Díaz Franco, Nuñez María José, Pino Pablo, Erranz Benjamín, Cruces Pablo
Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile.
Pediatric Intensive Care Unit, Clínica Alemana de Santiago, Santiago, Chile.
BMC Pediatr. 2018 Jun 26;18(1):207. doi: 10.1186/s12887-018-1188-6.
Fluid overload (FO) is associated with unfavorable outcomes in critically ill children. Clinicians are encouraged to avoid FO; however, strategies to avoid FO are not well-described in pediatrics. Our aim was to implement a bundle strategy to prevent FO in children with sepsis and pARDS and to compare the outcomes with a historical cohort.
A quality improvement initiative, known as preemptive fluid strategy (PFS) was implemented to prevent early FO, in a 12-bed general PICU. Infants on mechanical ventilation (MV) fulfilling pARDS and sepsis criteria were prospectively recruited. For comparison, data from a historical cohort from 2015, with the same inclusion and exclusion criteria, was retrospectively reviewed. The PFS bundle consisted of 1. maintenance of intravenous fluids (MIVF) at 50% of requirements; 2. drug volume reduction; 3. dynamic monitoring of preload markers to determine the need for fluid bolus administration; 4. early use of diuretics; and 5. early initiation of enteral feeds. The historical cohort treatment, the standard fluid strategy (SFS), were based on physician preferences. Peak fluid overload (PFO) was the primary outcome. PFO was defined as the highest FO during the first 72 h. FO was calculated as (cumulative fluid input - cumulative output)/kg*100. Fluid input/output were registered every 12 h for 72 h.
Thirty-seven patients were included in the PFS group (54% male, 6 mo (IQR 2,11)) and 39 with SFS (64%male, 3 mo (IQR1,7)). PFO was lower in PFS (6.31% [IQR4.4-10]) compared to SFS (12% [IQR8.4-15.8]). FO was lower in PFS compared to CFS as early as 12 h after admission [2.4(1.4,3.7) v/s 4.3(1.5,5.5), p < 0.01] and maintained during the study. These differences were due to less fluid input (MIVF and fluid boluses). There were no differences in the renal function test. PRBC requirements were lower during the first 24 h in the PFS (5%) compared to SFS (28%, p < 0.05). MV duration was 81 h (58,98) in PFS and 118 h (85154) in SFS(p < 0.05). PICU LOS in PFS was 5 (4, 7) and in SFS was 8 (6, 10) days.
Implementation of a bundle to prevent FO in children on MV with pARDS and sepsis resulted in less PFO. We observed a decrease in MV duration and PICU LOS. Future studies are needed to address if PFS might have a positive impact on health outcomes.
液体超负荷（FO）与危重症儿童的不良预后相关。鼓励临床医生避免液体超负荷；然而，儿科中避免液体超负荷的策略尚无详尽描述。我们的目的是实施一项集束策略，以预防脓毒症和小儿急性呼吸窘迫综合征（pARDS）患儿出现液体超负荷，并将结果与一个历史队列进行比较。
在一个拥有12张床位的普通儿科重症监护病房（PICU）实施一项名为“预防性液体策略（PFS）”的质量改进措施，以预防早期液体超负荷。前瞻性招募符合pARDS和脓毒症标准且正在接受机械通气（MV）的婴儿。为作比较，回顾性分析了2015年一个具有相同纳入和排除标准的历史队列的数据。PFS集束包括：1. 将静脉输液量（MIVF）维持在需求量的50%；2. 减少药物用量；3. 动态监测前负荷指标以确定是否需要给予液体推注；4. 早期使用利尿剂；5. 早期开始肠内喂养。历史队列的治疗，即标准液体策略（SFS），是基于医生的偏好。峰值液体超负荷（PFO）是主要结局。PFO定义为最初72小时内最高的液体超负荷。液体超负荷计算为（累积液体输入量 - 累积输出量）/体重（kg）×100。每12小时记录72小时的液体输入/输出量。
PFS组纳入37例患者（54%为男性，6个月（四分位间距[IQR]2,11）），SFS组39例（64%为男性，3个月（IQR1,7））。与SFS组（12% [IQR8.4 - 15.8]）相比，PFS组的PFO较低（6.31% [IQR4.4 - 10]）。入院后12小时起，PFS组的液体超负荷就低于SFS组[2.4(1.4,3.7) 对比 4.3(1.5,5.5)，p < 0.01]，且在研究期间一直保持。这些差异是由于液体输入量（MIVF和液体推注）较少。肾功能检查无差异。PFS组在最初24小时内红细胞悬液（PRBC）需求量为5%，低于SFS组的28%（p < 0.05）。PFS组的机械通气时长为81小时（58,98），SFS组为118小时（85,154）（p < 0.05）。PFS组的儿科重症监护病房住院时长为5（4, 7）天，SFS组为8（6, 10）天。
对接受MV治疗的pARDS和脓毒症患儿实施预防液体超负荷的集束措施，可降低PFO。我们观察到机械通气时长和儿科重症监护病房住院时长有所减少。未来需要开展研究，以确定PFS是否可能对健康结局产生积极影响。
