If, however, brevity were sacrificed to detail, an answer to Question 16 would resemble the following table. The overall merit of fluid balance calculation nevermind their accuracy is questionable. After all, what precisely are we measuring, and does it matter?

The normal healthy person, whose physiology is supposedly well understood, is still subject to fluid balance changes which may be measured in the litres, and which may not be accounted for by the usual cylinder diagrams.

There he is, the smug Healhy Person. Arrogantly sucking down an irresponsibly unmeasured volume of water while exercising with his iPod earphones. Probably listening to some sort of abominable Nu-Metal. He clearly has no idea of how much moisture he is losing per breath, nor of how much he is drinking, or how long he has been exercising for.

Moreover, the surface of his body will produce evaporative losses which are even harder to estimate, because they are contingent on body surface covering, surface temperature, sun exposure, ambient air humidity and temperature, convection by way of wind, and what if it starts raining?

In short, fluid balance estimates are difficult. Worse yet, they may be pointless. Consider a situation where one has precise control of all the abovementioned variables, and is able to measure every droplet of intake and output very accurately.

In such an implausible scenario, at the end of a day one ends up generating a number eg. At this level, neither the tonicity of the body fluid nor the pressure of the circulating compartment are affected, which means that the normal autoregulation mechanisms have not had to exert any homeostatic effect.

In short, the man's own pitutary doesn't care about this fluid shift. So why should we? Yes, there may be situations where fluid balance has clinical significance. It would be silly to completely ignore the value of input and output measurement, because ultimately a certain fluid input must be maintained for normal health, and in the intensive care unit the doctor has complete control over this variable.

In a reductio ad abdsurdum scenario such as a man dehydrating to death in the desert the importance of input and output volumes becomes readily apparent.

However, the question is not whether inputs and outputs are important, but whether there is a clinical significance in the fastidious attention to their measurement.

Let's say youre measurements are accurate; all of the fluid boluses are signed and accounted for. Still there will be some fluid losses and gains - potentially, vast ones - which remain impossibl to measure. Within the context of the situation, with severe trauma, organ system failure, rampant infection, missing limbs and potentially weeks of ICU stay, the relevance of the daily fluid balance becomes questionable, even if it is accurate.

It is hard to discern its effect on survival, that signal being lost in the deafening noise of critical illness.

So, if a fluid balance assessment question ever comes up again, it may come in the form of a miny-essay. In preparation for such a question, one should have a plan. Schneider, Antoine G.

Schoeller DA, van Santen E, Peterson DW, Dietz W, Jaspan J, Klein PD: Total body water measurement in humans with 18O and 2H labeled water. Am J Clin Nutr , 33 12 Charra, Bernard. Stephan, F. Chung, Hsaio-Min, et al. Schneider, Antoine Guillaume, et al. Perren, A. Should we really rely on it?.

Wilson, John N. Piccoli, Antonio, et al. Marik, Paul E. A systematic review of the literature and the tale of seven mares. Mitchell, John P. Bethlehem, Carina, et al. Schwann, Nanette M. Wheeler, A. Nguyen, Viviane TQ, et al. Schuller, D.

Is fluid gain a marker or a cause of poor outcome?. Monnet, Xavier, et al. Mattar, J. Brazilian Group for Bioimpedance Study. Foley, Kieran, et al. Barry, Ben N. House, Andrew A. Vincent, Jean-Louis, et al. Wiedemann HP, Wheeler AP, Bernard GR et al.

Comparison of two fluid-management strategies in acute lung injury. N Engl J Med ; — Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D; Sepsis Occurrence in Acutely Ill Patients Investigators.

Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. Malbrain, Manu LNG, et al. Breadcrumb Deranged Physiology Required Reading Electrolytes and Fluids.

Assessment of fluid balance. Previous chapter: The diagnostic utility of urinary electrolytes Next chapter: The use of albumin in critical illness. All SAQs related to this topic.

All vivas related to this topic. Methods used to Estimate Fluid Balance in the Critically Ill Patient Method Advantages Disadvantage Clinical estimates Cheap Easily performed at the bedside Interpreter-dependent Serial assessments across a series of clinicians may yield variation purely due to technique The assessment is qualitative Individually, no clinical sign has a clinically useful predictive value.

Take a closer look at the subtests and read about what potassium and sodium levels refer to. In addition to sodium, potassium is an important salt in the blood.

Certain diuretics, vomiting and diarrhoea may lower potassium levels. Elevated levels of potassium may indicate kidney failure. It is also known that certain diuretics cause an increase in potassium levels.

Potassium reference values in the test are 3. Sodium is one of the most important minerals in body fluids. Appropriate sodium levels in blood and other fluids are essential for a functioning metabolism. The sodium levels may also change due to certain diseases or medications.

Prolonged vomiting and diarrhoea can also cause sodium loss. The examination is done from a blood sample. Fluid balance assessment does not require fasting or morning sampling.

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Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, Christophi C, Leslie K, McGuinness S, Parke R, Serpell J, MTV C, Painter T, McCluskey S, Minto G, Wallace S, Australian, New Zealand College of Anaesthetists Clinical Trials N, the A, New Zealand Intensive Care Society Clinical Trials G Restrictive versus Liberal fluid therapy for major abdominal surgery.

National Heart L, Blood Institute Acute Respiratory Distress Syndrome Clinical Trials N, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL Comparison of two fluid-management strategies in acute lung injury.

Parker MJ, Thabane L, Fox-Robichaud A, Liaw P, Choong K, Canadian Critical Care Trials G, the Canadian Critical Care Translational Biology G A trial to determine whether septic shock reversal is quicker in pediatric patients randomized to an early goal-directed fluid-sparing strategy versus usual care SQUEEZE : study protocol for a pilot randomized controlled trial.

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Mitchell KH, Carlbom D, Caldwell E, Leary PJ, Himmelfarb J, Hough CL Volume overload: prevalence, risk factors, and functional outcome in survivors of septic shock. Ann Am Thorac Soc — Download references. The following individuals contributed to the formulation and content of this work in accordance with their participation in the 26th Acute Disease Quality Initiative ADQI XXVI and should be citable as collaborators on Pubmed.

Rashid Alobaidi 1 , David J. Askenazi 2 , Erin Barreto 3 , Benan Bayrakci 4 , O. Ray Bignall II 5 , Patrick Brophy 6 , Jennifer Charlton 7 , Rahul Chanchlani 8 , Andrea L. Conroy 9 , Akash Deep 10 , Prasad Devarajan 11 , Kristin Dolan 12 , Dana Fuhrman 13 , Katja M.

Gist 11 , Stephen M. Gorga 14 , Jason H. Greenberg 15 , Denise Hasson 11 , Emma Heydari 1 , Arpana Iyengar 16 , Jennifer Jetton 17 , Catherine Krawczeski 5 , Leslie Meigs 18 , Shina Menon 19 , Catherine Morgan 1 , Jolyn Morgan 11 , Theresa Mottes 20 , Tara Neumayr 21 , Danielle Soranno 9 , Natalja Stanski 11 , Michelle Starr 9 , Scott M.

Sutherland 22 , Jordan Symons 19 , Molly Vega 23 , Michael Zappitelli 24 , Claudio Ronco 25 , Ravindra L. Mehta 26 , John Kellum 27 , Marlies Ostermann Open access funding provided by Università degli Studi di Firenze within the CRUI-CARE Agreement. Representatives from the funders were present at the face-to-face meeting but did not participate in the panel discussions, voting, or final decisions.

Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA. Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA. Department of Emergency and Intensive Care, Pediatric Intensive Care Unit, Azienda Ospedaliero Universitaria Meyer, Florence, Italy.

Department of Health Science, University of Florence, Florence, Italy. Pediatric Nephrology Unit, Nephrology Center of Santa Casa de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.

Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada. You can also search for this author in PubMed Google Scholar.

Correspondence to Zaccaria Ricci. Goldstein reported receiving personal fees from BioPorto Diagnostics, grant support and personal fees from Medtronic, Nuwellis Inc. Akcan-Arikan reported receiving financial support for research from BioPorto research funds paid to her institution outside the submitted work.

Askenazi reported receiving personal fees from Baxter, Nuwellis Inc. Askenazi reported having a patent for Zorro-Flow, an external urine collection device pending, and a patent for continuous renal replacement therapy CRRT advancements pending.

Bagshaw reported receiving personal fees from Baxter and BioPorto during the conduct of the study. Barreto reported receiving financial support for research from FAST Biomedical Consultant and Wolters-Kluwer Consultant outside the submitted work.

Brophy reported receiving personal fees from UpToDate, during the conduct of the study, and American Board of Medical Specialities finance board.

Charlton reported receiving personal fees from Medtronics Carpediem Clinical Events Committee outside the submitted work. Gist reported receiving financial support for research from Medtronic Speaker Honorarium and financial support for research from BioPorto Diagnostics consulting fees outside the submitted work.

Menon reported receiving personal fees from Nuwellis Inc. outside the submitted work. Morgan reported receiving personal fees from Medtronic Consultant outside the submitted work. Mottes reported receiving financial support for research from Medtronic outside the submitted work.

Stanski reported receiving grants from National Center for Advancing Translational Sciences of the National Institutes of Health Institutional CT2 grant, 2UL1TRA1 and travel reimbursement from pADQI Travel funds to travel to consensus meeting flight and hotel during the conduct of the study; in addition, Dr.

Stanski reported holding a patent for PERSEVERE-II AKI Prediction Model pending. Zappitelli reported receiving financial support for research from BioPorto Inc. Honorarium for a national talk on CRRT not viewed by company ahead of time outside the submitted work. Kellum reported receiving personal fees from Dialco; being an employee of Spectral Medical and its wholly owned subsidiary Dialco outside the submitted work; and paid consultant for Astute Medical.

Ostermann reported receiving grants from Fresenius Research funding, grants from Baxter Research funding, and grants from bioMerieux Research funding during the conduct of the study.

Basu reported receiving personal fees from BioPorto Diagnostics outside of the submitted work and personal fees from bioMerieux outside of the submitted work.

During the conduct of the study, in addition, Dr. Basu reported having a patent for Renal Angina Index pending outside of the submitted work, and a patent for olfactomedin-4 pending outside of the submitted work.

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Download PDF. Abstract Background The impact of disorders of fluid balance, including the pathologic state of fluid overload in sick children has become increasingly apparent. Methods The 26th Acute Disease Quality Initiative was the first to be exclusively dedicated to pediatric and neonatal acute kidney injury pADQI.

Conclusions The 26th pADQI conference proposed harmonized terminology for fluid balance and for describing a pathologic state of fluid overload for clinical practice and research. Association between fluid overload and mortality in newborns: a systematic review and meta-analysis Article 02 November An update on the role of fluid overload in the prediction of outcome in acute kidney injury Article 20 October The role of fluid overload in the prediction of outcome in acute kidney injury Article 30 November Use our pre-submission checklist Avoid common mistakes on your manuscript.

Introduction In recent years, the deleterious impact of fluid overload in critically ill patients across the age spectrum has become clear [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ]. Methods The methodology utilized for ADQI meetings has been developed iteratively over the last two decades [ 26 ].

Question 1: What defines fluid balance in sick children? Question 2: What defines fluid overload in sick children? Statement: Fluid overload denotes a pathologic state of positive fluid balance associated with a clinically observable event s , which may vary by age, case-mix, acuity, and phase of illness.

No specific threshold of positive fluid balance alone can define fluid overload across all sick children In order to advance the field, the term percent cumulative fluid balance should be utilized to describe the cumulative positive fluid balance over a given time period.

Table 2 Selected studies evaluating the impact of fluid balance on outcomes Full size table. Full size image. Areas for future research Further understanding of the incidence of both positive and negative fluid balance in all sick children acute, critically ill, neonates, post-cardiac surgery, oncologic patients, etc.

Understand the impact of timing and trajectory of positive fluid balance on outcomes. Develop objective and reproducible measures of edema. Identify thresholds for intervention in various case mixes of sick children. Question 3: What are the challenges to translating observational data to clinical management of fluid balance?

Statement: The literature describing the association of fluid balance on outcomes is based on observational studies. Evidence from observational data alone cannot establish a causal relationship between fluid balance and outcomes In order to move the field forward and improve outcomes related to fluid balance, a better understanding and establishment of the causal link between fluid balance and outcomes are needed.

Study designs Table 3 outlines some of the ongoing and seminal studies that have been done to date in adults and children evaluating the impact of fluid balance on clinical outcomes. Areas for future research Pragmatic randomized trials such as crossovers, cluster RCTs, stepped-wedge, or other quasi-experimental designs are likely needed to further understand the complex relationship of fluid balance and mortality, and whether or not a causal link exists.

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Rationale for fluid balance measurements Critically ill patients are often subjected to large volumes of fluid resuscitation or fluid loss eg. by haemorrhage, diuresis or in burns. The trend in fluid balance can guide therapy in terms of further fluid resuscitation or diuresis Fluid balance records can help determine the dose of ultrafiltration.

Positive fluid balance has been associated with worse outcomes in certain disease states, eg. sepsis Vincent et al, For some conditions eg. ARDS a neutral or negative fluid balance has been associated with better outcomes Wiedemann et al, Neglect of fluid balance calculations can lead to dehydration or fluid overload Often, it is impractical to perform daily weight measurements though these are acknowledged as the gold standard.

Advantages of fluid balance calculations Quick and easy Can be outsourced to nursing staff Can be easily automated by computerised information systems Requires no special bed equipment or scales Requires only fluid input and output data, which is already collected in routine observation charts Disadvantages of fluid balance calculations Subject to human error or computer error Only as accurate as the records on which they are based Non-recorded losses eg.

evaporative, or losses into dressings or pads will not be reflected in the calculated fluid balance To increase accuracy eg. pre and post use weight of pads or absorbent dressings increases nursing workload The practice of calculating fluid balance is wildly inaccurate.

Moreover, about one third of them was arithmetically incorrect i. The authors were forced to conclude that "this reduced attention for the FB might theoretically hide a general sense of futility regarding the conventional practice" of fluid balance calculation.

The theoretical benefits of attention to fluid balance Frequently, ICU stay is associated with vigorous fluid resuscitation. The resulting positive fluid balance has been associated with poor outcomes It is thought that tissue oedema contributes to organ dysfunction: " Tissue oedema impairs oxygen and metabolite diffusion, distorts tissue architecture, impedes capillary blood flow and lymphatic drainage, and disturbs cell-cell interactions " Malbrain et al, Other mechanisms of harm from positive fluid balance include raised intra-abdominal pressure, worse perfusion of swollen encapsulated organs, oedema of anastomotic sites, and damage to the endothelial glycocalyx.

On the basis of studies which demonstrated a harmful impact of positive fluid balance on outcomes, "de-resuscitation" has been suggested as a valid practice- to aim for a neutral or negative fluid balance by days of critical illness.

However, it must be mentioned that the bulk of these studies have been performed using calculated fluid balances, with all the inaccuracy thereof. Moreover, the authors of the "de-resuscitation" strategy Malbrain et al, could not make any strong recommendation regarding how one should aim for this negative fluid balance, as there is no evidence to support the routine use of albumin or diuretics, versus letting the patient mobilise the fluid by normal homeostatic mechanisms.

The unclear clinical significance of changes in total body water Under ideal circumstances, the fluid balance calculations and body weight measurements will give a more or less accurate representation of the fluctuations of total body water. However, the significance of this variable is questionable.

Total body water is dispersed into a variety of compartments, and not all compartments have an equal significance for patient care. For instance, in shock states the intravascular compartment volume is of greatest interest, but this occupies only a small fraction of the total body water volume.

In ARDS, total body water only has importance insofar as it reflects the volume of extravascular lung water, which contributes to the poor lung compliance and gas exchange problems. In cardiogenic shock or post-operative cardiac surgery scenarios, the volume of interest is the end-diastolic volume which represents preload; total body water is even less related to this variable.

In states of critical ilness, the physiological processes which govern the movement of water between compartments are grossly deranged: The oncotic pressure gradient is gone your albumin is low The musculoskeletal pump is gone venous and lymphatic return is impaired by the prolonged immobility of a sedated intubated patient Capillaries are leaky due to inflammation encouraging water movement out of the circulatory volume into the interstitium Serosal surfaces are leaky due to inflammation, allowing the collection of fluid in "potential spaces" such as the pleural cavity In short, it is unclear how the manipulation of total body water affects clinically relevant fluid compartments.

And if it does, then it crudely affects all compartments, not only the ones of clinical interest. One might argue that fluid-related therapies eg.

fluid resuscitation, dialysis dosing, diuretics should be directed on the basis of other measurements. References Schneider, Antoine G. Am J Clin Nutr , 33 12 Charra, Bernard. Cheap Easily performed at the bedside. Interpreter-dependent Serial assessments across a series of clinicians may yield variation purely due to technique The assessment is qualitative Individually, no clinical sign has a clinically useful predictive value.

Accuracy depends on accuracy or recording Usually, cumulative balance records are inaccurate and tend to disagree with body weight measurements This technique fails to estimate losses into incontinence pads, spilled secretions, sweat, evaporative losses from wounds, and losses via the lungs; in short "insensate" losses are forgotten.

Easily performed in the presence of specialised bed equipment. Accuracy depends on accuracy of recording Requires expensive bed equipment Requires attention to detail - one must ensure the same amount of bedding and on-bed equipment is with the patient each time, otherwise fluctuations in weight may occur.

Correlates poorly with bedside charts Lack of evidence for cost-effectiveness. Easily performed at the bedside Constant monitoring is possible. Invasive Measures pressure, not volume Outdated as a means of assessing intravascular volume Assumption that patients with a higher CVP are better hydrated is not based on any robust evidence.

Solid physiological basis Reproducable measurements Use of PAC to guide fluid therapy may decrease the total fluid volume used. Very invasive Mortality is either not affected or actually increased by this technique In comparison to the known to be useless CVP measurements, PAC is no better in terms of mortality, but is associated with more complications.

Rapid Non-invasive Easily repeated serially Good sensitivity and specificity when compared to clinical examination by an expert. Interpreter-dependent Serial assessments across a series of clinicians may yield variation purely due to technique Yields information regarding chamber filling volumes rather than total body fluid volume - and then you infer the fluid balance from this.

May decrease ICU stay and duration of ventilation Appears related to survival Differentiates oedema from ARDS.

Invasive Labour-intensive thermodilution measurement Association with cardiac function makes it difficult to use lung water to estimate whole-body fluid balance. Non-invasive Potentially, easily reproduceable Potential benefits in patients with sepsis and multi-organ system failure.

For this reason the assessment of people with continence problems should emphasise visual observations and meticulous history-taking, using effective questioning and listening techniques.

In acute settings, where changes usually occur over a shorter period of time, it is easier to establish a cause-and-effect relationship by piecing events together in a chronological order.

This is far more difficult when changes occur over a longer period, as the number of variables and influencing factors multiply. It may be necessary to assess the fluid balance of patients with continence problems as part of their continence management or because they have presented with a separate medical condition.

This could include the following:. To get a complete picture, any assessment must be broad yet thorough and be founded on a good clinical knowledge base.

Many patients are extremely embarrassed about their continence problems and may be unable or reluctant to discuss them. Nurses must be responsive to these anxieties, and interpersonal skills are vital because a history is one of the main elements of a fluid-balance assessment.

Older patients with a fluid imbalance present additional challenges when it comes to assessment. In addition, two important assessment tools are invalid in many older patients. The second is the assessment of mucous membranes in older people, which may be dry as a result of decreased salivation rather than a fluid deficit.

History-taking is a key part of any fluid-balance assessment. For this reason and because any situation in which patients are unable to provide information - either because of speech difficulties, confusion, disorientation or depression - the help of carers may be required and it may be necessary to use alternative methods of communication.

A range of factors could precipitate either fluid loss or fluid gain. During the history-taking, any of the following conditions should be noted and explored:. Older people may also restrict their fluid intake in an attempt to alleviate continence problems or because mobility problems make it difficult for them to get to a toilet;.

During conversation, is the patient constantly trying to moisten his or her lips? This may be a sign of dry mucous membranes caused by fluid deficit. In the absence of any other causative factors, such as low plasma-albumin levels, peripheral oedema may indicate fluid overload.

Postural hypotension may become evident when the patient moves from a lying to a standing position.