ONLINE CLINICAL INVESTIGATIONS

Agreement Between Measured Weight and

Fluid Balance in Mechanically Ventilated
Children in Intensive Care
Ben Gelbart, MBBS, FRACP,
OBJECTIVES: To investigate the agreement between change in body weight FCICM1
(BW) and fluid balance (FB), and the precision and safety of BW measurement in Vanessa Marchesini, MD2
mechanically ventilated infants in intensive care.
Sudeep Kumar Kapalavai, MBBS,
DESIGN: Prospective observational study. MD, FNB3
SETTING: Tertiary PICU. Andrea Veysey, RN2
Alyssa Serratore, RN,
PATIENTS: Infants following cardiac surgery, at baseline, 24 hours, and 48 hours.
GDipNP(PaedCritCare),
INTERVENTIONS: BW and FB measurement at three time points. MAdvNursPrac2

MEASUREMENTS AND MAIN RESULTS: Between May 2021 and Jessica Appleyard,
RN, BNSc(Hons),
September 2022, we studied 61 children. The median age was 8 days (inter-
GDipNP(PaedCritCare),
quartile range [IQR], 1.0–14.0 d). The median BW at baseline was 3,518 g (IQR, MAdvNursPrac2
3,134–3,928 g). Change in BW was –36 g (IQR, –145 to 105 g) and –97 g (IQR,
Rinaldo Bellomo, MD, FRACP,
–240 to –28 g) between baseline and 24 hours, and between 24 and 48 hours,
FCICM4–8
respectively. Change in FB was –82 mL (IQR, –173 to 12 mL) and –107 mL (IQR,
–226 to 103) between baseline and 24 hours, and between 24 and 48 hours, Warwick Butt, MBBS, FRACP,
FCICM, FELSO1
respectively. In Bland-Altman analyses, the mean bias between BW and FB at 24
and 48 hours was 54 g (95% CI, 12–97) and –43 g (95% CI, –108 to 23), re- Trevor Duke, PhD, MBBS, FRACP,
FCICM1
spectively. This exceeded 1% of the median BW, and limits of agreement ranged
from 7.6% to 15% of baseline BW. The precision of paired weight measurements,
performed sequentially at each time interval, was high (median difference of ≤1%
of BW at each time point). The median weight of connected devices ranged from
2.7% to 3% of BW. There were no episodes of tube or device dislodgments and
no change in vasoactive therapies during weight measurements.
CONCLUSIONS: There is moderate agreement between the changes in FB and
BW, albeit greater than 1% of baseline BW, and the limits of this agreement are
wide. Weighing mechanically ventilated infants in intensive care is a relatively safe
and precise method for estimating change in fluid status. Device weight repre-
sents a relatively large proportion of BW.
KEY WORDS: agreement; body weight; fluid balance; fluid overload; mechanical
ventilation; pediatric intensive care

B
ody weight (BW) is a fundamental measurement in both the acute and
ambulatory cares of children. It is used to assess fluid status, nutrition, and
growth trajectories (1). However, BW is infrequently measured in seriously
unwell children in intensive care (2), particularly during the acute phase of illness.
Barriers to performing weight measurements in this setting include the lack of ac-
curate scales or equipment, the safety risk of lifting such children, and the potential Copyright © 2023 by the Society of
for measurement error related to attachment of devices. However, changes in BW Critical Care Medicine and the World
during acute illness, theoretically, are more representative of change in fluid status, Federation of Pediatric Intensive and
compared with fluid balance (FB) charts, because FB has inherent limitations such Critical Care Societies

as undocumented or unmeasured fluid loss or gain. Differences between FB and DOI: 10.1097/PCC.0000000000003258

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 Gelbart et al
RESEARCH IN CONTEXT
• Fluid balance charts are the most common re-
ported method for measuring change in fluid
status; however, it has inherent inaccuracies
such as the inability to measure insensible
losses and the reliance on accurate documen-
tation of fluid input and output.
• Body weight-based determination of fluid
status, overcomes some limitations of chart-
based methods but is technically more chal-
lenging, relies on accurate scales, and must
account for the weight of attached devices, and
there are few data regarding its agreement with
chart-based methods.
• There is moderate agreement between changes
in body weight and fluid balance; however, the
limits of agreement are wide, suggesting that
they may not be interchangeable. Body weight
measurements are safe and precise, but the
weight of attached devices is considerable.
weight-based estimates of fluid status have been reported
to be wide (3–5); however, there are few prospective data
regarding the precision of weight measurement, the con-
tribution of device weight to BW, or the agreement be-
tween BW and FB in estimating change in fluid status in
critically ill children (6, 7).
Fluid accumulation has been widely reported to
be associated with harm in children in intensive care
(8–10). In such reports, the FB chart has been the most
common method for quantifying fluid accumulation,
and only few studies have reported change in BW (7,
11). The net difference between fluid intake and output
is easily calculated; however, it can also be inaccurate
because it does not account for insensible water loss or
gain. Several studies have reported that weight change
in critically ill adults correlates poorly with recorded
measurements of FB (5) ([r = 0.34] [4] and [r = 0.28])
(3). In children, the relationship appears stronger
(r =0.63); however, large differences between these
measurements challenge its clinical utility (6) but
also highlight potential inaccuracies of both. Previous
reports of the precision of weight-based estimation of
fluid status either rely on retrospective weight mea-
surements (7) or do not report the validation of weigh-
ing technique or the contribution of device weights (6).
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Accordingly, we performed a prospective study to in-
vestigate the agreement between changes in BW and
FB, the precision of sequential BW measurements,
and the weight of devices as a proportion of BW. BW
and FB are not expected to agree perfectly; however,
we hypothesized that, when accounting for device
weights, the agreement between change in BW and
change in FB would be less than one percent.
MATERIALS AND METHODS
A prospective, observational study aiming to quan-
tify edema was performed at the Royal Children’s
Hospital, PICU between May 2021 and September
2022. Permission to conduct the study was provided by
the Royal Children’s Hospital Human Research Ethics
Committee (HREC number HREC/65005/RCHM-
2020), and procedures were followed in accordance
with the Helsinki Declaration of 1975.
Children were eligible if they were admitted or
returned from theater within the previous 72 hours,
were mechanically ventilated, and were expected to re-
main so for at least 48 hours. Children were excluded if
they had other reasons for facial edema (such as caval
or cerebral venous obstruction, facial injuries, or pro-
longed prone positioning) or were previously enrolled
in the study. Demographic and clinical characteris-
tics including age, sex, weight, admission diagnosis
(Australian and New Zealand Paediatric Intensive
Care Registry [ANZPICR] diagnostic codes), Risk
Adjustment for Congenital Heart Surgery, Pediatric
Index of Mortality score (12), duration of invasive MV,
duration of respiratory support (noninvasive and in-
vasive ventilation excluding high-flow nasal cannula
therapy), use of extracorporeal membrane oxygenation
and renal replacement therapy, intensive care and hos-
pital length of stay, and mortality were recorded from
the PICU database. Data were entered into a Research
Electronic Data Capture (REDCap) database V10.7.1
(2021, Vanderbilt University, Nashville, TN).
Weight Measurements
Following parental consent, two consecutive (paired)
weight measurements were performed at each time
point (baseline, 24 hr, and 48 hr from enrollment), and
the mean was recorded. The Atom infant warmer cot
(Parker Healthcare, Victoria, Australia) with built-in
scales was used after testing for accuracy using calibrated
October 2023 • Volume 24 • Number 10

weights (13). The weighing procedure is outlined in the
Supplementary Appendix (http://links.lww.com/PCC/
C370). Each measurement was performed by the primary
investigator (B.G.) or trained fellows (V.M., S.K.K.) with
assistance from nursing staff. The number and type of in-
dwelling devices were recorded at each time point, and
their dry weights were subtracted from the mean BW. The
dry weight for each device was measured separately and
assigned a reference weight from which the total device
weight was calculated. To ensure that in-dwelling perito-
neal dialysate was accounted equally for FB and weight
measurements, its volume was subtracted from the total
weight, where appropriate. If only one weight measure-
ment was performed at each time point, due to logistic or
clinical reasons, the single measurement was used.
Fluid Balance Measurements
FB was calculated as the absolute net difference be-
tween fluid input and output as an absolute value and
as a percentage of BW at enrollment. It was recorded
at 24 and 48 hours and aligned with the timing of BW
measurements. Net fluid input included all intrave-
nous and enteral fluid. Net fluid output included urine,
stool, drain, and peritoneal dialysis effluent.
Outcomes
The primary outcome was the agreement between
change in BW measurement and change in FB. The
secondary outcomes included the precision of BW
measurements and the median device weight and its
proportion of median BW.
Statistical Analysis
Demographic and clinical characteristics were
described using frequencies and proportions.
Symmetry of the data was inspected by histogram
plots. Nonsymmetrically distributed data were sum-
marized using median and interquartile range. The
changes in FB and weight for each 24-hour interval
were summarized and presented as scatter plots. The
weight of devices and attachments were described,
and the percentages of the BW were calculated.
Agreement between FB and weight was assessed using
Bland-Altman analysis of mean bias and 95% lim-
its of agreement. All analyses were performed using
the R software, Version 4.1.0 (The R Foundation for
Pediatric Critical Care Medicine
Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
Online Clinical Investigations
Statistical Computing, Vienna, Austria). R pack-
ages are listed in the Supplemental Digital Content
(http://links.lww.com/PCC/C370). A p value of less
than 0.05 was considered statistically significant. The
Strengthening the Reporting of Observational Studies
in Epidemiology checklist for cohort studies was
completed and is found in the Supplemental Digital
Content File (http://links.lww.com/PCC/C371).
RESULTS
Between May 2021 and September 2022, 61 children
were enrolled, and 59 children had two time intervals
for analysis. Two families withdrew consent: one after
the first study day and another after the second day.
Sixty children were enrolled following cardiac surgery,
including eight children with delayed sternal closure,
and one child was enrolled prior to cardiac surgery.
The demographic and clinical characteristics of chil-
dren enrolled in the study are shown in Table 1.
Body Weight Characteristics
There was a total of 353 weight measurements per-
formed over three time points. The median BW at each
time point, the change in BW between time points,
and the device weights at each time point are shown
in Table 2 and Supplementary Figure 1 (http://links.
lww.com/PCC/C370). The individual weight measure-
ments for each child, at each time point, are shown
in Supplementary Figure 2 (http://links.lww.com/
PCC/C370). The mean change in weight between time
intervals is shown in Figure 1 and the distribution of
percentage weight change for each time interval in
Supplementary Figure 3 (http://links.lww.com/PCC/
C370). Supplementary Tables 1 and 2 (http://links.
lww.com/PCC/C370) show the median and percentage
difference between the two paired, consecutive weight
measurements, performed at each time interval.
Fluid Balance
FB data were available for each child at each time point.
The individual FB from baseline to 48 hours is shown in
Supplementary Figure 4 (http://links.lww.com/PCC/
C370). Table 2 shows the absolute and change in FB dur-
ing the study period. The distribution of change in fluid
balance for all time points is shown in Supplementary
Figure 5 (http://links.lww.com/PCC/C370).
www.pccmjournal.org     e461
 Gelbart et al

TABLE 1. FB is shown in Figure 3. Between baseline and 24 hours,

Demographic and Clinical Characteristics
of All Children
Characteristic
Age (d)
Sex (male), n (%)
Pediatric Index of Mortality III
Risk Adjustment Congenital Heart
Surgery (%)
Diagnosis, n (%)
 Aortic insufficiency
 Aortic stenosis
 Atrioventricular septal defect
 Coarctation of the aorta
 Double outlet right ventricle
 Hypoplastic left heart syndrome
Hypoplastic left ventricle (not hypo-
plastic left heart syndrome)
Interrupted or hypoplastic aortic
arch
Levo-transposition of the great
arteries
 Pulmonary atresia or stenosis
Total anomalous pulmonary venous
drainage
 d-Transposition of the great arteries
 Tricuspid atresia or stenosis
 Truncus arteriosus
 Ventricular septal defect
Cardiopulmonary bypass, n (%)
Time from surgery to first weight (hr),
n = 60
Mechanical ventilation duration (hr)
Peritoneal dialysis, n (%)
Extracorporeal membrane oxygenation,
n (%)
Intensive care length of stay (hr)
(117.2–302.5)
Survival, n (%)
Data are median (interquartile range) unless stated.
Agreement Between Change in BW and
Change in Fluid Balance
For each infant, the changes in weight and FB for each
time interval are shown in Figure 2. Bland-Altman
analysis of agreement between the change in BW and
the mean bias was 54 (95% CI,12–97), and the 95% lim-
its of agreement were (–270 to 379). Between 24 and
48 hours, the mean bias was –43 (95% CI, –108 to 23),
n = 61 and the 95% limits of agreement were (–528 to 443)
8.0 (1.0–14.0) (Supplementary Table 3, http://links.lww.com/PCC/
37 (60.7) C370). These mean biases represented 54/3,518 (1.5%)
and 43/3,440 (1.3%) of the median BW, respectively.
2.1 (1.4–5.7)
There were no episodes of device dislodgement or
20.9 (14.3–32.4)
hemodynamic disturbance requiring change in vaso-
active doses associated with weight measurements, nor
were weight measurements not performed because of
1 (1.6)
clinical instability.
1 (1.6)
4 (6.6)
DISCUSSION
1 (1.6)
1 (1.6) In a prospective study of mechanically ventilated chil-
3 (4.9) dren following cardiac surgery, we found moderate
2 (3.3) agreement between change in BW and FB with biases
of positive 54 g and negative 43 g for each time in-
5 (8.2) terval, respectively. These represented 1.5% and 1.3%
of median BW for each time interval. Moreover, the
2 (3.3) upper and lower limits of agreement were wide, rang-
ing from 7.6% to 15%. The precision between two se-
8 (13.1) quential, paired weight measurements, performed at
5 (8.2) each time point, as a proportion of median BW, ranged
from 0.6% to 1%. Device weight added approximately
18 (29.5) 3% of BW. Weighing mechanically ventilated infants
2 (3.3)
1 (1.6)
7 (11.5)
49 (80.3)
AT THE BEDSIDE
26.9 (23.6–29.7)
93.0 (67.0–163.8) • There is moderate agreement between chart-
29 (47.5)
based and body weight-based measurement of
fluid balance; however, the limits of this agree-
4 (6.6) ment are wide, suggesting that they both have
inherent inaccuracies or they represent true dif-
164.8 ferences in the estimation of fluid balance.
61 (100.0)
• Precision of protocolized body weight measure-
ments is high with a median difference between
consecutive measurements of 1%, but the me-
dian weight of attached tubes and devices was
3% of body weight.
• Weighing critically ill infants appears safe, and,
in this study, there were no events of device dis-
lodgment or hemodynamic instability.

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 Online Clinical Investigations

TABLE 2.
Body Weight and Fluid Balance Characteristics at Each Time Point and Changes Between
Time Intervals During the Study Period
Variable Baseline 24 hr 48 hr

Body weight (gm), median (IQR) 3,518 (3,134–928) 3,440 (3,244–3,939) 3,350 (3,088–3,795)
Device weight (gm), median (IQR); (%) of 105 (92–119); 3.0 97 (85–112); 2.8 90 (67–105); 2.7
median body weight
Change in body weight between time inter- NA –36 (–145 to –105) –97 (–240 to –28)
vals (gm), median (IQR)
Fluid balance (mL), median (IQR) 0 –82 (–173 to –12) –150 (–270 to –54)
Change in fluid balance between time NA –82 (–173 to –12) –107 (–226 to –103)
intervals (mL), median (IQR)
IQR, interquartile range.

Figure 1. Change in body weight (mean and 95% CI) between time points and from baseline to 48 hr.

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 Gelbart et al

Figure 2. Scatter plot of individual change in body weight and fluid balance between baseline and 24 hr (A) and 24–48 hr (B). The red
dashed line represents the reference line of a one to one relationship between fluid balance and body weight. Data do not control for
regression to the mean effect within variables.

appeared safe with no episodes of device dislodg-
ment or associated hemodynamic deterioration in 353
weight measurements.
Several studies in children in intensive care have
reported the relationship between change in FB and
change in BW (6, 7, 14). These studies have either re-
ported the differences between the association of each
variable with intensive care outcomes (7) or reported
the relationship between these two variables (6). The
first study reported moderate agreement (0.75–0.92
[Pearson correlation coefficient]) (7) in an older cohort,
and, the second, a mean difference of over 300 mL (ap-
proximately 3% of admission BW) despite correlation
coefficients of >0.63 (6). However, the former study re-
ported that both BW and FB had a similar relationship
in predicting mortality (7). These studies either did
not provide the weighing protocol and report device
weight, and Bland-Altman analyses were reported in
only one (6).
A retrospective, multicenter study of 2,235 children
having cardiac surgery reported that the frequency
of weight measurements on day 2 ranged widely be-
tween centers (2–98%), but the average was 45% (14).
This study also reported that correlation and agree-
ment between weight and FB were poor (mean bias
of 12% of BW). This finding far exceeds our estima-
tion of agreement. This likely reflects the difficulty of
using electronic medical record data, in a multicenter
retrospective study with perhaps, varying protocols
for measuring weight, fluid input/output, and urine
output.
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Several studies of adults in intensive care have re-
ported the relationship between change in FB and
weight (3, 4, 15, 16). These studies, some accounting
for insensible losses, generally reported poor agree-
ment. However, they relied on electronic bed scales
and noted a large weight of unmovable devices. The
ability to lift infants for weight measurements may en-
hance the accuracy of weight measurements.
Both FB charts and BW have inherent limitations
for assessing fluid status in mechanically ventilated
children in intensive care. There appears to be mod-
erate agreement between weight and chart-based esti-
mation of FB when using prospectively collected data,
with protocolized methods, and accounting for weight
of devices and attachments. However, in this study, the
difference exceeded the prespecified hypothesis, and
the limits of agreement were wide, suggesting that both
measurements may represent true differences between
approaches for estimating fluid status. For instance,
positive FB may exist in the presence of weight loss be-
cause of unmeasured insensible fluid losses, or weight
gain may exist with negative FB if there are undocu-
mented fluid administrations or insensible water gain.
Humidification of ventilator circuits prevents insensible
water loss from the lung (17) and, in theory, could con-
tribute to water gain (18). A study in the 1950s estimated
that insensible water loss is higher in infants compared
with older children, suggesting the susceptibility of this
population to such changes; however, change in in-
sensible fluid loss or gain is difficult to quantify (19).
Moreover, the addition of device weight can exceed the
October 2023 • Volume 24 • Number 10
 Online Clinical Investigations

Figure 3. Bland-Altman plot of agreement between change in body weight and fluid balance.

change in daily BW, thereby generating a large potential
source of error, particularly when the interval changes
in FB and weight, between study days, were small. In
our study, weight measurement was precise and safe.
It may reflect absolute change in total body water bet-
ter than FB, because it accounts for insensible water
loss or gain. However, the weight of attached devices
needs to be accounted for, and accurate scales are re-
quired. FB shares some of these factors but, importantly,
avoids the handling of unwell children. Therefore, to
propose which method is superior requires comparison
of their associations with important clinical outcomes.
Comparing these methods may also need to account for
the effect of tissue edema, a third component of evaluat-
ing fluid status, which may have independent effects on
outcomes, but has not been evaluated. Further research
is required to compare these associations with outcomes
and to identify methods for quantifying edema.

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 Gelbart et al
The strengths of this study are the prospective study
design, the protocolized technique for weight measure-
ments, and the accounting for the weight of attached
devices. We used accurate scales (13) and demonstrated
the precision of weight measurements. We used Bland-
Altman analyses as the optimal analysis for agreement
but also present the individual patient data to display its
distribution. The timing of FB assessment was aligned
with weight measurements, and we investigated an im-
portant cohort of critically ill children requiring invasive
therapies. However, we acknowledge some limitations.
The potential sources of error for weight measure-
ment include the estimation of the weight of devices
and the method for holding such devices during lift-
ing. However, we performed two measurements at each
time interval and used a standardized, protocolized
approach, and weighing was performed exclusively by
small group of trained clinicians. FB data were retrieved
from the electronic medical record and, therefore, may
have inaccuracies. However, these data were manually
calculated by investigators, timed with weight measure-
ment, and are those routinely relied on for clinical care.
The study was limited to infants, and therefore, general-
izability to larger children is not possible.
CONCLUSIONS
There is moderate agreement between the changes in
FB and BW; however, the limits of this agreement are
wide. Weighing mechanically ventilated infants in in-
tensive care appears safe and is a precise method for
estimating change in fluid status. However, device
weight represents a substantial contribution to BW,
particularly when the daily change in BW is small. This
confounder is important when using weight to esti-
mate change in fluid status over time. Whether weight-
based fluid management leads to different treatment
and outcomes compared with FB-based management
requires systematic investigation.
ACKNOWLEDGMENTS
We thank the families that consented to have their chil-
dren participate in this study and the nurses of the PICU
who provided assistance with weight measurements.
1 Paediatric Intensive Care Unit, University of Melbourne,
Murdoch Children’s Research Institute, Royal Children’s
Hospital, Parkville, VIC, Australia.
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2 Paediatric Intensive Care Unit, Murdoch Children’s
Research Institute, The Royal Children’s Hospital, Parkville,
VIC, Australia.
3 Paediatric Intensive Care Unit, The Royal Children’s
Hospital, Parkville, VIC, Australia.
4 Intensive Care Unit, Austin Hospital, Melbourne, VIC,
Australia.
5 Data Analytics Research and Evaluation (DARE) Centre,
Austin Hospital, Melbourne, VIC, Australia.
6 Department of Critical Care, The University of Melbourne,
Melbourne, VIC, Australia.
7 Department of Intensive Care, Royal Melbourne Hospital,
Melbourne, VIC, Australia.
8 Australian and New Zealand Intensive Care Research
Centre, School of Public Health and Preventive Medicine,
Monash University, Melbourne, VIC, Australia.
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s website
(http://journals.lww.com/pccmjournal).
The authors have disclosed that they do not have any potential
conflicts of interest.
For information regarding this article, E-mail: ben.gelbart@rch.
org.au
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