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. 2025 Apr 1;26(4):e454-e462.
doi: 10.1097/PCC.0000000000003693. Epub 2025 Jan 21.

Fluid Management Bundle in Critically Ill Children With Respiratory Failure Is Associated With a Reduced Prevalence of Excess Fluid Accumulation

Matthew J Foglia  1 , Sarah M Bedoyan  2 , Christopher M Horvat  2   3 , Anthony Fabio  4 , Dana Y Fuhrman  2   3
Affiliations

Fluid Management Bundle in Critically Ill Children With Respiratory Failure Is Associated With a Reduced Prevalence of Excess Fluid Accumulation

Matthew J Foglia et al. Pediatr Crit Care Med. .

Abstract

Objectives: To report the feasibility of a fluid management practice bundle and describe the pre- vs. post-implementation prevalence and odds of cumulative fluid balance greater than 10% in critically ill pediatric patients with respiratory failure.

Design: Retrospective cohort from May 2022 to December 2022.

Setting: Quaternary care PICU in Pittsburgh, PA.

Patients: Children older than 28 days receiving invasive mechanical ventilation for greater than 48 hours.

Interventions: None.

Measurements and main results: We reviewed data from 205 patients; 104 before bundle implementation and 101 after bundle implementation. At the time of implementation in 2022, our PICU clinicians were educated on the use of the fluid management practice bundle, which included the following during daily rounds: goal-setting for daily fluid balance; assessing transition to enteral nutrition; and fluid conservation measures such as concentrating infusions or using enteral formulations of medications. A cumulative fluid balance greater than 10% occurred in 46 of 104 patients (44%) pre-implementation and 26 of 101 patients (26%) post-implementation. We failed to identify an association between implementation epoch grouping (pre- and post-) and adverse outcomes, including mortality, duration of mechanical ventilation, acute kidney injury, and ICU length of stay. In a multivariable logistic regression model, management during the fluid management bundle was associated with lower odds of a cumulative fluid balance greater than 10% (adjusted odds ratio, 0.35 [95% CI, 0.18-0.68]).

Conclusions: In our PICUs 2022 peri-implementation testing of a fluid management bundle in critically ill children with respiratory failure, we have first found that such a practice change is feasible. Second, we identified an associated decrease in the prevalence and lower odds of fluid accumulation. We continue to use this fluid management bundle in our center but more widespread prospective studies are needed to test the benefit in clinical practice.

Keywords: acute kidney injury; critical illness; fluid accumulation; fluid restriction; fluid therapy.

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Conflict of interest statement

Dr. Horvat’s institution received funding from the National Institute of Child Health and Human Development. Drs. Horvat, Fabio, and Fuhrman received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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