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Agreement Between Measured Weight and Fluid Balance in Mechanically Ventilated Children in Intensive Care
Agreement Between Measured Weight and Fluid Balance in Mechanically Ventilated Children in Intensive Care
Agreement Between Measured Weight and Fluid Balance in Mechanically Ventilated Children in Intensive Care
MEASUREMENTS AND MAIN RESULTS: Between May 2021 and Jessica Appleyard,
RN, BNSc(Hons),
September 2022, we studied 61 children. The median age was 8 days (inter-
GDipNP(PaedCritCare),
quartile range [IQR], 1.0–14.0 d). The median BW at baseline was 3,518 g (IQR, MAdvNursPrac2
3,134–3,928 g). Change in BW was –36 g (IQR, –145 to 105 g) and –97 g (IQR,
Rinaldo Bellomo, MD, FRACP,
–240 to –28 g) between baseline and 24 hours, and between 24 and 48 hours,
FCICM4–8
respectively. Change in FB was –82 mL (IQR, –173 to 12 mL) and –107 mL (IQR,
–226 to 103) between baseline and 24 hours, and between 24 and 48 hours, Warwick Butt, MBBS, FRACP,
FCICM, FELSO1
respectively. In Bland-Altman analyses, the mean bias between BW and FB at 24
and 48 hours was 54 g (95% CI, 12–97) and –43 g (95% CI, –108 to 23), re- Trevor Duke, PhD, MBBS, FRACP,
FCICM1
spectively. This exceeded 1% of the median BW, and limits of agreement ranged
from 7.6% to 15% of baseline BW. The precision of paired weight measurements,
performed sequentially at each time interval, was high (median difference of ≤1%
of BW at each time point). The median weight of connected devices ranged from
2.7% to 3% of BW. There were no episodes of tube or device dislodgments and
no change in vasoactive therapies during weight measurements.
CONCLUSIONS: There is moderate agreement between the changes in FB and
BW, albeit greater than 1% of baseline BW, and the limits of this agreement are
wide. Weighing mechanically ventilated infants in intensive care is a relatively safe
and precise method for estimating change in fluid status. Device weight repre-
sents a relatively large proportion of BW.
KEY WORDS: agreement; body weight; fluid balance; fluid overload; mechanical
ventilation; pediatric intensive care
B
ody weight (BW) is a fundamental measurement in both the acute and
ambulatory cares of children. It is used to assess fluid status, nutrition, and
growth trajectories (1). However, BW is infrequently measured in seriously
unwell children in intensive care (2), particularly during the acute phase of illness.
Barriers to performing weight measurements in this setting include the lack of ac-
curate scales or equipment, the safety risk of lifting such children, and the potential Copyright © 2023 by the Society of
for measurement error related to attachment of devices. However, changes in BW Critical Care Medicine and the World
during acute illness, theoretically, are more representative of change in fluid status, Federation of Pediatric Intensive and
compared with fluid balance (FB) charts, because FB has inherent limitations such Critical Care Societies
as undocumented or unmeasured fluid loss or gain. Differences between FB and DOI: 10.1097/PCC.0000000000003258
weights (13). The weighing procedure is outlined in the Statistical Computing, Vienna, Austria). R pack-
Supplementary Appendix (http://links.lww.com/PCC/ ages are listed in the Supplemental Digital Content
C370). Each measurement was performed by the primary (http://links.lww.com/PCC/C370). A p value of less
investigator (B.G.) or trained fellows (V.M., S.K.K.) with than 0.05 was considered statistically significant. The
assistance from nursing staff. The number and type of in- Strengthening the Reporting of Observational Studies
dwelling devices were recorded at each time point, and in Epidemiology checklist for cohort studies was
their dry weights were subtracted from the mean BW. The completed and is found in the Supplemental Digital
dry weight for each device was measured separately and Content File (http://links.lww.com/PCC/C371).
assigned a reference weight from which the total device
weight was calculated. To ensure that in-dwelling perito- RESULTS
neal dialysate was accounted equally for FB and weight
measurements, its volume was subtracted from the total Between May 2021 and September 2022, 61 children
weight, where appropriate. If only one weight measure- were enrolled, and 59 children had two time intervals
ment was performed at each time point, due to logistic or for analysis. Two families withdrew consent: one after
clinical reasons, the single measurement was used. the first study day and another after the second day.
Sixty children were enrolled following cardiac surgery,
including eight children with delayed sternal closure,
Fluid Balance Measurements
and one child was enrolled prior to cardiac surgery.
FB was calculated as the absolute net difference be- The demographic and clinical characteristics of chil-
tween fluid input and output as an absolute value and dren enrolled in the study are shown in Table 1.
as a percentage of BW at enrollment. It was recorded
at 24 and 48 hours and aligned with the timing of BW Body Weight Characteristics
measurements. Net fluid input included all intrave-
nous and enteral fluid. Net fluid output included urine, There was a total of 353 weight measurements per-
stool, drain, and peritoneal dialysis effluent. formed over three time points. The median BW at each
time point, the change in BW between time points,
Outcomes and the device weights at each time point are shown
in Table 2 and Supplementary Figure 1 (http://links.
The primary outcome was the agreement between lww.com/PCC/C370). The individual weight measure-
change in BW measurement and change in FB. The ments for each child, at each time point, are shown
secondary outcomes included the precision of BW in Supplementary Figure 2 (http://links.lww.com/
measurements and the median device weight and its PCC/C370). The mean change in weight between time
proportion of median BW. intervals is shown in Figure 1 and the distribution of
percentage weight change for each time interval in
Statistical Analysis Supplementary Figure 3 (http://links.lww.com/PCC/
C370). Supplementary Tables 1 and 2 (http://links.
Demographic and clinical characteristics were lww.com/PCC/C370) show the median and percentage
described using frequencies and proportions. difference between the two paired, consecutive weight
Symmetry of the data was inspected by histogram measurements, performed at each time interval.
plots. Nonsymmetrically distributed data were sum-
marized using median and interquartile range. The
Fluid Balance
changes in FB and weight for each 24-hour interval
were summarized and presented as scatter plots. The FB data were available for each child at each time point.
weight of devices and attachments were described, The individual FB from baseline to 48 hours is shown in
and the percentages of the BW were calculated. Supplementary Figure 4 (http://links.lww.com/PCC/
Agreement between FB and weight was assessed using C370). Table 2 shows the absolute and change in FB dur-
Bland-Altman analysis of mean bias and 95% lim- ing the study period. The distribution of change in fluid
its of agreement. All analyses were performed using balance for all time points is shown in Supplementary
the R software, Version 4.1.0 (The R Foundation for Figure 5 (http://links.lww.com/PCC/C370).
TABLE 2.
Body Weight and Fluid Balance Characteristics at Each Time Point and Changes Between
Time Intervals During the Study Period
Variable Baseline 24 hr 48 hr
Body weight (gm), median (IQR) 3,518 (3,134–928) 3,440 (3,244–3,939) 3,350 (3,088–3,795)
Device weight (gm), median (IQR); (%) of 105 (92–119); 3.0 97 (85–112); 2.8 90 (67–105); 2.7
median body weight
Change in body weight between time inter- NA –36 (–145 to –105) –97 (–240 to –28)
vals (gm), median (IQR)
Fluid balance (mL), median (IQR) 0 –82 (–173 to –12) –150 (–270 to –54)
Change in fluid balance between time NA –82 (–173 to –12) –107 (–226 to –103)
intervals (mL), median (IQR)
IQR, interquartile range.
Figure 1. Change in body weight (mean and 95% CI) between time points and from baseline to 48 hr.
Figure 2. Scatter plot of individual change in body weight and fluid balance between baseline and 24 hr (A) and 24–48 hr (B). The red
dashed line represents the reference line of a one to one relationship between fluid balance and body weight. Data do not control for
regression to the mean effect within variables.
appeared safe with no episodes of device dislodg- Several studies of adults in intensive care have re-
ment or associated hemodynamic deterioration in 353 ported the relationship between change in FB and
weight measurements. weight (3, 4, 15, 16). These studies, some accounting
Several studies in children in intensive care have for insensible losses, generally reported poor agree-
reported the relationship between change in FB and ment. However, they relied on electronic bed scales
change in BW (6, 7, 14). These studies have either re- and noted a large weight of unmovable devices. The
ported the differences between the association of each ability to lift infants for weight measurements may en-
variable with intensive care outcomes (7) or reported hance the accuracy of weight measurements.
the relationship between these two variables (6). The Both FB charts and BW have inherent limitations
first study reported moderate agreement (0.75–0.92 for assessing fluid status in mechanically ventilated
[Pearson correlation coefficient]) (7) in an older cohort, children in intensive care. There appears to be mod-
and, the second, a mean difference of over 300 mL (ap- erate agreement between weight and chart-based esti-
proximately 3% of admission BW) despite correlation mation of FB when using prospectively collected data,
coefficients of >0.63 (6). However, the former study re- with protocolized methods, and accounting for weight
ported that both BW and FB had a similar relationship of devices and attachments. However, in this study, the
in predicting mortality (7). These studies either did difference exceeded the prespecified hypothesis, and
not provide the weighing protocol and report device the limits of agreement were wide, suggesting that both
weight, and Bland-Altman analyses were reported in measurements may represent true differences between
only one (6). approaches for estimating fluid status. For instance,
A retrospective, multicenter study of 2,235 children positive FB may exist in the presence of weight loss be-
having cardiac surgery reported that the frequency cause of unmeasured insensible fluid losses, or weight
of weight measurements on day 2 ranged widely be- gain may exist with negative FB if there are undocu-
tween centers (2–98%), but the average was 45% (14). mented fluid administrations or insensible water gain.
This study also reported that correlation and agree- Humidification of ventilator circuits prevents insensible
ment between weight and FB were poor (mean bias water loss from the lung (17) and, in theory, could con-
of 12% of BW). This finding far exceeds our estima- tribute to water gain (18). A study in the 1950s estimated
tion of agreement. This likely reflects the difficulty of that insensible water loss is higher in infants compared
using electronic medical record data, in a multicenter with older children, suggesting the susceptibility of this
retrospective study with perhaps, varying protocols population to such changes; however, change in in-
for measuring weight, fluid input/output, and urine sensible fluid loss or gain is difficult to quantify (19).
output. Moreover, the addition of device weight can exceed the
e464 www.pccmjournal.org October 2023 • Volume 24 • Number 10
Copyright © 2023 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
Online Clinical Investigations
Figure 3. Bland-Altman plot of agreement between change in body weight and fluid balance.
change in daily BW, thereby generating a large potential avoids the handling of unwell children. Therefore, to
source of error, particularly when the interval changes propose which method is superior requires comparison
in FB and weight, between study days, were small. In of their associations with important clinical outcomes.
our study, weight measurement was precise and safe. Comparing these methods may also need to account for
It may reflect absolute change in total body water bet- the effect of tissue edema, a third component of evaluat-
ter than FB, because it accounts for insensible water ing fluid status, which may have independent effects on
loss or gain. However, the weight of attached devices outcomes, but has not been evaluated. Further research
needs to be accounted for, and accurate scales are re- is required to compare these associations with outcomes
quired. FB shares some of these factors but, importantly, and to identify methods for quantifying edema.
The strengths of this study are the prospective study 2 Paediatric Intensive Care Unit, Murdoch Children’s
design, the protocolized technique for weight measure- Research Institute, The Royal Children’s Hospital, Parkville,
VIC, Australia.
ments, and the accounting for the weight of attached
3 Paediatric Intensive Care Unit, The Royal Children’s
devices. We used accurate scales (13) and demonstrated Hospital, Parkville, VIC, Australia.
the precision of weight measurements. We used Bland- 4 Intensive Care Unit, Austin Hospital, Melbourne, VIC,
Altman analyses as the optimal analysis for agreement Australia.
but also present the individual patient data to display its 5 Data Analytics Research and Evaluation (DARE) Centre,
distribution. The timing of FB assessment was aligned Austin Hospital, Melbourne, VIC, Australia.
with weight measurements, and we investigated an im- 6 Department of Critical Care, The University of Melbourne,
Melbourne, VIC, Australia.
portant cohort of critically ill children requiring invasive
7 Department of Intensive Care, Royal Melbourne Hospital,
therapies. However, we acknowledge some limitations.
Melbourne, VIC, Australia.
The potential sources of error for weight measure-
8 Australian and New Zealand Intensive Care Research
ment include the estimation of the weight of devices Centre, School of Public Health and Preventive Medicine,
and the method for holding such devices during lift- Monash University, Melbourne, VIC, Australia.
ing. However, we performed two measurements at each Supplemental digital content is available for this article. Direct
time interval and used a standardized, protocolized URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s website
approach, and weighing was performed exclusively by (http://journals.lww.com/pccmjournal).
small group of trained clinicians. FB data were retrieved The authors have disclosed that they do not have any potential
from the electronic medical record and, therefore, may conflicts of interest.
have inaccuracies. However, these data were manually For information regarding this article, E-mail: ben.gelbart@rch.
calculated by investigators, timed with weight measure- org.au
ment, and are those routinely relied on for clinical care.
The study was limited to infants, and therefore, general-
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