(1340) Development and Implementation of a Fluid Management Strategy in the Pediatric ICU

Introduction: Fluid overload, the pathologic state of positive fluid balance, is common in the pediatric intensive care unit (PICU) and independently associated with poor outcomes. There is a lack of quality improvement-based processes to measure and assess fluid balance in critically ill children. We sought to develop and implement a fluid management strategy to standardize measurement and assessment of fluid balance and fluid administration in critically ill children.

Methods: We developed the four components of our fluid management strategy and sought adherence in at least 50% of PICU patients. These include: 1) create a fluid balance dashboard that tracks percent cumulative fluid balance over time; 2) documentation of daily weights; 3) fluid balance reporting and discussion incorporated into standardized rounds; 4) active total intravenous (IV) fluid order if receiving continuous IV fluids. We utilized Plan-Do-Study-Act (PDSA) cycles to implement, track, and improve compliance to each measure.

Results: We reviewed 280 PICU patient encounters from May 2023 to April 2024. We achieved our primary aim of at least 50% compliance with the fluid management strategy and maintained this success over time. Updating our PICU admission order set to include a total IV fluid order and order for daily weights coincided with achieving at least 50% compliance with the fluid management strategy, with the center line increasing from 30% to 70% after this intervention. The center lines for each process measure as of April 2024 are: 100% patients on fluid balance dashboard, 80% documented daily weights, 90% fluid balance reported on rounds, and 100% with an active total IV fluid order.

Conclusions: We achieved our aim of at least 50% compliance with our fluid management strategy since September 2023. Future work will involve daily utilization of the fluid balance dashboard to evaluate each patient’s cumulative fluid balance and highlight patients with likely pathologic fluid balance that may require intervention. We will also evaluate clinical outcomes such as use of continuous renal replacement therapy (CRRT) and percent fluid overload at CRRT initiation over time. This important first step is needed as a foundation for targeting optimal fluid balance and mitigating harmful effects of fluid overload.