Initiative Aims to Reduce Fluid Overload in NICU Infants

A baby in a Neonatal Intensive Care Unit (Stock photo)

A new effort led by Children’s of Alabama pediatric nephrologist Lindsey Gordon, D.O., is taking aim at fluid overload and its harmful offshoots—including acute kidney injury, prolonged ventilation and hospital stays—in hopes of smoothing the path for infants in the NICU toward a healthier future. The initiative, dubbed CAN-U-P-LOTS, encapsulates a 10-step clinical practice bundle that will be tested over the coming year in collaboration with Children’s NICU clinicians.

Babies in the NICU face many grave health challenges, not least of which is fluid overload from IV medications and nutrition intended to keep them alive and help them thrive.

“New evidence shows how fluid overload in these neonates can cause a lot of problems in the long run, and many times, this can lead to a poor outcome,” Gordon, a third year fellow at Children’s and the University of Alabama at Birmingham (UAB), explained. “We’re trying to recognize the problem early to prevent some of these negative outcomes.”

Elements of the CAN-U-P-LOTS practice bundle include:

  • C: Evaluating the cause of fluid overload
  • A: Assessing albumin level and replenishing as needed
  • N: Limiting nephrotoxic medications that can hurt the kidneys
  • U: Assessing and treating high levels of uric acid and using dialysis for ultra-filtration to remove extra fluid
  • P: Perfusion to the kidneys by increasing blood pressure to ensure adequate blood flow
  • L: Lasix stress test and attempting diuretic use to assess if the kidneys respond
  • O: Monitoring urine output/obstruction carefully and considering placing a Foley catheter or doing a renal ultrasound to ensure no blockage
  • T: Monitoring total fluid intake with an eye toward reducing fluid amounts without sacrificing nutrition
  • S: Considering steroid use if a patient is on several vasopressors to further support blood pressure

Some NICU neonates have risk factors that confer a high risk for fluid imbalance, including patients:

  • with sepsis or acute kidney injury
  • receiving multiple antibiotics
  • being prepared for major surgery
  • requiring blood pressure support with multiple medications

“Preliminary data suggest that the vast majority of neonates admitted to the Children’s of Alabama NICU meet the criteria at least once for fluid overload problems,” Gordon said.

The CAN-U-P-LOTS effort “will produce valuable data that will help us understand whether and how this practice bundle can be implemented on a widespread basis,” said David Askenazi, M.D., director of the Children’s Pediatric and Infant Center for Acute Nephrology (PICAN).

“The idea started with a collaborative approach to help standardize care of these children and educate providers in an effort to equip the NICU team with these systematic tools, so babies don’t ever have to develop fluid overload—the soggy lungs or wet heart that will keep them sicker longer,” Askenazi said. “It takes a village because a project like this takes multiple people, conversations and opportunities to learn from one another.”

“Our hunch is it’s going to work,” he added. “If we can show clinical improvements in these vulnerable babies, we can communicate this to our colleagues to help babies around the country and world. We’re giving them 10 things to think about that can help them maximize medical management before these babies need dialysis.”

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