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

Douglas F. Willson, Neal J. Thomas, Robert Tamburro, Edward J Truemper, Jonathon Truwit, Mark Conaway, Christine Traul, Edmund E. Egan

Research output: Contribution to journalArticle

30 Citations (Scopus)

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/m2 over the first 7 days of the trial. Subjects who died accumulated on average 8.7 ± 9.5 L/m2 versus 1.2 ± 2.4 L/m2 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.

Original languageEnglish (US)
Pages (from-to)666-672
Number of pages7
JournalPediatric Critical Care Medicine
Volume14
Issue number7
DOIs
StatePublished - Jan 1 2013

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Adult Respiratory Distress Syndrome
Acute Lung Injury
Pediatrics
Water-Electrolyte Balance
Mechanical Ventilators
calfactant
Guidelines
Mortality
Lung Injury
Surface-Active Agents
Caregivers
Survivors
Catheters
Randomized Controlled Trials
Placebos
Oxygen

Keywords

  • Calfactant
  • Direct lung injury
  • Fluid overload
  • Fluid restriction
  • Hypoxemia index
  • Oxygen saturation index
  • Pulmonary edema
  • Respiratory failure
  • Surfactant

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Critical Care and Intensive Care Medicine

Cite this

The relationship of fluid administration to outcome in the pediatric calfactant in acute respiratory distress syndrome trial. / Willson, Douglas F.; Thomas, Neal J.; Tamburro, Robert; Truemper, Edward J; Truwit, Jonathon; Conaway, Mark; Traul, Christine; Egan, Edmund E.

In: Pediatric Critical Care Medicine, Vol. 14, No. 7, 01.01.2013, p. 666-672.

Research output: Contribution to journalArticle

Willson, DF, Thomas, NJ, Tamburro, R, Truemper, EJ, Truwit, J, Conaway, M, Traul, C & Egan, EE 2013, 'The relationship of fluid administration to outcome in the pediatric calfactant in acute respiratory distress syndrome trial', Pediatric Critical Care Medicine, vol. 14, no. 7, pp. 666-672. https://doi.org/10.1097/PCC.0b013e3182917cb5
Willson, Douglas F. ; Thomas, Neal J. ; Tamburro, Robert ; Truemper, Edward J ; Truwit, Jonathon ; Conaway, Mark ; Traul, Christine ; Egan, Edmund E. / The relationship of fluid administration to outcome in the pediatric calfactant in acute respiratory distress syndrome trial. In: Pediatric Critical Care Medicine. 2013 ; Vol. 14, No. 7. pp. 666-672.
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