(1521) Fluid Management Strategies of Pediatric Intensivists, Nephrologists, and Cardiac Intensivists

Introduction: Evidence that fluid overload is deleterious to patient outcomes has become more clear. Yet, it is unknown if that has changed clinical practice patterns. This study investigated the hypothesis that physicians working in the pediatric critical care unit (PICU) are still practicing liberal fluid administration in children with acute respiratory failure.

Methods: Anonymous electronic cross-sectional survey of pediatric intensivists and nephrologists disseminated to Pediatric Acute Lung Injury and Sepsis Investigators Network.

Results: Of 127 respondents, 110 (87%) were pediatric intensivists, 7% were nephrologists and 6% were pediatric cardiac intensivists. The median years after training was 8 (IQR 4-15) in intensivists, 12 (IQR 6.5-23) in nephrologists and 10 (IQR 5-20) in pediatric cardiac intensivists (p=0.257). Almost all work in a PICU with ECMO (84%) and renal replacement therapy (91%) capabilities. While half of intensivists (51%) reported starting intravenous fluids at an hourly rate lower than the 100% maintenance rate, none of the nephrologists fluid restrict (p < 0.001). A larger proportion of pediatric intensivists and cardiac intensivists reported starting diuretics within 48 hours of hemodynamic stability than nephrologists (79% versus 56%, respectively). Enteral nutrition was not included in the total intake and output calculations by 11% of intensivists and 22% reported that they do not alter the feeding volume or caloric density of feeds as a fluid management strategy. Only 30% of intensivists reported that they would lower the enteral feeding volume or increase caloric density of feeds to meet fluid goals, compared to 78% of nephrologists and 71% of pediatric cardiac intensivists (p=0.002).

Conclusions: The majority of pediatric intensivists and cardiac intensivists are fluid restricting and half start diuretics within 48 hours of hemodynamic stability. More restrictive fluid management strategies may be key to early liberation from the ventilator and overall lower morbidity. Enteral nutrition is not always considered in fluid calculations. Further study appears warranted on the effect of enteral fluid intake on overall fluid management strategies.