This study defines Acute respiratory distress syndrome (ARDS) is a disease of acute hypoxemia, with 18–35% mortality in pediatrics. Increased alveolar-capillary permeability contributes to pulmonary edema (4). One proposed pathogenic mediator is angiopoietin-2, which correlates with increased mortality in pediatric ARDS (5,6). In adult ARDS, conservative fluid management resulted in improved oxygenation and more ventilator-free days (VFDs) at 28 days (7). Angiopoietin-2 predicted worse outcomes in a subset of these patients (8). In retrospective analyses of pediatric ARDS, a positive cumulative fluid balance at day 3 of illness and beyond has been associated with fewer VFDs (9), longer length of stay, and increased mortality. 

While the correlation between fluid overload and worse outcomes is established in pediatric ARDS, it is unclear “when” in the illness time-course the relationship between fluid overload and outcomes becomes relevant, as most studies simply report cumulative balance at 72 hours. Specifically, it is unclear whether fluid overload during the initial resuscitation period in early ARDS, the period of de-resuscitation after initial stabilization or both, carries a stronger association with outcome. A granular understanding of the temporal relationship of fluid overload with poor outcomes could clarify the timing of de-resuscitation in future studies. Furthermore, existing studies are limited by small sample sizes and low mortality rates, precluding the inclusion of several potential confounders.

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