• Kamal Abulebda, Natalie Z Cvijanovich, Neal J Thomas, Geoffrey L Allen, Nick Anas, Michael T Bigham, Mark Hall, Robert J Freishtat, Anita Sen, Keith Meyer, Paul A Checchia, Thomas P Shanley, Jeffrey Nowak, Michael Quasney, Scott L Weiss, Arun Chopra, Sharon Banschbach, Eileen Beckman, Christopher J Lindsell, and Hector R Wong.
• 1Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH. 2Children's Hospital and Research Center Oakland, Oakland, CA. 3Penn State Hershey Children's Hospital, Hershey, PA. 4Children's Mercy Hospital, Kansas City, MO. 5Children's Hospital of Orange County, Orange, CA. 6Akron Children's Hospital, Akron, OH. 7Nationwide Children's Hospital, Columbus, OH. 8Children's National Medical Center, Washington, DC. 9Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY. 10Miami Children's Hospital, Miami, FL. 11Texas Children's Hospital, Houston, TX. 12CS Mott Children's Hospital at the University of Michigan, Ann Arbor, MI. 13Children's Hospital and Clinics of Minnesota, Minneapolis, MN. 14The Children's Hospital of Philadelphia, Philadelphia, PA. 15St. Christopher's Hospital for Children, Philadelphia, PA. 16Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH. 17Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
• Crit. Care Med.. 2014 Feb 1;42(2):397-403.

ObjectiveObserved associations between fluid balance and septic shock outcomes are likely confounded by initial mortality risk. We conducted a risk-stratified analysis of the association between post-ICU admission fluid balance and pediatric septic shock outcomes.DesignRetrospective analysis of an ongoing multicenter pediatric septic shock clinical and biological database.SettingSeventeen PICUs in the United States.PatientsThree hundred and seventeen children with septic shock.InterventionsNone.Measurements And Main ResultsWe stratified subjects into three mortality risk categories (low, intermediate, and high) using a validated biomarker-based stratification tool. Within each category, we assessed three fluid balance variables: total fluid intake/kg/d during the first 24 hours, percent positive fluid balance during the first 24 hours, and cumulative percent positive fluid balance up to 7 days. We used logistic regression to estimate the effect of fluid balance on the odds of 28-day mortality, and on complicated course, which we defined as either death within 28 days or persistence of two or more organ failures at 7 days. There were 40 deaths, and 91 subjects had a complicated course. Increased cumulative percent positive fluid balance was associated with mortality in the low-risk cohort (n = 204; odds ratio, 1.035; 95% CI, 1.004-1.066) but not in the intermediate- and high-risk cohorts. No other associations with mortality were observed. Fluid intake, percent positive fluid balance in the first 24 hours, and cumulative percent positive fluid balance were all associated with increased odds of a complicated course in the low-risk cohort but not in the intermediate- and high-risk cohorts.ConclusionsWhen stratified for mortality risk, increased fluid intake and positive fluid balance after ICU admission are associated with worse outcomes in pediatric septic shock patients with a low initial mortality risk but not in patients at moderate or high mortality risk.

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