Improving fluid management of extreme premature infants by providing a restrictive fluid management algorithm in the ICN
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Intro: Excessive fluid intake in extremely premature infants during the first week of life is known to increase risk of adverse events such as necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), and overall mortality. There also is some correlation with the need for mechanical ventilation and development bronchopulmonary dysplasia (BPD). While fluid restriction is recommended to decrease the likelihood of adverse outcomes, at our institution we found there was a wide variability in and lack of evidence-based standards on fluid management in this vulnerable population. We aimed to improve the fluid management of the extremely premature infants by standardizing a restrictive fluid algorithm. Methods: Children’s Mercy Hospital admitted a total of 107 premature infants <28 6/7 weeks gestation to the ICN during 2021, and 25 of these infants were admitted during the timeframe of our study. The restrictive fluid management algorithm (Fig. 1) was initiated in April of 2021. During a 6-month period we monitored clinician compliance as outcome measures and patient clinical indicators of fluid status as balancing measures (percentage of birth weight lost, time to diuresis, and time back to birth weight). Results: Of 25 patients started on the algorithm, 3 patients were excluded due to admission after 12 hours of life or death on day of life 1 and 14 patients followed algorithm on all 3 days. The infrequent number of admissions during this period lead to presenting data in g-chart format. The process measure of clinician compliance with total fluid volume algorithm showed mild improvement over time after the education, initiation, and availability of the algorithm began in our ICN with overall mean of 1.89 patients outside protocol of total fluids between those patients on protocol (Fig. 2). This was again reflected in additional outcome measure of compliance with total fluid volume algorithm plus an additional 20ml/kg/day of fluid with overall mean was 0.63 patients outside protocol between patients on protocol (Fig. 3) showing a modest sustainability. The results of following the restrictive fluid algorithm did not result in excessive weight loss, absence of diuresis, or prolonged time back to birth weight based on the balancing measures tracked during this time period (Fig. 4-6). Conclusion: The fluid algorithm for premature infants did allow for a modest improvement in standardizing fluid management as compliance with a more restrictive plan improved without resulting in concerning short term consequences, such as excessive weight loss. The next step would be to provide continued education regarding the fluid algorithm to help sustain improvement. We are currently in process of obtaining baseline data prior to onset of current algorithm to further compare past and present fluid management to better help determine if changes have improved patient outcomes thus leading to a new standard in our ICN. In the future, we would like to follow up the current patients to determine if the fluid algorithm was helpful in avoiding adverse outcomes such as BPD, NEC, or PDA.
Ward, Jacob S.; Hubbard, Dena; and Clark, Nicholas, "Improving fluid management of extreme premature infants by providing a restrictive fluid management algorithm in the ICN" (2022). Posters. 305.
Presented at Children's Hospitals Neonatal Consortium (CHNC) Annual Symposium 2022; Indianapolis, IN; October 31 - November 2,2022.