Non-resuscitation fluid in excess of hydration requirements is associated with higher mortality in critically ill children

Background: Large volumes of non-resuscitation fluids are often administered to critically ill children. We hypothesize that excess maintenance fluid is a significant contributor to non-resuscitation fluid and that non-resuscitation fluid administered beyond hydration requirements is associated with worse clinical outcomes in critically ill children. Methods: We evaluated all patients admitted to two large urban pediatric intensive care units (PICU) between January 2010–August 2016 and January 2010–August 2018, respectively, who survived and remained in the hospital for at least 3 days following PICU admission. The primary outcome was in-hospital mortality. Association of excess fluid with outcomes was adjusted for confounders (age, Pediatric Risk of Mortality III score, study site, day 3 acute kidney injury, PICU era, resuscitation volume, and volume output) using multivariable regression. Results: We evaluated 14,483 patients; 52% received non-resuscitation fluid in excess of hydration requirements. Non-resuscitation fluid in excess of hydration requirements was associated with higher in-hospital mortality after adjustment for confounders (adjusted odds ratio 1.01 per 10 mL/kg in excess fluid, 95% confidence interval: 1.002–1.02). Conclusions: Non-resuscitation fluid in excess of hydration requirements is associated with increased mortality in critically ill children. Excess maintenance fluid is a modifiable contributor to this fluid volume. Strategies to reduce excess maintenance fluids warrant further study. Impact: Critically ill children frequently receive non-resuscitation fluid in excess of their estimated hydration requirements.Non-resuscitation fluid volume in excess of estimated hydration requirements is associated with higher morbidity and mortality in critically ill children.Critically ill children receive a large volume burden from maintenance fluid.Maintenance fluid represents a modifiable contributor of non-resuscitation fluid in excess of hydration requirements.Strategies focused on limitation of maintenance fluid warrant further study.