference in EVLW over time (P = 0.111) and lung wet-to-dry weight ratio [6.1, interquartile range (IQR) = 6.0-7.3 vs. 7.1, IQR = 6.6-9.4, restrictive vs. liberal, P = 0.725] between fluid strategies. Both fluid strategies stabilized blood pressure in this model, yet early fluid restriction abated CO. Early fluid restriction did not limit the formation of pulmonary edema; therefore, this study suggests that in the early phase of PARDS, a restrictive fluid strategy is not beneficial in terms of immediate cardiopulmonary effects.
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Affiliation(s)
- Sarah A Ingelse
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marloes M IJland
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Lex M van Loon
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Cardiovascular and Respiratory Physiology Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Reinout A Bem
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Kaskinen AK, Martelius L, Kirjavainen T, Rautiainen P, Andersson S, Pitkänen OM. Assessment of extravascular lung water by ultrasound after congenital cardiac surgery. Pediatr Pulmonol 2017; 52:345-352. [PMID: 27740725 DOI: 10.1002/ppul.23531] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/28/2016] [Accepted: 07/02/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Lung ultrasounds show vertical artifacts known as B-lines in the presence of increased extravascular lung water (EVLW). We aimed to investigate whether lung ultrasound could estimate EVLW after congenital cardiac surgery. METHODS This prospective observational study comprised 61 children (age range 3 days to 7.4 years) undergoing congenital cardiac surgery. We compared postoperative B-line scores from lung ultrasounds, early postoperative ultrasound as our primary interest, with corresponding postoperative chest radiography (CXR) lung edema scores, with static lung compliance, and with short-term clinical outcome interpreted as time on mechanical ventilation and length of pediatric intensive care unit (PICU) stay. RESULTS Our findings showed lung ultrasound B-line scores and CXR lung edema scores as correlating 1-6 hr postoperatively (r2 = 0.41, P < 0.0001), on the first postoperative day (r2 = 0.15, P = 0.004) and on the fourth postoperative day (r2 = 0.28, P = 0.008). The B-line score or CXR lung edema score showed no correlation with lung compliance. We found that in multivariable analyses, with length of perfusion and presence of postoperative complications as covariates, both lung ultrasound (P ≤ 0.02) and CXR (P ≤ 0.002) 1-6 hr postoperatively predicted the length of mechanical ventilation and PICU stay. The interobserver variability was less for lung ultrasound B-line score than for CXR lung edema score (P = 0.001). CONCLUSIONS Our results show that lung ultrasound in assessment of postoperative EVLW predicted length of mechanical ventilation and stay in the PICU, and it had less interobserver variability than CXR. Accordingly, lung ultrasound may complement CXR in assessment of lung edema after surgery for congenital heart defect. Pediatr Pulmonol. 2017;52:345-352. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Anu K Kaskinen
- Divisions of Pediatric Cardiology, Anesthesia and Intensive Care, and Neonatology, University of Helsinki and Helsinki University Hospital, Children's Hospital, Helsinki, Finland.,Department of Pediatrics, Päijät-Häme Central Hospital, Lahti, Finland
| | - Laura Martelius
- Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Children's Hospital, Helsinki, Finland
| | - Turkka Kirjavainen
- Divisions of Pediatric Cardiology, Anesthesia and Intensive Care, and Neonatology, University of Helsinki and Helsinki University Hospital, Children's Hospital, Helsinki, Finland
| | - Paula Rautiainen
- Divisions of Pediatric Cardiology, Anesthesia and Intensive Care, and Neonatology, University of Helsinki and Helsinki University Hospital, Children's Hospital, Helsinki, Finland
| | - Sture Andersson
- Divisions of Pediatric Cardiology, Anesthesia and Intensive Care, and Neonatology, University of Helsinki and Helsinki University Hospital, Children's Hospital, Helsinki, Finland
| | - Olli M Pitkänen
- Divisions of Pediatric Cardiology, Anesthesia and Intensive Care, and Neonatology, University of Helsinki and Helsinki University Hospital, Children's Hospital, Helsinki, Finland
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Vrancken SL, Nusmeier A, Hopman JC, Liem KD, van der Hoeven JG, Lemson J, van Heijst AF, de Boode WP. Estimation of extravascular lung water using the transpulmonary ultrasound dilution (TPUD) method: a validation study in neonatal lambs. J Clin Monit Comput 2015; 30:985-994. [PMID: 26563187 PMCID: PMC5081382 DOI: 10.1007/s10877-015-9803-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/03/2015] [Indexed: 11/25/2022]
Abstract
Increased extravascular lung water (EVLW) may contribute to respiratory failure in neonates. Accurate measurement of EVLW in these patients is limited due to the lack of bedside methods. The aim of this pilot study was to investigate the reliability of the transpulmonary ultrasound dilution (TPUD) technique as a possible method for estimating EVLW in a neonatal animal model. Pulmonary edema was induced in 11 lambs by repeated surfactant lavages. In between the lavages, EVLW indexed by bodyweight was estimated by TPUD (EVLWItpud) and transpulmonary dye dilution (EVLWItpdd) (n = 22). Final EVLWItpud measurements were also compared with EVLWI estimations by gold standard post mortem gravimetry (EVLWIgrav) (n = 6). EVLWI was also measured in two additional lambs without pulmonary edema. Bland–Altman plots showed a mean bias between EVLWItpud and EVLWItpdd of −3.4 mL/kg (LOA ± 25.8 mL/kg) and between EVLWItpud and EVLWIgrav of 1.7 mL/kg (LOA ± 8.3 mL/kg). The percentage errors were 109 and 43 % respectively. The correlation between changes in EVLW measured by TPUD and TPDD was r2 = 0.22. Agreement between EVLWI measurements by TPUD and TPDD was low. Trending ability to detect changes between these two methods in EVLWI was questionable. The accuracy of EVLWItpud was good compared to the gold standard gravimetric method but the TPUD lacked precision in its current prototype. Based on these limited data, we believe that TPUD has potential for future use to estimate EVLW after adaptation of the algorithm. Larger studies are needed to support our findings.
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Affiliation(s)
- S L Vrancken
- Department of Pediatrics - Neonatology, Radboud University Medical Center, Internal Postal Code 804, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - A Nusmeier
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J C Hopman
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - K D Liem
- Department of Pediatrics - Neonatology, Radboud University Medical Center, Internal Postal Code 804, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - J G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Lemson
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A F van Heijst
- Department of Pediatrics - Neonatology, Radboud University Medical Center, Internal Postal Code 804, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - W P de Boode
- Department of Pediatrics - Neonatology, Radboud University Medical Center, Internal Postal Code 804, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Abstract
OBJECTIVES To define near-normal values of extravascular lung water indexed to body weight in children. DESIGN Prospective multicenter observational study. SETTING Medical/surgical PICUs of 5 multinational hospitals. PATIENTS Fifty-eight children with a median age of 4 years (range 1 month to 17 year) with heterogeneous PICU admission diagnoses were included. Extravascular lung water measurements from these children were collected after resolution of their illness. Obtained values were indexed to actual body weight and height and subsequently related to age. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Extravascular lung water indexed to body weight correlated with age (r2 = 0.7) and could be categorized in three-age groups consisting of significantly different median extravascular lung water indexed to body weight values (5th-95th percentile): less than 1 year, 9-29 mL/kg; 1-5 years, 7-25 mL/kg; and 5-17 years, 5-13 mL/kg. Extravascular lung water indexed to height did not correlate to age and resulted in an age-independent near-normal value of less than 315 mL/m. CONCLUSIONS Younger children have higher values of extravascular lung water indexed to actual body weight. Age categorized near-normal values of extravascular lung water indexed to body weight are presented for possible clinical use. Furthermore, we suggest to index extravascular lung water to height, which seems to be age independent.
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Martelius L, Süvari L, Janér C, Helve O, Kaskinen A, Kirjavainen T, Pitkänen O, Andersson S. Lung Ultrasound and Static Lung Compliance during Postnatal Adaptation in Healthy Term Infants. Neonatology 2015; 108:287-92. [PMID: 26345316 DOI: 10.1159/000438453] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 07/08/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND B-lines in lung ultrasound can be used to estimate lung liquid. B-lines are ring-down artifacts that arise from alterations to subpleural lung parenchyma. Lung ultrasound has been used to differentiate between diseases causing respiratory symptoms in neonates. B-lines are also seen in healthy infants during postnatal adaptation. Static lung compliance is a measure of the elasticity of the lungs. OBJECTIVES Our aim was to document lung ultrasound findings, static lung compliance and their relationship during postnatal adaptation in healthy term infants. METHODS Lung ultrasound and measurement of static lung compliance were performed in 34 infants at ages of 0-4 and 24 h. B-lines in lung ultrasound were scored using a 5-step scale. Separate ultrasound scores for the upper and lower fields were also calculated. RESULTS A significant decrease in the abundance of B-lines and a concomitant significant improvement in static lung compliance was observed from <4 to 24 h of age. At <4 h the B-lines were significantly more abundant in the lower fields. No significant correlation existed between lung ultrasound and static lung compliance. CONCLUSION The concomitant decrease in the B-lines in ultrasound and the increase in lung compliance during the first 24 h are likely to reflect clearance of lung liquid.
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Affiliation(s)
- Laura Martelius
- Department of Radiology, HUS Medical Imaging Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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