Fluid balance in pediatric patients in prone position: a pragmatic study

Agnese, Rosirene Maria Frohlich Dall’; Oliveira, Petrônio Fagundes de; Costa, Caroline A. D.; Tonial, Cristian T.; Bruno, Francisco; Enloft, Paulo R.; Fiori, Humberto H.; Garcia, Pedro Celiny R-.

doi:10.1590/1806-9282.65.6.839

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Revista da Associação Médica Brasileira

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Original Article • Rev. Assoc. Med. Bras. 65 (6) • June 2019 • https://doi.org/10.1590/1806-9282.65.6.839 copy

Fluid balance in pediatric patients in prone position: a pragmatic study

Authorship SCIMAGO INSTITUTIONS RANKINGS

SUMMARY

OBJECTIVE:

To verify the association between prone position, increased diuresis, and decreased cumulative fluid balance in critically ill pediatric patients who underwent mechanical ventilation (MV) for pulmonary causes and describe adverse events related to the use of the position.

METHODS:

This is a retrospective observational study. Patients aged between 1 month and 12 years who underwent MV for pulmonary causes, between January 2013 and December 2015, were selected and divided between those who were put on prone position (PG) and those who were not (CG) during the hospitalization at the Pediatric Intensive Care Unit (PICU). Data were analyzed longitudinally from D1 to D4.

RESULTS:

A total of 77 patients (PG = 37 and CG = 40) were analyzed. The general characteristics of both groups were similar. In the comparison between the groups, there was no increase in diuresis or decrease in cumulative fluid balance in the prone group. In the longitudinal analysis of D1 to D4, we saw that the PG presented higher diuresis (p = 0.034) and a lower cumulative fluid balance (p = 0.001) in D2. Regarding the use of diuretics, there was greater use of furosemide (P <0.001) and spironolactone (P = 0.04) in the PG. There was no increase in adverse events during the use of the prone position.

CONCLUSION:

The prone position was not associated with increased diuresis or decreased cumulative fluid balance in critically ill pediatric patients who underwent to MV for pulmonary causes.

KEYWORDS:
Prone position; Diuresis; Water Balance; Positive-Pressure Respiration; Intensive Care Units, Pediatric

	Prone Group n = 37	Control Group n = 42	P-value
Age (months); median (IQR)	3.0 (2.0-6.0)	4.0 (2.0-9.0)	0.485
Male; n (%)	22.0 (59.5%)	23.0 (54.8%)	0.674
Mortality score PIM2; median (IQR)	2.0 (1.0-5.3)	1.1 (0.9-5.3)	0.914
Main diagnosis; n (%) Bronchiolitis / Wheezing baby Pneumonia / Pneumonia with pleural effusion Others	33 (89.2%) 4 (10.8%) 0 (0%)	34 (81.0%) 6 (14.2%) 2 (4.8%)	0.308 0.643 0.178
MV parameters (first 3 days of MV) PIP (cmH2O), mean (SD) PEEP (cmH2O), mean (SD) FiO2 (%)	32.9 (3.5) 5.7 (1.7) 0.45 (0.15)	29.6 (4.6) 5.3(1.5) 0.40 (0.11)	<0.01 0.054 0.01

	Prone Group n = 37	Control Group n = 42	P-value^ Numerical variables – Mann-Whitney test; Categorical variables – the chi-squared or Fisher's exact test; CA = Cardiac arrest.
Time of MV (days); median (IQR)	9.9 (7.1-12.2)	6.7 (4.8-8.6)	<0.001
Length of stay in the PICU (days); median (IQR)	14.0 (10.0-19.0)	10.5 (7.0-14.0)	<0.001
Length of hospital stay (days); median (IQR)	21.0 (16.0-27.0)	18.0 (15.0-24.0)	0.460
Death; n (%)	1.0 (2.7%)	1.0 (2.4%)	0.927
Diuretics Furosemide (mg/kg/day); median (IQR) Spironolactone (mg/kg/day); median (IQR)	1.62 (1.29-2.33) 0.91 (0.56-1.43)	1.04 (0.58-1.40) 0.71 (0-1.11)	<0.001 0.04
Index of vasoactive drugs; median (IQR)	9.11 (6.54-12.89)	10.0 (6.25-14.55)	0.906
Intercurrent event; n (%) Absent Pneumothorax CA on prone position CA on supine position Accidental extubation during prone position Accidental extubation during supine position Extubation failure Others	27 (73.0%) 2 (5.4%) 1 (2.7%) 2 (5.4%) 0 (0%) 1 (2.7%) 1 (2.7%) 3 (8.1%)	35 (83.3%) 3 (7.1%) 0 (0%) 0 (0%) 0 (0%) 1 (2.4%) 1 (2.4%) 2 (4.8%)	0.263 0.751 --- --- --- 0.927 0.927 0.542

Time	Prone Group^* Legend: *Mean (standard error), based on marginal estimates; n = 37	Control Group^* Legend: *Mean (standard error), based on marginal estimates; n = 40	Mean difference (95% CI)	P-value^ Adjustment for multiple comparisons.
Diuresis (ml/kg/h)
Day 1	3.19 (0.22)	2.90 (0.21)	0.29 (-0.317 a 0.895)	0.345
Day 2	3.89 (0.20)	3.30 (0.19)	0.59 (0.047 a 1.1370)	0.034
Day 3	3.92 (0.22)	4.15 (0.22)	-0.23 (-0.852 a 0.389)	0.460
Day 4	4.08 (0.22)	4.30 (0.21)	-0.22 (-0.824 a 0.387)	0.474
Fluid balance (ml/kg/day)
Day 1	37.57 (4.90)	50.11 (4.71)	-12.54 (-26 07 to 1.00)	0.069
Day 2	13.48 (4.40)	34.26 (4.23)	-20.77 (-32.94 to −8.61)	0.001
Day 3	15.27 (5.17)	7.05 (4.97)	8.23 (-6.07 to 22.52)	0.255
Day 4	13.29 (4.37)	5.43 (4.20)	7.86 (- 4.22 to 19.94)	0.199
Furosemide (mg/kg/day)
Day 1	1.03 (0.15)	0.05 (0.14)	0.98 (0.57 a 1.38)	< 0.001
Day 2	1.49 (0.15)	0.29 (0.14)	1.19 (0.78 a 1.61)	< 0.001
Day 3	1.76 (0.16)	0.78 (0.16)	0.98 (0.53 a 1.43)	< 0.001
Day 4	2.14 (0.18)	1.22 (0.17)	0.92 (0.42 a 1.42)	< 0.001

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[1] CORRESPONDING AUTHOR: Caroline Abud Drumond Costa, Av. Ipiranga, 6690, Bairro Partenon, Porto Alegre, RS, Brasil – CEP 90619-900 E-mail: carolabuddrumond@gmail.com