Various fluid removal strategies are utilized to mitigate the deleterious effects of fluid accumulation in neonates following cardiac surgery. We aim to describe practice patterns and identify associations of fluid management strategies with outcomes in neonates undergoing cardiac surgery using the Neonatal and Pediatric Heart and Renal Outcomes Network dataset.

Multicentre retrospective study including neonates who underwent cardiac surgery between 2015 and 2018. Primary outcomes were duration of mechanical ventilation, delay in first negative daily fluid balance, peak cumulative fluid balance, and severe persistent acute kidney injury. Multivariable logistic and ordinal regression models assessed associations between fluid removal strategies and clinical outcomes.

Of 2,240 neonates, 25% (n = 560) received furosemide in the operating room. Peritoneal catheters were placed in 24% (n = 527), and 8.6% (n = 193) underwent prophylactic peritoneal dialysis. Diuretic use on postoperative day 0 ranged 6–95% across institutions. Diuretics on postoperative day 0 were associated with shorter time to negative daily fluid balance (odds ratio 0.55; 95% confidence interval 0.30–0.995) and shorter duration of mechanical ventilation (odds ratio 0.58; 95% confidence interval 0.39–0.86). Intraoperative diuretics were also associated with shorter duration of mechanical ventilation (odds ratio 0.60; 95% confidence interval 0.42–0.86). Receipt of continuous diuretic infusion on postoperative day 0 or 1 was associated with longer duration of mechanical ventilation (odds ratio 3.02; 95% confidence interval 1.98–4.58). No association of diuretic use with severe persistent acute kidney injury was found.

Early use of diuretics in neonatal cardiac surgery is highly variable and has a differential association with outcomes. Future studies that standardize the dose, timing, and mode of administration (intermittent vs continuous) of diuretics are warranted to identify potential associations with outcomes.

A standardised multi-site approach to manage paediatric post-operative chylothorax does not exist and leads to unnecessary practice variation. The Chylothorax Work Group utilised the Pediatric Critical Care Consortium infrastructure to address this gap.

Over 60 multi-disciplinary providers representing 22 centres convened virtually as a quality initiative to develop an algorithm to manage paediatric post-operative chylothorax. Agreement was objectively quantified for each recommendation in the algorithm by utilising an anonymous survey. “Consensus” was defined as ≥ 80% of responses as “agree” or “strongly agree” to a recommendation. In order to determine if the algorithm recommendations would be correctly interpreted in the clinical environment, we developed ex vivo simulations and surveyed patients who developed the algorithm and patients who did not.

The algorithm is intended for all children (<18 years of age) within 30 days of cardiac surgery. It contains rationale for 11 central chylothorax management recommendations; diagnostic criteria and evaluation, trial of fat-modified diet, stratification by volume of daily output, timing of first-line medical therapy for “low” and “high” volume patients, and timing and duration of fat-modified diet. All recommendations achieved “consensus” (agreement >80%) by the workgroup (range 81–100%). Ex vivo simulations demonstrated good understanding by developers (range 94–100%) and non-developers (73%–100%).

The quality improvement effort represents the first multi-site algorithm for the management of paediatric post-operative chylothorax. The algorithm includes transparent and objective measures of agreement and understanding. Agreement to the algorithm recommendations was >80%, and overall understanding was 94%.