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As there are no pediatric guidelines for intravascular fluid administration and management, this survey is intended to describe current practice patterns of pediatric intensivists in children with acute respiratory failure from primary respiratory disease or secondary PARDS from multi-organ failure related to sepsis or septic shock.
Answer all questions to reflect your actual current practice at the bedside. The information you provide could inform future research into this critical aspect of management in critically ill children.
All responses are anonymous. By entering the survey, you are consenting to participation in this study. This project was approved by the IRB at the University of Buffalo. Contact Amanda Hassinger, MD ([email protected] or 716-878-1859) or Stacey Valentine, MD ([email protected] or 774-442-2164) with questions or suggestions.
Tell us something about you and your critical care unit.
After training, how many years have you been in practice in pediatric critical care?
__________________________________
How many medical and surgical beds are there in the PICU where you primarily practice (excluding CICU beds)?
__________________________________
Do you have pediatric critical care attendings
in-house 24 hours per day? Yes No
Do you have a pediatric critical care fellowship? Yes No
Do you provide ECMO in your institution? Yes No
Approximately how many patients are placed on continuous renal replacement therapy in your PICU every year?
None 0-5 per year 6-10 per year 11-20 per year
>20 per year
Do you have a sedation protocol in routine use for children with acute respiratory failure on
mechanical ventilation?
Yes No
Do you routinely perform daily extubation readiness testing in children with acute respiratory failure on mechanical ventilation to determine time of extubation?
Yes No
Answer all questions below pertinent to the maintenance intravenous fluid administration and management of a child with acute respiratory failure and/or multi-organ failure from sepsis or septic shock.
When starting continuous intravenous fluids on a patient who is older than 2 months upon admission to the pediatric intensive care unit, what are typical base fluids you order (choose all that apply)?
Dextrose 5%, 0.45 saline ("Half normal saline") Dextrose 5%, 0.9 saline ("Normal saline")
Dextrose 5%, 0.23 saline ("Quarter normal saline") Dextrose 5%, water
Dextrose 5%, lactated ringer's 0.9 saline without dextrose 0.45 saline without dextrose Lactated ringer's without dextrose
What calculation do you use to determine the "maintenance" hourly rate of intravenous fluids?
The "4-2-1" rule = 4ml/kg for the first 10kg + 2ml/kg for the next 10kg + 1ml/kg for all kg above 20kg 100ml per body surface area in meters squared
Other, please specify Other fluid calculation used:
__________________________________
When starting intravenous fluids upon PICU admission for a child with acute respiratory failure, what rate do you typically choose?
One and a half times (150%) maintenance (100%) Maintenance
Whatever rate is needed to keep the TOTAL fluid intake including other medications and drips at the hourly maintenance rate (likely < 100%)
Two-thirds maintenance (67%)
Less than two-thirds maintenance (< 67%)
After the initial presentation and resuscitation, how often do you assess or adjust the hourly fluid administration rate in a child with acute respiratory failure and/or multi-organ failure from sepsis (choose all that apply)?
Rate ordered on admission and not adjusted until enteral nutrition introduced
Rate adjusted with dynamic changes in the patient including hypotension, fluid accumulation or worsening oxygenation
Rate assessed daily on rounds
Rate adjusted by the bedside nurse constantly to maintain total fluids at the ordered hourly rate
04/26/2017 3:42pm www.projectredcap.org
Answer the following questions related to fluid resuscitation or bolus administration in children upon presentation or while intubated for primary or secondary PARDS:
What is your preferred method of correcting intravascular depletion in a critically ill child during the initial resuscitation period (assuming they cannot tolerate enteral nutrition or water)?
Fluid resuscitation with 10ml/kg fluid boluses until vital signs improve
Fluid resuscitation with 20ml/kg fluid boluses until up to 60ml/kg regardless of vital signs Initial fluid bolus of 10-20ml/kg followed by IVF at 150% or 200% maintenance
Using fluid challenges to determine ongoing fluid needs
Calculating the amount of intravascular depletion and replacing just that amount with intravenous fluid boluses
Calculating the amount of intravascular depletion and replacing that amount with continuous intravenous fluids above maintenance intravenous fluids
Which of the following do you consider INDEPENDENT triggers for fluid bolus administration for a child with acute respiratory failure on sedation and mechanical ventilation?
Drop in urine output Elevated heart rate Low CVP
Hypotension
Change in perfusion Metabolic acidosis Sunken fontanelle Other
Please specific other INDEPENDENT triggers you use for fluid bolus administration:
__________________________________
What size fluid bolus do you typically give for a child with acute respiratory failure on mechanical ventilation without cardiac disease after any of the triggers you chose above?
5ml/kg 10ml/kg 15ml/kg 20ml/kg
More than 20ml/kg
What type of fluid is your first choice for fluid boluses in this scenario?
Normal saline Lactated ringers 5% Albumin
Blood products if possible Other
Specify what other fluid type you routinely use for fluid bolus administration:
__________________________________
distress, hypoalbuminemia and a positive net fluid balance since admission?
I administer exogenous albumin when the serum albumin falls below 3.0gm/dL I administer exogenous albumin when the serum albumin falls below 2.5gm/dL I administer exogenous albumin when the serum albumin falls below 2gm/dL
I administer exogenous albumin regardless of serum level when using diuretics to augment effect I use albumin for colloid effect to improve intravascular volume only, regardless of serum level I do not routinely administer exogenous albumin
In a child with hypotension or a need for vasopressors to maintain adequate hemodynamics, how soon after
hemodynamic stability (WITHOUT a need for any vasopressor above dopamine of 5mcg/kg/min) would you consider restricting intravenous fluids or starting diuretics?
0-6 hours
>6-12 hours
>12-24 hours More than 24 hours
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The following questions are intended to explore the management of ongoing fluid
administration and fluid balance in children with acute respiratory failure from primary or secondary PARDS.
Which of the following are the TOP THREE ways you assess intravascular fluid status at the bedside (choose only 3)?
CVP
Total fluid balance (intake minus output) Daily weights
Physical exam
Passive leg raise testing Ultrasonography of the IVC Pulse pressure variability Other
Specify what other way you assess intravascular fluid status at the bedside:
__________________________________
Of the following, which are "vital" signs you discuss every day when rounding on a child in acute respiratory failure that are RELATED TO FLUID STATUS (choose the ones that are most often discussed daily)?
Temperature Heart Rate Respiratory Rate Blood pressure
Pulse oximetry reading CVP
Fluid balance from midnight to midnight Fluid balance from 7a to 7a
Net or cumulative fluid balance since PICU admission Daily weight
When looking at the fluid status of your patients, do you include blood products in the calculation of net fluid balance (fluid intake minus fluid output)?
Yes No
Do you routinely administer a diuretic with a blood Never product administration or transfusion in a child Rarely with PARDS and a positive net fluid balance since Sometimes
admission? Often
Always Do you make fluid management decisions based on the
CVP? Never Rarely Sometimes
Often Always In the absence of any cardiac dysfunction, what is
your LOW end of the target CVP in a child with PARDS who is hemodynamically stable?
>2 >4 >6
>8
In the absence of any cardiac dysfunction, what is the HIGH end of your target CVP in a child with PARDS?
< 8 < 10 < 12
< 16 < 20
Do you make fluid management decisions based on the NET or daily balance between fluid intake and fluid output?
Yes No
cumulative fluid balance to guide daily fluid No
management decisions? I do not calculate or determine level of fluid
overload routinely
In a child with acute respiratory failure on >50ml/kg or 5% fluid positive mechanical ventilation who is NOT on full enteral >100ml/kg or 10% fluid positive nutrition, what cumulative positive fluid balance >150ml/kg or 15% fluid positive since admission would trigger you to make fluid >200ml/kg or 20% fluid positive management changes?
In a child with acute respiratory failure on >50ml/kg or 5% fluid positive mechanical ventilation who is on FULL enteral >100ml/kg or 10% fluid positive nutrition, what cumulative positive fluid balance >150ml/kg or 15% fluid positive would trigger you to make management changes? >200ml/kg or 20% fluid positive
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Which of the following are the management steps you typically take in correcting a positive fluid balance in a child with PARDS who is hemodynamically stable?
Decrease total fluids to 100%mainten
ance
Decrease total fluid intake to
< 100%
maintenance
Start intermittent
lasix
Start lasix infusion
Start another diuretic
Watch and wait
The FIRST step
If that does not achieve the goals, the SECOND step (Leave this blank if would continue to watch and wait)
The THIRD step (Leave this blank if would continue to watch and wait)
Which of the following would make you STOP diuretic therapy ENTIRELY in a child with ongoing acute respiratory failure despite still having a positive fluid balance (choose any that apply)?
BUN increase to >50
Serum creatinine and BUN increase of any amount Serum creatinine increase to 2 times the baseline level Metabolic alkalosis
Hypokalemia
I don't stop diuretics until the fluid balance is improved
At what positive fluid balance do you think of starting continuous renal replacement therapy for fluid removal if diuretics are not effective?
20ml/kg 50ml/kg 100ml/kg 200ml/kg
>2L positive (regardless of weight) I do not use CRRT for fluid removal only
The following questions are intended to describe your understanding of the relationship between fluid balance/accumulation and outcomes in children with primary or secondary PARDS.
Where does fluid accumulation or a positive fluid balance play into the condition of a child with PARDS from primary acute respiratory failure or multi-organ failure from sepsis?
Fluid accumulation is part of being sick and there is not need to intervene
Fluid accumulation is part of being sick but needs some attention and intervention when it occurs Fluid accumulation contributes to worse outcomes and should be prevented or treated
When compared to the current standard of care, how do you view conservative or restrictive fluid management in children with ARDS?
Fluid removal or restriction could be dangerous and should be avoided in all PARDS patients
There is likely no difference in outcomes between liberal and conservative fluid management in children with PARDS
Conservative fluid management in PARDS is likely to be beneficial or protective
In what way do you consider conservative fluid management (fluid restriction or diuretic use) as potentially harmful?
Promoting a more negative fluid balance could CAUSE acute kidney injury There could be an association with cognitive impairment
Fluid accumulation is a symptom of capillary leak and needs to mobilize naturally when the condition resolves
Conservative fluid management is unlikely to cause harm
What do you see as the potential benefits of conservative over liberal fluid management in children with PARDS?
Decreased mortality
Decreased duration of mechanical ventilation
Lower rate of new or progressive multi-organ dysfunction Lower rates of acute kidney injury
There is unlikely to be a benefit, fluid accumulation is a marker of disease
PREVENTING a positive cumulative fluid balance can improve patient outcomes in PARDS.
Strongly Agree Agree
Neither Agree nor Disagree Disagree
Strongly Disagree
Excessive cumulative fluid balance can contribute to capillary leak in children with ongoing capillary leak, multi-organ failure or PARDS.
Strongly Agree Agree
Neither Agree nor Disagree Disagree
Strongly Disagree
04/26/2017 3:42pm www.projectredcap.org
A 6 month old child is on ventilator day #2 for moderate PARDS from RSV pneumonia, is hemodynamically stable but not on enteral nutrition yet, and the following happen below.
Please choose the SINGLE answer that BEST represents what you would typically do in each brief scenario.
Give fluid bolus 20ml/kg
Give fluid bolus 5-10ml/kg
Watch for 1 hour Decrease IVF to 2/3rds maintenance
Give a diuretic
Mean blood pressure goes from 60 to 45mmHg after versed x1, HR normal
Urine output 0.5-1ml/kg/hr with normal perfusion, HR and BP;
net PICU fluid balance:
+50ml/kg.
Slowly worsening CR over 8 hours, UOP>2ml/kg/hr, normal HR and BP; net PICU fluid balance: +60ml/kg
CVP goes from 12 to 8 over 6 hours, BP/HR normal,
UOP>1ml/kg/hr, net PICU fluid balance: +100ml/kg
CVP 12-18 overnight, net PICU fluid balance: +100ml/kg
A 6 month old child is on ventilator day #2 for moderate PARDS related to multi-organ failure from gram-positive bacteremia. The child is currently hemodynamically stable and has been off all vasopressors for >12 hours. For each brief scenario below, choose the SINGLE answer that BEST represents what you would typically do.
Give fluid bolus 20ml/kg
Give fluid bolus 5-10ml/kg
Watch for 1 hour Decrease IVF to 2/3rds maintenance
Give a diuretic
Mean blood pressure goes from 60 to 45mmHg after versed, HR normal
Urine output 0.5-1ml/kg/hr with normal perfusion, HR and BP;
net PICU fluid balance: +50ml/kg Slowly worsening CR over 8 hours, UOP>2ml/kg/hr, normal HR and BP, net PICU fluid balance: +60ml/kg
CVP goes from 12 to 8 over 6 hours. BP/HR are normal, UOP>1ml/kg/hr, net PICU fluid balance: +100ml/kg
CVP 12-18 overnight, net PICU fluid balance: +100ml/kg
