Table 1 CAN-U-P-LOTS bundle to prevent and treat fluid overload
From: Reducing NICU ventilator days by preventing fluid overload with the CAN-U-P-LOTS standardized bundle
BUNDLE ELEMENT | INTERVENTION |
|---|---|
C – Cause/Compartment syndrome | Consider and address the underlying cause of fluid overload if present |
- If significant abdominal distension consider measuring bladder pressure, and if bladder pressure is elevated (>10–12 mmHg) and oliguria is present, consider abdominal tap/drain | |
A – Albumin | Assess for hypoalbuminemia. If albumin <2 g/dL, give 1 g/kg of 25% intermittently until albumin >2 g/dl. (If extremely low birth weight in the first few weeks of life, consider 1 g/kg 25% albumin if <1.5 g/dL) |
N – Nephrotoxic medications | Review the medication list for nephrotoxic medications and transition to alternatives as feasible |
Avoid additional nephrotoxic medications if possible | |
If using Vancomycin or aminoglycosides, obtain the trough level and ensure that levels are below the recommended threshold before redosing | |
U – Uric acid | Obtain uric acid level. If >9 mg/dL, screen for G6PD and if negative, give Rasburicase 0.1 mg/kg |
U – Ultrafiltration | Consider ultrafiltrate (i.e., PD, SCUF, or CRRT) if unable to meet desired fluid balance goals or unable to provide nutrition without worsening fluid overload |
P – Perfusion | Incrementally increase mean arterial pressure (MAP) goals by 5–10 mmHg q 4 h until an increase in UOP is achieved. Do not exceed the 90th percentile for age. |
Consider increasing intravascular volume with 2 × 10 mL/kg of packed red blood cells to keep HCT > 30–50%, or FFP or crystalloid | |
Use vasopressors to maintain the goal if no response to fluids | |
Consider the addition of hydrocortisone for refractory hypotension | |
L – Lasix stress test | If, after optimizing intravascular volume and MAP, the patient remains oliguric (<1 mL/kg/h), consider the Lasix stress test |
Give 1 mg/kg Lasix, document UOP within 2 h of administration | |
- If responsive (>1 ml/kg/h), assure adequate perfusion. Can adjust diuretics to maintain fluid goals | |
- If non-responsive, avoid escalating diuretic use and call nephrology | |
O –Output/obstruction | Measure urine output continuously with an indwelling or external urine collection device |
- If concern for inadequate bladder drainage, obtain an ultrasound | |
- If bladder obstruction is confirmed or suspected, place an indwelling bladder catheter | |
T – Total fluid intake | Concentrate fluids while maintaining proper nutrition |
Document total fluid intake goals | |
S – Steroids | Consider the addition of hydrocortisone for refractory hypotension if requiring pressors |
