Pharmacologic recipes for tracheal intubation in the PICU: what's on the menu?

290 www.pccmjournal. org March 2015 • Volume 16 • Number 3 by fluid removal did not improve outcomes, suggesting perhaps that prevention of fluid overload might be more important than fluid removal (10). Even simple measures such as awareness of unintended excessive fluid administration, use of maximal concentration in medications, and concentration of feeds might be impactful. Up until now, the pediatric world suffered from lack of innovative devices specifically designed for children, leaving clinicians circumnavigating machines with large extracorporeal volumes and higher pump speeds for pediatric use. The current interest in new miniaturized devices could play a revolutionary role in pediatrics allowing us to deliver safer and accurate ultrafiltration and renal support over a wider age range (11). Prospective studies to determine the optimal way to manage fluids in pediatric critically ill patients are urgently needed. However, the most important step will be determination of the underlying cause—is fluid overload a manifestation of an underlying excretion problem—oliguric acute kidney injury (AKI) in disguise? The functional AKI marker used—creatinine—is impacted by total body water (12, 13) and is falsely low in the fluid overloaded patient leading to underdiagnosis of AKI. In addition, endogenous creatinine production is decreased in critically ill adults, although no data exist in pediatrics. It is imperative to identify the patients who have AKI with oliguria who are at highest risk of fluid accumulation early to try to prevent further harm. This aspect is perhaps the most important shortcoming of the current study, a missed opportunity, as the authors did not consider AKI and associated oliguria and its impact on overall fluid balance in their study design. Patients with oliguric AKI are at higher risk for adverse outcomes compared with nonoliguric patients and should be managed differently. Once hemodynamic stability is reached, further fluid administration in the critically ill should also be goal directed, aimed at preventing excessive fluid accumulation with early consideration for fluid removal. Although the ideal timing and method of fluid removal in pediatric patients remain yet unknown, it is time to consider protocolized fluid management in pediatric ALI with careful attention to fluid dose and elimination. REFERENCES 1. Koyner JL, Murray PT: Mechanical ventilation and lung-kidney interactions. Clin J Am Soc Nephrol 2008; 3:562–570 2. Sinitsky L, Walls D, Nadel S, et al: Fluid Overload at 48 Hours Is Associated With Respiratory Morbidity but Not Mortality in a General PICU: Retrospective Cohort Study. Pediatr Crit Care Med 2015; 16:205–209 3. 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Abulebda K, Cvijanovich NZ, Thomas NJ, et al: Post-ICU admission fluid balance and pediatric septic shock outcomes: A risk-stratified analysis. Crit Care Med 2014; 42:397–403 9. Martin GS, Mangialardi RJ, Wheeler AP, et al: Albumin and furosemide therapy in hypoproteinemic patients with acute lung injury. Crit Care Med 2002; 30:2175–2182 10. Selewski DT, Cornell TT, Blatt NB, et al: Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy. Crit Care Med 2012; 40:2694–2699 11. Ronco C, Garzotto F, Brendolan A, et al: Continuous renal replacement therapy in neonates and small infants: Development and first-inhuman use of a miniaturised machine (CARPEDIEM). Lancet 2014; 383:1807–1813 12. 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