Fluid management in critically ill pediatric patients with congenital heart disease

Fluid balance management in pediatric critically ill patients is a challenging task, since fluid overload (FO) in the pediatric ICU is considered a trigger of multiple organ dysfunction. Pediatric patients with congenital heart disease (CHD) have several pre, intra and postoperative risk factors of derangements in fluid management. In particular, the smallest patients with acute kidney injury are at highest risk of developing severe interstitial edema, capillary leak syndrome and FO. Several studies previously showed a significantly higher percentage of FO among children with severe renal dysfunction requiring RRT, strongly associated with poor outcomes. For this reason, in children, priority indication is currently given to the correction of water overload. The present review will discuss recent literature addressing the issue of fluid balance in critically ill children with CHD, dosages, benefits and drawbacks of diuretic therapy, alternative diuretic/ nephroprotective drugs currently proposed in the pediatric cardiac surgery setting. Monitoring of fluid balance will be reviewed. Specific modalities of pediatric extracorporeal fluid removal will be presented.