The relationship of fluid administration to outcome in the pediatric calfactant in acute respiratory distress syndrome trial.

Abstract

OBJECTIVES:

Adult studies have demonstrated the relationship between fluid overload and poor outcomes in acute lung injury/acute respiratory distress syndrome. The approach of pediatric intensivists to fluid management in acute lung injury/acute respiratory distress syndrome and its effect on outcomes is less clear. In a post hoc analysis of our Calfactant in Acute Respiratory Distress Syndrome trial, we examined the relationship of fluid balance to in-hospital outcomes in subjects with acute lung injury/acute respiratory distress syndrome.

DESIGN:

Calfactant in Acute Respiratory Distress Syndrome was a masked randomized controlled trial of calfactant surfactant versus placebo in pediatric patients with acute lung injury/acute respiratory distress syndrome due to direct lung injury. Caregivers were encouraged to follow a conservative fluid management guideline based on the adult Fluid and Catheter Treatment Trial. Daily fluid balance was collected for the first 7 days after trial enrollment and correlated with clinical outcomes.

PATIENTS AND SETTING:

Children admitted to PICUs with acute lung injury/acute respiratory distress syndrome from 24 children's hospitals in six different countries.

INTERVENTION:

Post hoc analysis of daily fluid balance in subjects from the Pediatric Calfactant in Acute Respiratory Distress Syndrome trial.

MEASUREMENTS AND MAIN RESULTS:

Despite the conservative fluid guideline, fluid management was more consistent with a "liberal" approach. On average, study subjects accumulated 1.96 ± 4.2 L/m over the first 7 days of the trial. Subjects who died accumulated on average 8.7 ± 9.5 L/m versus 1.2 ± 2.4 L/m in survivors. Increasing fluid accumulation was associated with fewer ventilator-free days and worsening oxygenation. Multivariable regression models that included age, gender, Pediatric Risk of Mortality score, initial oxygen saturation index and PaO2/FIO2 ratio, injury category, and treatment arm failed to account for the differences in fluid management.

CONCLUSIONS:

Pediatric intensivists generally follow a "liberal" approach to fluid management in children with acute lung injury/acute respiratory distress syndrome. Illness severity or oxygenation disturbance did not explain differences in fluid accumulation but such accumulation was associated with worsening oxygenation, a longer ventilator course, and increased mortality. A more conservative approach to fluid management may improve outcomes in children with acute lung injury/acute respiratory distress syndrome.

• Authors: Douglas F Willson, Neal J Thomas, Robert Tamburro, Edward Truemper, Jonathon Truwit, Mark Conaway, Christine Traul, Edmund E Egan, Pediatric Acute Lung and Sepsis Investigators Network
• Journal: Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies (Pediatr Crit Care Med) Vol. 14 Issue 7 Pg. 666-72 (Sep 2013) ISSN: 1529-7535 [Print] United States
• PMID: 23925143 (Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Chemical References

• Biological Products
• Pulmonary Surfactants
• calfactant

Topics

• Adolescent
• Biological Products (administration & dosage, therapeutic use)
• Blood Gas Analysis
• Child
• Child, Preschool
• Female
• Fluid Therapy (methods)
• Humans
• Intensive Care Units, Pediatric
• Male
• Pulmonary Surfactants (administration & dosage, therapeutic use)
• Respiration, Artificial
• Respiratory Distress Syndrome, Newborn (drug therapy, therapy)