Relationship between fluid overload and mortality and morbidity in pediatric intensive care unit

OBJECTIVE

The relationship between fluid overload and clinical outcomes was investigated.

DESIGN

This study is an observational and analytic study of a retrospective cohort.

SETTINGS

Pediatric intensive care units.

PATIENTS OR PARTICIPANTS

Between 2019 and 2021 children who needed intensive care were included in the study.

INTERVENTIONS

No intervention.

MAIN VARIABLE OF INTEREST

Early, peak and cumulative fluid overload were evaluated.

RESULTS

The mortality rate was 11.7% (68/513). When fluid overloads were examined in terms of mortality, the percentage of early fluid overload was 1.86 and 3.35, the percent of peak fluid overload was 2.87 and 5.54, and the percent of cumulative fluid overload was 3.40 and 8.16, respectively, in the survivor and the non-survivor groups. After adjustment for age, severity of illness, and other potential confounders, peak (aOR = 1.15; 95%CI 1.05-1.26; p: 0.002) and cumulative (aOR = 1.10; 95%CI 1.04-1.16; p < 0.001) fluid overloads were determined as independent risk factors associated with mortality. When the cumulative fluid overload is 10% or more, a 3.9-fold increase mortality rate was calculated. It is found that the peak and cumulative fluid overload, had significant negative correlation with intensive care unit free days and ventilator free days.

CONCLUSIONS

It is found that peak and cumulative fluid overload in critically ill children were independently associated with intensive care unit mortality and morbidity.

Association between fluid overload and mortality in children with sepsis: a systematic review and meta-analysis

BACKGROUND

Sepsis is one of the main causes of morbidity and mortality worldwide. Fluid resuscitation is among the most common interventions and is associated with fluid overload (FO) in some patients. The objective of this systematic review and meta-analysis was to summarise the available evidence on the association between FO and morbimortality in children with sepsis.

METHODS

A systematic search was carried out in PubMed/Medline, Embase, Cochrane and Google Scholar up to December 2022 (PROSPERO 408148), including studies in children with sepsis which reported more than 10% FO 24 hours after admission to intensive care. The risk of bias was assessed using the Newcastle-Ottawa scale. Heterogeneity was assessed using I2, considering it absent if <25% and high if >75%. A sensitivity analysis was run to explore the impact of the methodological quality on the size of the effect. Mantel-Haenszel's model of random effects was used for the analysis. The primary outcome was to determine the risk of mortality associated with FO and the secondary outcomes were the need for mechanical ventilation (MV), multiple organ dysfunction syndrome (MODS) and length of hospital stay associated with FO.

RESULTS

A total of 9 studies (2312 patients) were included, all of which were observational. Children with FO had a higher mortality than patients without overload (46% vs 26%; OR 5.06; 95% CI 1.77 to 14.48; p<0.01). We found no association between %FO and the risk of MODS (OR: 0.97; 95% CI 0.13 to 7.12; p=0.98). Children with FO required MV more often (83% vs 47%; OR: 4.78; 95% CI 2.51 to 9.11; p<0.01) and had a longer hospital stay (8 days (RIQ 6.5-13.2) vs 7 days (RIQ 6.1-11.5); p<0.01).

CONCLUSION

In children with sepsis, more than 10% FO 24 hours after intensive care admission is associated with higher mortality, the need for MV and length of hospital stay.

Intravenous Fluid Bolus Rates Associated with Outcomes in Pediatric Sepsis: A Multi-Center Analysis

Purpose

Patients and Methods

Results

Conclusion

Immunomodulator use in paediatric severe sepsis and septic shock

INTRODUCTION

The use of drugs that modulate the immune system during paediatric severe sepsis and septic shock may alter the course of disease and is poorly studied. This study aims to characterise these children who received immunomodulators and describe their clinical outcomes.

METHODS

This is a retrospective chart review of patients with severe sepsis and septic shock admitted into the paediatric intensive care unit (PICU). Clinical, haematological and outcome characteristics of patients with or without exposure to immune-modulating drugs were compared. Primary outcome was PICU mortality; secondary outcomes were 28-day ventilator-free days (VFD) and intensive care unit-free days (IFD). Univariate and multivariable analyses were performed for these outcomes.

RESULTS

A total of 109 patients with paediatric severe sepsis or septic shock were identified. Of this number, 47 (43.1%), 16 (14.7%) and 3 (2.8%) patients received systemic corticosteroids, intravenous immunoglobulins and granulocyte colony stimulating factor, respectively. Patients who received immune-modulating drugs were more likely to require invasive ventilation (38/54 [70.4%] versus 26/55 [47.3%], P=0.019) compared to those who did not. PICU mortality was indifferent between the 2 groups (20/54 [37.0%] vs 11/55 [20.0%], P=0.058) even after accounting for chronic complex conditions and admission organ dysfunction (PELOD score) (adjusted odds ratio 1.90, confidence interval [0.72-5.01], P=0.193). However, VFD (19.5 [0-28] vs 25 [12-28] days, P=0.038) and IFD (15 [0-24] vs 22 [9-26] days, P=0.024) were decreased in the immunomodulator group compared to the non-immunomodulator group.

CONCLUSION

Immune-modulating drugs were frequently used in paediatric severe sepsis and septic shock. Patients who received these drugs seemed to require more PICU support. Further studies are required to examine this association thoroughly.