Renal Critical Care
Profile of Fluid Exposure and Recognition of Fluid
Overload in Critically Ill Children
Zahraa H. Al-Lawati, MD1,2; Moushumi Sur, MD2; Curtis E. Kennedy, MD, PhD2;
Ayse Akcan Arikan, MD2,3
Objectives: Fluid overload is common in the PICU and has been
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associated with increased morbidity and mortality. It remains un-
clear whether fluid overload is a surrogate marker for severity of
illness and need for increased support, an iatrogenic modifiable
risk factor, or a sign of oliguria. The proportions of various fluid
intake contributing to fluid overload and its recognition have not
been adequately examined. We aimed to: 1) describe the types
and amounts of fluid exposure in the PICU and 2) identify the clini-
cians’ recognition of fluid overload.
Setting: Noncardiac PICU in a quaternary care hospital.
Patients: Pediatric patients admitted for more than 24 hours.
Design: Prospective observational study over 28 days.
Interventions: Data were collected on the amount and type of
fluid exposure—resuscitative boluses, blood products, enteral in-
take, parenteral nutrition (total parenteral nutrition), or modifiable
fluids (IV fluids and medications) indexed to the patients’ admis-
sion body surface area on days 1 and 3. Charts of patients admit-
ted for 3 days who developed 15% fluid overload were reviewed
to assess clinicians’ recognition of fluid overload.
Measurements and Main Results: One hundred two patients were
included. Day 1 median fluid exposure was 2,318 mL/m2 (1,831–
3,037 mL/m2; 1,646 mL/m2 [1,296–2,086 mL/m2] modifiable flu-
ids). Forty-seven patients (46%) received fluid boluses, and 16
(16%) received blood products. Day 3 median fluid exposure was
2,233 mL/m2 (1,904–2,556 mL/m2; 750 mL/m2 [375–1,816 mL/
m2] modifiable fluids). Of the 54 patients, one patient (1.9%)
received a fluid bolus and two (3.7%) received blood products.
In our cohort, 47 of 54 (87%) had fluid exposure greater than
1,600 mL/m2 on day 3. Fluid overload was not recognized by the
clinicians in 30% of the patients who developed more than 15%
fluid overload.
1
Department of Pediatrics/Division of Critical Care, Wayne State Univer-
sity, Detroit, MI.
2
Department of Pediatrics/Section of Critical Care, Baylor College of
Medicine, Houston, TX.
3
Department of Pediatrics/Renal Section, Baylor College of Medicine,
Houston, TX.
Copyright © 2020 by the Society of Critical Care Medicine and the World
Federation of Pediatric Intensive and Critical Care Societies
DOI: 10.1097/PCC.0000000000002337
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Copyright © 2020 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
Conclusions: Although resuscitation fluids contributed more to
fluid exposure on day 1 compared with day 3, fluid exposure
frequently exceeded maintenance requirements on day 3. Fluid
overload was not always recognized by PICU practitioners. Fur-
ther studies to correlate modifiable fluid exposure to fluid over-
load and explore modifiable practice improvement opportunities
are needed. (Pediatr Crit Care Med 2020; 21:760–766)
Key Words: critical care; fluid administration; fluid balance; fluid
overload; pediatric intensive care unit; pediatrics
L
iberal fluid administration is ubiquitous in the ICU,
especially in patients with shock who are undergo-
ing active resuscitation to optimize cardiac output and
organ perfusion (1, 2). Unfortunately, fluid overload (FO) is
also a common occurrence in the PICU and is associated with
increased morbidity and mortality (3–6).
First demonstrated in pediatric patients on renal replace-
ment therapy, positive fluid balance is an independent pre-
dictor of worse oxygenation, longer ventilator duration, and
longer length of ICU stay in pediatric critically ill patients
(5, 7–12) including children following cardiac surgery (13,
14). Furthermore, conservative fluid strategy in adult respi-
ratory distress syndrome patients resulted in improved lung
function, shorter duration of mechanical ventilation, and
shorter ICU stay compared with patients receiving liberal
fluids (15).
Multiple studies have shown associating adverse outcomes
with positive fluid balance, but the causes of FO remain elu-
sive. Excessive fluid administration, oliguria and acute kidney
injury (AKI), and severity of illness are all postulated to play
a role, although the cause of FO has not been fully identified.
FO as a biomarker in the clinical setting has also not been
adopted despite its link with morbidity and mortality and may
be underrecognized by the practitioner.
PICU patients commonly receive large volume of fluids
for resuscitation, medications, and nutrition. Patients who
are severely ill are often placed on parenteral fluids instead
of enteral nutrition (16). The actual amount of maintenance
fluid needs in critically ill children is unknown as available

information was derived from studies done in healthy children
(17). Although total volume of fluids and cumulative fluid ad-
ministration have been investigated, type and amount of fluid
exposure (FE) and whether these fluids play a role in FO in
pediatric patients have not been studied. Although a recent
study evaluated self-reported physician fluid management
(18), studies evaluating recognition of FO by the clinician
are also lacking; recognition of FO by clinicians may modify
physician’s prescribing behavior of fluids and potentially the
treatment plan. Therefore, the aims of this study were to: 1)
describe the amount and type of FE in PICU patients on day
1 (initial) and day 3 (ongoing) and 2) identify whether FO is
recognized by the PICU practitioner.
MATERIALS AND METHODS
This was a single-center prospective exploratory study at a
quaternary care pediatric hospital in a 31-bed noncardiac unit
with 1,200 admissions per year. All patients admitted to the
PICU for at least 24 hours over a month (February 2015) were
included. Patients on extracorporeal renal or life support were
excluded.
Fluid Administration
We examined the amount and types of FE on days 1 and 3 of
PICU stay; fluids administered prior to PICU admission were
not taken into consideration as records of their administra-
tion were not always recorded. We chose days 1 and 3 to assess
initial fluid management when stabilizing the patient (day 1)
compared with fluid management later during the PICU stay,
when shock, if initially present, was theorized to have resolved
(day 3). Therefore, we chose to examine fluid administration
these 2 days with the goal of investigating associations with FO
at a later time.
Fluids were categorized into obligate fluids (fluid boluses,
blood products, total parenteral nutrition [TPN], and enteral
intake) and modifiable fluids (IV fluids and medications) in
order to evaluate nonnutritive, nonresuscitative, non-blood
product FE received by the patients. Data were also collected
on demographics, ventilatory status, need for vasoactive
medications, FO status, and urine output. FO was calculated
as a percentage of ([cumulative fluid in (L ) − fluid out (L )]/
PICU admission weight × 100) as previously reported (19).
We defined FO as greater than or equal to 15% because this
threshold has previously been shown to be independently as-
sociated with longer duration of ventilation, PICU stay, and
hospital length of stay (LOS) in our unit (3).
FO Recognition
We assessed patients admitted for at least 3 days in the PICU
for the development of FO within 7 days from PICU admis-
sion; we also examined clinicians’ recognition of FO via screen-
ing of medical record for documentation for description of an
edematous patient on physical examination in the progress
note, documentation of “Fluid Overload” in the patient chart
or problem list, or initiation of “minimum dilution protocol”
(“Minimum dilution protocol” is an institutional pharmacy
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Renal Critical Care
protocol of the practice of concentrating medications. It is an
order placed by prescribers that triggers a protocol for concen-
tration to be followed by pharmacy where all possible medica-
tions are maximally concentrated to minimize FE. Therefore,
it requires awareness of FE on the part of the prescribing cli-
nician). We do not have any other protocols that would affect
the amount of fluids administered (IV fluid [IVF] protocols or
nutrition protocols). We additionally surmised that clinicians
who initiated diuretic treatment might be recognizing FO as
diuretics are used to treat fluid excess; hence, their prescription
is a surrogate of FO recognition.
The institutional Review Board of Baylor College of
Medicine approved the study protocol and waived the in-
formed consent requirement.
Statistical Analysis
Our study was a descriptive analysis, where cumulative fluid
balance data and subset of fluids administered were meas-
ured as a continuous variable over the first 3 days of PICU
admission. Daily fluid balance was calculated from the time
they were admitted in increments of 24 hours from admis-
sion. Continuous variables were presented as median with in-
terquartile range (IQR) and mean ± sd. Categorical variables
were presented as proportions. STATA statistical software
package (StataCorp, LLC, College Station, TX) and R (version
3.2.1; R Core Team, Vienna, Austria) were used for all analyses.
RESULTS
Fluid Administration
Patient Population. Of the 140 patients admitted, 102 met in-
clusion criteria (37 were admitted for < 24 hr, and one patient
was on peritoneal dialysis) (Fig. 1). Forty-nine (48%) were
female, and median age was 17 months (IQR, 6–112). Fifty-
four patients were in the PICU for more than 72 hours and
hence were included in day 3 analysis. Forty-eight patients
(47%) were on invasive mechanical ventilation on day 1, and
32 out of the 54 (59%) on day 3 of PICU stay. Of these patients,
two (3.7%) were intubated after day 1 of admission. Thirteen
(13%) of the patients were receiving vasoactive medications on
day 1 as opposed to six (11%) on day 3 of PICU stay—of these
six patients, five were continued on vasoactive medications
from day 1, and one patient was started after the first day in the
PICU (Table 1). Median peak FO was 8.8% (IQR, 4.3–18) dur-
ing PICU stay. Median PICU LOS was 68 hours (IQR, 39–142),
and median length of mechanical ventilation (LMV) for venti-
lated patients was 74 hours (IQR, 28–160), with a mortality of
2.9% (3/102). Of the patients who met 15% FO, median ICU
LOS was 143 hours (IQR, 62–281); median LMV for ventilated
patients was 143 hours (IQR, 98–249) with 0% mortality.
Day 1 Fluid Administration. Patients received a median of
2,318 mL/m2 (IQR, 1,831–3,037 mL/m2) or 107 mL/kg (IQR,
75.2–137 mL/kg) of fluids on day 1, and enteral fluids com-
promised a median of 22 mL/m2 (IQR, 0–168 mL/m2) or 1 mL/
kg (IQR, 0–6.8 mL/kg). Forty-seven patients (46%) received
fluid boluses, 16 patients (16%) received blood products, and
 Al-Lawati et al

(2/48). The remainder of the 54

patients who stayed longer than
72 hours received 2,330  mL/
m2 (IQR, 2,010–3,057 mL/m2)
and 1,668 mL/m2 (IQR, 1,421–
2,086 mL/m2) modifiable fluids
on day 1 of PICU stay; mortality
was 1.8% (1/54).
Day 3 Fluid Administration.
FE on day 3 of PICU stay was
2,233 mL/m2 (1,904–2,556 mL/
m2) or 103  mL/kg (IQR,
87.8–128  mL/kg). Enteral flu-
ids compromised a median of
724 mL/m2 (IQR, 37–1,892 mL/
m2) or 28.8 mL/kg (IQR, 1.36–
90.8 mL/kg). Only one patient
(1.9%) received fluid boluses of
194 mL/m2 or 9.9 mL/kg. Two
patients (4%) received blood
products of 313  mL/m2 and
970 mL/m . Of the 10 patients
2

who received TPN, the median

Figure 1. Flow diagram of the patients selected and included in the study.
12 patients (12%) received TPN. Of those patients who re-
ceived fluid boluses, the median amount was 574 mL/m2 (IQR,
415–1,135 mL/m2) or 20 mL/kg (IQR, 20–47 mL/kg). Of those
who received blood products, the median amount was 256 mL/
m2 (IQR, 133–565 mL/m2) or 10 mL/kg (IQR, 6–28 mL/kg). Of
those who received TPN, the median amount was 1,317 mL/
m2 (IQR, 1,023–1,658) or 49 mL/kg (IQR, 40–62 mL/kg). Of
the 47 patients who received fluid boluses, nine (19%) also
received blood products. When bolus fluids, blood products,
TPN, and enteral fluids were subtracted from total FE, patients
received a median of 1,646 mL/m2 (IQR, 1,296–2,086 mL/
m2) or 73.9 mL/kg (IQR, 43.9–101 mL/kg) as modifiable flu-
ids (Fig. 2). Cumulative fluid balance on day 1 was 812 mL/m2
(IQR, 321–1,444 mL/m2) or 31.5 mL/kg (IQR, 11.7–66.7 mL/
kg). Median FO on day 1 was 3.2% (IQR, 1.2–6.7), and 11
patients (11%) had more than 15% positive fluid balance and
therefore, FO.
Urine output in the first 24 hours was 2.6 mL/kg/hr (IQR, 1.7–
3.6 mL/kg/hr) (Table 1). Based on the Kidney Disease Improving
Global Outcomes (KDIGO) urine output AKI criteria, one pa-
tient was oliguric (using KDIGO urine criteria of < 0.5 mL/kg/
hr) (20). Because urine output was recorded in increments of 12
hours, frequency of stage 1 AKI by KDIGO urine output crite-
ria could not be established. Net fluid output was 1,422 mL/m2
(IQR, 894–2,325 mL/m2) or 63 mL/kg (IQR, 40.2–87.4 mL/kg).
Of the patients included in the study, 48 patients did not
stay for more than 72 hours and therefore were not included in
data analysis of fluids on day 3. On day 1, these patients received
2,257 mL/m2 (IQR, 1,574–2,957 mL/m2) of fluids or 1,615 mL/m2
(IQR, 1,030–2,216 mL/m2) of modifiable fluids; mortality was 4%
amount was 1,468 mL/m2 (IQR,
973–1,825 mL/m2) or 57.9 mL/
kg (IQR, 41.8–83 mL/kg).
When fluid boluses, blood products, TPN, and enteral flu-
ids were subtracted, patients received 750 mL/m2 (IQR, 375–
1,816 mL/m2) or 36.5 mL/kg (IQR, 18–68 mL/kg) of modifiable
fluids (Fig. 2). Cumulative fluid balance on day 3 was 414 mL/
m2 (IQR, 45–958 mL/m2) or 21.6 mL/kg (IQR, 1.49–45.9 mL/
kg). Of the 54 patients, 13 (24%) had a negative cumulative
fluid balance. Twenty-three patients (43%) received less than
300 mL/m2 of fluids enterally; of these, only 10 (18%) were on
TPN. Median FO on day 3 was 12 (IQR, 8–16), and 19 patients
(35%) had more than 15% positive fluid balance.
Urine output was 3.56 mL/kg/hr (IQR, 2.3–4.3 mL/kg/hr)
(Table 1). Based on KDIGO urine output criteria, none of the
patients were oliguric on day 3. Net fluid output was 1,699 mL/m2
(IQR, 1,321–2,180 mL/m2) or 85 mL/kg (IQR, 53.4–103 mL/kg).
Forty-seven (87%) of the patients received more than
1,600 mL/m2 of fluids on day 3 of their PICU stay with a mean
of 750 mL/m2 of modifiable fluids.
FO Recognition
Of the 102 patients, 69 patients were admitted to the PICU for
at least 3 days, and 30 of 69 (43%) of them met FO criteria in
the first 7 days of ICU admission. Patients developed FO in a
median of 2.5 days (IQR, 1–4) from PICU admission.
Of the 30 patients who met FO criteria, only seven patients
(23%) had explicit documentation of FO in their electronic
medical record (EMR) and 14 (47%) appeared to be recog-
nized based on surrogate markers of the use of minimum dilu-
tion protocol or diuretic use. Four patients (13%) were placed
on minimal dilution protocol (MDP); only two (6.6%) of the
patients on MDP had the designation of FO in their EMR.

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 Renal Critical Care

TABLE 1. Patient Demographics and Fluid Exposure on Study Days

Variable Day 1 Day 3

Total patients 102 54

Median age 17 mo (6–112) 9 mo (3–26)
Female, n (%) 49 (48) 28 (52)
Diagnoses, n (%) Acute respiratory failure: 31 (30) Acute respiratory failure: 26 (48)
Status asthmaticus: 3 (2.9) Status asthmaticus: 2 (3.7)
Bronchiolitis/croup: 4 (3.9) Bronchiolitis/croup: 2 (3.7)
Pneumonia: 5 (4.9) Pneumonia: 3 (5.6)
Septic shock: 6 (5.9) Septic shock: 2 (3.7)
Postsurgical management: 5 (4.9) Postsurgical management: 4 (7.4)
Malignant neoplasm/leukemia: 12 (12) Malignant neoplasm/leukemia: 4 (7.4)
Neurologic disease: 11 (11) Neurologic disease: 3 (5.6)
End-stage liver disease: 1 (0.98) Other: 8 (15)
Other: 21 (21)
Ventilated patients, n (%) 48 (47) 32 (59)
Patients on vasoactive medications, n (%) 13 (13) 6 (11)
Fluid boluses, n (%) 47 (46) 1 (1.9)
Fluid boluses (mL/m2/d), median (IQR) 0 (0–529) 0 (0–0)
% of total fluids 15 0
Blood products, n (%) 16 (16) 2 (3.7)
Blood products (mL/m2/d), median (IQR) 0 (0–0) 0 (0–0)
% of total fluids 3 1
TPN, n (%) 12 (12) 10 (19)
TPN (mL/m /d), median (IQR)
2
0 (0–0) 0 (0–0)
% of total fluids 5.8 12
Enteral fluids (mL/m /d), median (IQR)
2
22 (0–168) 724 (37–1,892)
% of total fluids 9.8 41
Modifiable fluid (mL/m /d), median (IQR)
2
1,646 (1,296–2,086) 750 (375–1,816)
% of total fluids 65 46
Total fluid (mL/m /d), median (IQR)
2
2,318 (1,831–3,037) 2,233 (1,904–2,556)
FO (%) 3.2 (1.2–6.7) 12 (8–16)
Patients with > 15% FO, n (%) 11 (11) 19 (35)
Urine output (mL/kg/hr), median (IQR) 2.6 (1.7–3.6) 3.56 (2.3–4.3)
FO = fluid overload, IQR = interquartile range, TPN = total parenteral nutrition.
Patient demographics and description of patients including analysis of types of fluid administered. All data are shown as median (IQR) unless otherwise noted.
Diagnoses extracted from patient’s problem list are included. The percentage of each fluid category compromised of the total was calculated using means.

Of the 30 patients who had FO, 20 patients (66%) were
on diuretics prior to or within 48 hours of meeting FO.
Of these, seven patients (23%) were already on diuretics
prior to meeting FO criteria, 12 (40%) got started within 24
hours, and one (3.3%) within 48 hours. All of the patients
on MDP were also on diuretics. Of the seven patients
recognized by clinicians as having FO, six (86%) were on
diuretics, and two (29%) were also on MDP. When the use
of diuretics as a surrogate marker for FO recognition was
combined along with clinical documentation and institu-
tion of MDP, 21 of the 30 patients (70%) were recognized
as having FO by the clinicians (Fig. 3). Thus, around one in

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 Al-Lawati et al

resuscitative phase of their ill-

ness. Our study demonstrated
that resuscitative fluids con-
tributed more to day 1 FE
compared with day 3 (15% vs
0.17%). However, we found
that a large number of patients
continued to receive signifi-
cantly more fluids than main-
tenance requirement on day 3
of PICU stay. This additional
FE was mostly due to poten-
tially modifiable (nonnutritive,
nonresuscitative) FE. FO was
missed by clinicians in nearly
nine of 30 patients (30%).
Although associated with
morbidity and mortality (3,
7, 11, 21, 22), the causes of
FO in the ICU are not fully
understood. Renal injury and
resultant oliguria and exces-
sive fluid administration from
aggressive resuscitation in se-
Figure 2. Graph showing the components of the fluid administered on days 1 (solid circles) and 3 (striped verely ill patients are postu-
circles). Modifiable fluids are defined as IV fluids and medications. Obligatory fluids are the sum of blood lated to be contributing factors
products, total parenteral nutrition (TPN), enteral fluids, and bolus fluids. Calculations (and proportions) are
made using means (not medians) for each category as labeled above. (23). It is likely that some of
the surplus fluid administra-
four patients who were 15% FO did not have any indication tion is obligatory, due to the need for multiple medications
of FO in their chart. and hemodynamic support with escalating severity of illness.
In our patient cohort, almost 90% of patients continued to re-
DISCUSSION ceive more than maintenance fluids on PICU day 3. Although
A high amount of fluid administration is not an atypical we have characterized modifiable fluids as a combination of
occurrence in critically ill pediatric patients during the initial IVF and medications, it would be interesting to explore to
what extent the excessive FE noted in our patients could actu-
ally be modifiable. Understanding nature and quantity of FE as
a contributor to FO is important. Bolus fluid resuscitation has
been noted to increase risk of death at 48 hours in acutely ill
African children with hypovolemic shock (24). Although this
study cannot be generalized, it raises questions regarding the
effects of fluid administration on mortality in the PICU set-
ting. Excessive FE may have deleterious consequences, even be-
yond the resuscitative phase. Interestingly, in pediatric septic
patients, when stratified by severity of illness, only the low-risk
group’s cumulative fluid balance was associated with mortality,
and not in the intermediate- and high-risk groups (21). We did
not adequately address severity of illness in our cohort and,
therefore, were not able to classify whether patients with higher
severity of illness were the ones who received excessive FE and/
or had FO. However, only a minority of our patients were on
vasoactive medications on PICU day 3.
Previous studies have demonstrated the association be-
tween AKI and resultant oliguria with FO. AKI is common in
critically ill children with an incidence of around 30% (25).
Figure 3. A representative graph signifying recognition of greater than
15% fluid overloaded patients; values given as n (%). MDP = minimum Particularly, oliguric AKI has been shown to have adverse
dilution protocol. clinical outcomes (26). The frequency of AKI in our study

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population was quite lower; however, 43% of our patients still
met 15% FO during the first 7 days of their PICU stay, and only
one patient was oliguric (using KDIGO urine criteria) on day
1 and none on day 3 (20). Of note, we did not examine cre-
atinine levels, which may be a reason why AKI frequency was
underestimated. Most of the data regarding relation between
FO and AKI in critically ill children is retrospective and hence
cannot explore the temporal relationship between the two or
reveal causation. Additionally, we limited our data collection to
the first 7 days of ICU stay, as opposed to previous studies that
used peak FO throughout the duration of ICU stay.
Our study showed that 87% of the patients received a total
of more than 1,600 mL/m2 on day 3 of their PICU stay which
may point to the lack of awareness by the clinician of the total
amount of fluid administered; of the fluids they were receiving,
750 mL/m2 (IQR, 375–1,816 mL/m2) (46% of total fluids) were
modifiable fluids. Maintenance IVF defined as 1,500–1,600 mL/
m2/d or calculated using a weight-based method (17, 27) is
used to provide water needs and replenish physiologic losses. A
recent study observing fluid administration strategies showed
that maintenance fluids contributed to a third of the total flu-
ids received in the PICU (28). In actuality, the correct dose of
IVF needed in critically ill patients is unknown. For example,
in intubated patients on humidified closed-circuit ventilators,
transpulmonary losses are negligible. Maintenance fluid needs
likely need revision in these patients. The term “maintenance
fluid” can lead to a cognitive bias in the prescriber, with the
implication that these fluids are essential to maintain health in
the patient. Additionally, a key component of managing a con-
gested state is fluid restriction. Murphy et al (29) also showed
that patients receiving adequate fluid resuscitation followed by
conservative late fluid management had decreased mortality
compared with those receiving adequate fluid resuscitation
alone. Failure of recognition of FO could lead to overprescrip-
tion of IVF. Confounding by indication, where IVF is used to
deliver essential medications, is always a possibility in sicker
patients with high FE. However, if clinicians are not aware of
the amount of FE created by medications, they will neglect to
adjust total fluid intake. In patients receiving a large number of
medications, additional IV fluids are often unnecessary as total
daily FE might far exceed the “maintenance.” A “fluid stew-
ardship,” similar to antibiotic stewardship, has been proposed
by some authors (30). Additionally, although malnutrition is
common in the PICU (31), our results showed that 35% of
our patients were not receiving any TPN or significant enteral
nutrition (> 30 mL/m2/d) by day 3 of PICU stay; thus, the flu-
ids received could be classified nonessential and did not con-
tribute to caloric intake. This is not to say that TPN should be
initiated by day 3, but only to emphasize potentially modifiable
fluids were not prescribed for nutrition. A multicenter study
also noted that 40% of the patients did not have any enteral
nutrition for more than 48 hours from PICU admission (32).
Only seven of the 30 patients who reached 15% FO state had
documentation in their chart. An additional two patients were
placed on MDP—thus, FO was recognized, but they did not
have FO diagnosis noted in their chart. Failure to document
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may be due to time constraints in the busy environment of the
PICU but could also signal an underlying lack of awareness
on the association between FO and associated adverse clinical
outcomes. Ability to leverage the EMR in order to auto-track
the amount of FO and alert the clinicians when predetermined
thresholds are reached could provide a fail-safe systematic so-
lution (33). It would also be interesting to assess whether the
use of MDP facilitated a decrease in FE alone or whether a
change in prescribing behavior (i.e., converting medications to
enteral route, discontinuing drips) was also contributory.
There are several limitations to this study. As this is a sin-
gle-center prospective study, our results might have limited
generalizability. Calculations for FO depended on admission
weight as with all previous FO studies; for patients who were
dehydrated at admission, a premorbid baseline weight would
be ideal to calculate an accurate FO status. As IVF and medica-
tions are both documented as IV fluids in the electronic med-
ical record, it was difficult to accurately delineate medication
administration from IVF; therefore, modifiable fluids included
medications which are, in fact, essential. Although medica-
tions are an obligate requirement for ICU patients, the volume
administered can often be modified by either concentrating
the medication or optimizing the route of administration.
We characterized TPN as obligate fluids since the provision of
nutrition is an essential part of ICU care; although TPN can
technically be modified, it is the degree of nutritional support
required that dictates the amount of TPN the patient receives.
Fluid boluses given in the emergency department and the acute
ward were not incorporated in our study as we strictly looked
at fluids administered in the ICU. As this was a small study, our
sample size did not allow us to further analyze data and assess
for associations between FE and FO; a future study where we
can divide and compare patients based on the amount of FE
accounting for severity of illness to examine outcomes would
be insightful. Also, when examining recognition of FO, we used
diuretics as a surrogate marker for recognition although this
underscores the fact that FO as a diagnosis was only used in
seven patients (23%). However, some patients were on diuret-
ics prior to achieving 15% FO. We were not able to ascertain
whether these diuretics were a home medication or whether
they were in fact started or increased due to concern for fluid
status. Initial documentation was not always updated to reflect
home medication doses at admission. FO recognition may be
overestimated as some patients may have been on diuretics
prior to admission, and thus, these patients were not recog-
nized as FO, rather their home medications were continued.
In the PICU, FE exceeds conventional maintenance require-
ments on day 3; the majority of this fluid is potentially modi-
fiable (nonnutritive, nonresuscitative FE), and only half of the
patients are receiving more than 30 mL/m2/d of enteral nutrition.
Nonnutrition, nonresuscitation fluids may play a major role in
ongoing FO in PICU patients. A system which leverages the EMR
for the presence of FO might raise awareness and potentially lead
to a decrease in FE. Our findings open up a new area of inves-
tigation regarding the intensivists’ awareness of the types and
amounts of fluids administered to their patients. Further studies
 Al-Lawati et al
to correlate modifiable FE to FO and explore practice improve-
ment opportunities are needed to decrease excessive fluid admin-
istration and increase FO recognition in the PICU.
This work was performed at Texas Children’s Hospital, Baylor College of
Medicine, Houston, TX.
Dr. Akcan Arikan received funding from Baxter International and Medtronic.
The remaining authors have disclosed that they do not have any potential
conflicts of interest.
For information regarding this article, E-mail: zallawati@med.wayne.edu
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