Pharmacist-driven Fluid Stewardship in the Neuro Intensive Care Unit

Intravenous fluid administration is the most common intervention in the neuro intensive care unit (NICU). Although often considered a benign intervention, over the past decade there has been a growing body of literature to suggest administration of chloride-rich fluids can result in deleterious consequences on patient outcomes. Hyperchloremia has emerged as the most detrimental consequence of chloride-rich fluid administration, as hyperchloremia carries a significant risk of acute kidney injury (AKI), metabolic acidosis, and ICU-related mortality in NICU patients. (Rhai, 2017) NICU patients are at a substantially increased risk for the harms of hyperchloremia, as these patients receive excessive chloride loads from hyperosmolar therapy with hypertonic saline, nutritional support, and medications with an inherently high fluid burden (i.e. nicardipine). In fact, chloride-rich medication diluents have been shown to contribute up to ~63% of the total IV volume intake during an individual’s ICU stay. (Magee, 2018) Despite the alarming data and heightened awareness of the harms associated with chloride-rich fluids, minimal evidence to date has addressed preventative strategies to mitigate exposure and the risk of hyperchloremia in critically ill NICU patients. As front-line medication experts, clinical pharmacists are well-positioned to optimize patient outcomes through promoting fluid stewardship, aimed at minimizing excess chloride exposure. Our prospective, randomized, single-center pilot study is designed to evaluate the impact of a pharmacist-driven fluid stewardship protocol that allows pharmacists to optimize fluid composition and dose in critically ill NICU patients. The primary outcome will be the incidence of hyperchloremia (chloride >110mEq/L), with secondary outcomes including AKI, length of NICU stay, length of hospital stay, and in-hospital mortality. AKI will be assessed using standard measures of serum creatinine, in addition to novel biomarkers of kidney injury, IGFBP7*TIMP2. Use of this novel biomarker as a more timely, accurate predictor of medication-induced nephrotoxicity will allow for prompt identification and subsequent interventions to mitigate the risk of further kidney injury.