(87) Medication Use as a Contributor to Fluid Overload for Neonates on ECMO: A Retrospective Study

Background: Neonates requiring extracorporeal membrane oxygenation (ECMO) are at high risk for fluid overload (FO), which contributes to adverse outcomes such as increased mortality, increased time on the ECMO circuit, longer duration of mechanical intubation and increased length of hospital stay. Although the burden of medication intake on fluid overload has been studied in the pediatric intensive care unit (PICU) population, limited data exists for neonates.

Objectives: This study aimed to evaluate (1) the association of resuscitative and modifiable fluid intake with fluid overload in neonates on ECMO, and (2) the relationship between fluid overload and clinical outcomes including mortality, ECMO duration, ventilator days, and hospital length of stay.

Design/Methods: A retrospective cohort study was conducted on 97 neonates without congenital cardiac or renal anomalies who underwent ECMO from 2012–2023 at a single quaternary NICU. Fluid intake was categorized as resuscitative (e.g., boluses, albumin, blood products) or modifiable (e.g., medications, flushes, TPN). Percent fluid overload (%FO) was calculated daily. Multivariable models assessed associations between fluid intake, %FO, and clinical outcomes.

Results: On ECMO Day 0, patients received a median of 101 ml/kg of modifiable fluid and 71 ml/kg of resuscitative fluid. Both fluid types were significantly associated with increased %FO early in the ECMO course. In fixed-effects models, modifiable and resuscitative intake were independently associated with increased %FO (p < 0.001), while gestational age and diagnosis were not. Each 1 ml/kg increase in modifiable or resuscitative volume was associated with a 0.046% and 0.065% increase in %FO, respectively. Over time, %FO declined as urine output increased. Logistic regression revealed that higher %FO was significantly associated with increased mortality (p = 0.001), though not with ECMO duration, ventilation time, or hospital stay.

Conclusions: Both modifiable and resuscitative fluid intake significantly contribute to fluid overload in neonates on ECMO, particularly early in the course. Given the association between fluid overload and mortality, strategies to minimize modifiable volume, including concentrating medications and reducing unnecessary carriers, may improve outcomes. These findings support the need for fluid stewardship protocols and prospective interventional studies.