Abstract
Background:
Fluid resuscitation plays a central role in the management of critically ill children who receive care in pediatric intensive care units (PICUs). Although liberal bolus-based resuscitation has been recommended historically, recent evidence suggests worse respiratory outcomes and increased morbidity with excessive fluid administration. The best approach to fluid volume in critically ill children is unclear.
Objectives:
To compare restrictive and liberal fluid resuscitation strategies in critically ill children managed in PICU-level settings and to quantify the effect of restrictive strategies on mechanical ventilation using randomized controlled trial evidence.
Methods:
A systematic review using a PRISMA guide of the randomized controlled trials was performed. Trials with critically ill children (age up to 18 years) in a PICU level setting comparing restrictive and liberal fluid resuscitation strategies were included. Three RCTs were suitable to be quantitatively combined (Nallasamy 2025; FiSh 2019; Duron 2023). Five other RCTs were synthesized narratively because of differences in intervention type, people or outcome comparability (Somasetia 2014; FEAST 2011; Balamuth 2020; Akech 2006; Maitland 2005). Random-effects meta-analysis was carried out for the need for mechanical ventilation. Low event rates and/or non-comparable reports across the volume-strategy trials caused the lack of pooling of mortality.
Results:
Eight RCTs (3 quantitative, 5 qualitative) were included. In the quantitative meta-analysis, restrictive strategies were found to have a non-significant effect on mechanical ventilation in comparison with liberal strategies (RR 0.68; 95% CI 0.45-1.03). Mortality pooling was not feasible due to low event rates and non-comparable reporting across volume-strategy trials. Historical evidence of other pediatric shock trials indicated some heterogeneity in responses by disease circumstance and type of strategy, even in the context of settings in which bolus-heavy methods were negatively linked.
Conclusion:
Among critically ill children in care in a pediatric intensive care unit, restrictive fluid strategies may help reduce the need for mechanical ventilation compared with liberal fluid strategies with no evidence of increased harm in pooled trials on volume strategy; however, the evidence for this is limited to small trial sizes and low event rates. Larger multicenter RCTs are required to establish ideal fluid resuscitation volumes in pediatric critical care.