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Assessment of fluid balance after neonatal cardiac surgery: a description of intake/output vs. weight-based methods

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Abstract

Background

Fluid overload associates with poor outcomes after neonatal cardiac surgery, but consensus does not exist for the most clinically relevant method of measuring fluid balance (FB). While weight change-based FB (FB-W) is standard in neonatal intensive care units, weighing infants after cardiac surgery may be challenging. We aimed to identify characteristics associated with obtaining weights and to understand how intake/output-based FB (FB-IO) and FB-W compare in the early postoperative period in this population.

Methods

Observational retrospective study of 2235 neonates undergoing cardiac surgery from 22 hospitals comprising the NEonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) database.

Results

Forty-five percent (n = 998) of patients were weighed on postoperative day (POD) 2, varying from 2 to 98% among centers. Odds of being weighed were lower for STAT categories 4 and 5 (OR 0.72; 95% CI 0.53–0.98), cardiopulmonary bypass (0.59; 0.42–0.83), delayed sternal closure (0.27; 0.19–0.38), prophylactic peritoneal dialysis use (0.58; 0.34–0.99), and mechanical ventilation on POD 2 (0.23; 0.16–0.33). Correlation between FB-IO and FB-W was weak for every POD 1–6 and within the entire cohort (correlation coefficient 0.15; 95% CI 0.12–0.17). FB-W measured higher than paired FB-IO (mean bias 12.5%; 95% CI 11.6–13.4%) with wide 95% limits of agreement (− 15.4–40.4%).

Conclusions

Weighing neonates early after cardiac surgery is uncommon, with significant practice variation among centers. Patients with increased severity of illness are less likely to be weighed. FB-W and FB-IO have weak correlation, and further study is needed to determine which cumulative FB metric most associates with adverse outcomes.

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Acknowledgements

The authors wish to acknowledge the data collection teams at all of the participating centers.

NEPHRON Investigators (Contributing authors)

The following individuals served as collaborators and site investigators for the NEPHRON study and are collaborators on this manuscript and should be indexed in PubMed as collaborators on this manuscript:

Parthak Prodhan, MDa, Xiomara Garcia, MDa, Shannon Ramer, BSN, RNCa, Mindy Albertson, RNa, Michael Gaies, MD, MPH, MSb, David S. Cooper, MD, MPHb, Zahidee Rodriquez, MDb, Mary Lukacsb, Dominic Zanaboni, MDc, Joan Sanchez de Toledo, MD, PhDd, Yuliya A. Domnina, MDd, Lucas Saenz, MDd, Tracy Baust, BAd, Jane Kluck, RN, BSNe, Linda Duncan, RN, BSNe, Joshua D. Koch, MDf, Joshua Freytagg, Amanda Sammonsg, Hideat Abrahag, John Butcherg, Jun Sasaki, MDh, Rebecca A. Bertrandt, MDi, Jason R. Buckley, MDj, Luke Schroeder, MDj, Aanish Raees, MBBSk, Lisa J. Sosa, ARNPl, Natasha S. Afonso, MD, MPHm, Erika R. O’Neal, MDm, Javier J. Lasa, MDm, Patrick A. Phillipsn, Amy Ardisanao, Kim Gonzalezo, Tammy Domano, Suzanne Vierso, Wenying Zhang, MSp, Kristal M. Hock, MSN, RN, CNLq, Santiago Borasino, MD, MPHq, Joshua J. Blinder, MDr

aArkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas; bDivision of Pediatric Cardiology, The Heart Institute, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; cDivision of Cardiac Critical Care Medicine, Department of Anesthesia/Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; dDepartment of Critical Care Medicine and Pediatrics, UMPC Children’s Hospital of Pittsburg, University of Pittsburg School of Medicine, Pittsburg, Pennsylvania; eChildren’s Hospital of Wisconsin, Milwaukee, Wisconsin; fDivision of Critical Care Medicine, Department of Pediatrics, Children’s Medical Center of Dallas, University of Texas Southwestern Medical School, Dallas, Texas; gCincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; hDivision of Cardiac Critical Care Medicine, Nicklaus Children’s Hospital, Miami, Florida; iDivision of Critical Care, Department of Pediatrics, Children’s Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin; jMedical University of South Carolina Children’s Hospital, Charleston, South Carolina; kMonroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt, Tennessee; lNicklaus Children’s Hospital, Miami, Florida; mPediatric Critical Care, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas; nChildren’s of Alabama, University of Alabama at Birmingham, Birmingham, Alabama; oCS Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan; pCenter for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; qSection of Cardiac Critical Care Medicine, Department of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama; rLucile Packard Children’s Hospital Stanford, Palo Alto, California.

Funding

This study is financially supported by Castin’ ‘N Catchin’ Charity Organization and Cincinnati Children’s Hospital Medical Center Heart Institute Research Core.

Author information

Authors and Affiliations

  1. Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Pediatric Nephrology, Washington University School of Medicine, St. Louis, MO, USA

    Tara M. Neumayr

  2. University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    Jeffrey A. Alten, Katie L. Brandewie & Huaiyu Zang

  3. Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA

    David K. Bailly

  4. Department of Pediatrics, Sections of Critical Care Medicine and Cardiology, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX, USA

    Priya N. Bhat

  5. Division of Cardiac Critical Care Medicine, Children’s National Hospital, Washington, DC, USA

    J. Wesley Diddle

  6. Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA

    Muhammad Ghbeis

  7. Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, USA

    Catherine D. Krawczeski

  8. Stanford University School of Medicine, Palo Alto, CA, USA

    Kenneth E. Mah

  9. Pediatric Cardiac Intensive Care, Medical City Children’s Hospital, Dallas, TX, USA

    Tia T. Raymond

  10. University of Michigan, Ann Arbor, MI, USA

    Garrett Reichle

  11. Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA

    David T. Selewski

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  1. Tara M. Neumayr
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Consortia

NEPHRON Investigators

  • Parthak Prodhan
  • , Xiomara Garcia
  • , Shannon Ramer
  • , Mindy Albertson
  • , Michael Gaies
  • , David S. Cooper
  • , Zahidee Rodriquez
  • , Mary Lukacs
  • , Dominic Zanaboni
  • , Joan Sanchez de Toledo
  • , Yuliya A. Domnina
  • , Lucas Saenz
  • , Tracy Baust
  • , Jane Kluck
  • , Linda Duncan
  • , Joshua D. Koch
  • , Joshua Freytag
  • , Amanda Sammons
  • , Hideat Abraha
  • , John Butcher
  • , Jun Sasaki
  • , Rebecca A. Bertrandt
  • , Jason R. Buckley
  • , Luke Schroeder
  • , Aanish Raees
  • , Lisa J. Sosa
  • , Natasha S. Afonso
  • , Erika R. O’Neal
  • , Javier J. Lasa
  • , Patrick A. Phillips
  • , Amy Ardisana
  • , Kim Gonzalez
  • , Tammy Doman
  • , Suzanne Viers
  • , Wenying Zhang
  • , Kristal M. Hock
  • , Santiago Borasino
  •  & Joshua J. Blinder

Corresponding author

Correspondence to Tara M. Neumayr.

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Neumayr, T.M., Alten, J.A., Bailly, D.K. et al. Assessment of fluid balance after neonatal cardiac surgery: a description of intake/output vs. weight-based methods. Pediatr Nephrol 38, 1355–1364 (2023). https://doi.org/10.1007/s00467-022-05697-w

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