Fluid Overload Prior To Continuous Hemofiltration and Survival in Critically Ill Children

Fluid Overload Prior To Continuous Hemofiltration and Survival in Critically Ill ChildrenJ Foland, J Fortenberry, B Warshaw, R Pettignano, R Merritt, M Heard, K Rogers, C Reid, A Tanner, K Easley

Children’s Healthcare of Atlanta at EglestonEmory University School of MedicineAtlanta, Georgia

Accepted for publication in Critical Care Medicine, August 2004

Backgroundo Renal replacement therapy is used for

primary and secondary renal failure

o Continuous venovenous hemofiltration

(CVVH) is the preferred modality in

our ICUs

Backgroundo Goldstein et al. (Pediatrics, 2000)

o 21 ICU children on CVVH(D) Survival associated with ICU fluid

overload prior to CVVHo GFR had no association with survival

o Lane et al. (Bone Marrow Transplant, 1994)o 30 pediatric BMT recipientso Survival associated with < 10% weight gain

from baseline

Hypotheseso CVVH survivors have less fluid

overload than non-survivors prior to

CVVH

o Increasing fluid overload prior to CVVH

is associated with decreasing survival

Methodso Database of all Egleston patients

receiving CVVH from Nov ‘97 to Dec ‘02 (excluding ECMO)

o Review of o Demographicso Diagnoseso Clinical & laboratory findingso Indication for CVVH

Total Input - Total

Output (L)*Ideal Body Weight (kg)

Definitionso Total fluid overload (%)

* For 7 days prior to CVVH

o GFR: Schwartz Formula

X 100

Definitionso ICU fluid overload (%)

* From ICU admission to CVVH initiation

X 100Total Input - Total

Output (L)*Ideal Body Weight (kg)

Resultso 113 patients received CVVHo Median

o Age: 9.6 years (2.5, 14.3)o Number of days on CVVH: 4 (2.0,

10.0)o PRISM III: 13 (9.0, 17.0)o %Fluid Overload: 10.9 (2.8, 22.1)o Creatinine: 3.1 (1.7, 4.9) mg/dL

o 71% intubated o 70% vasoactive infusions

Patient Diagnoses

25%

75%

PrimaryRenalFailure

SecondaryRenalFailure

CVVH Indications

37%

30%

25%

6% 2% Acute Fluid Overload

Acute Renal Failure

Electrolyte Imbalance

Acute on Chronic RenalFailureHyperammonemia

Patient Survival

61%

90%

51%57%

52%

0%

25%

50%

75%

100%

All PrimaryRenal

Failure

SecondaryRenal

Failure

MODS 3 OrganMODS

*p=0.0002 vs. Primary Renal Failure

*

Severity of IllnessSurvival

* p<0.001

*

15.5

12

0

5

10

15

20

Died Lived

91%

58%

0%

25%

50%

75%

100%

Died Lived

84%

61%

0%

25%

50%

75%

100%

Died Lived

PRISM III Intubated Vasoactive

Infusions†

p<0.001‡

p=0.009

† ‡

Day

s

Survival *p<0.001

*

15

3

0

5

10

15

20

Died Lived

Days in Hospital Prior to CVVH

All Patients

Days in ICU prior to CVVHAll PatientsD

ays

Survival *p=0.03

*

3

1

0

1

2

3

4

Died Lived

Tota

l % F

luid

O

verl

oad

Survival *p=0.02

*

15.1%

7.8%

0%

5%

10%

15%

20%

Died Lived

Median % Fluid OverloadAll Patients

Tota

l % F

luid

O

verl

oad

Survival *p=0.01

*

15.5%

9.2%

0%

5%

10%

15%

20%

Died Lived

Median % Fluid OverloadMODS & 3 Organ

Involvement

Patient Outcomeso No survival difference seen with...

o Duration of CVVH

o Ultrafiltration rates

o Membrane Type

o Estimated GFR

o Age adjusted serum creatinine

o P/F ratios

Multivariable AnalysisFactors Associated with Mortality

All patients, n=94

Effect Odds Ratio 95% CI p

PRISM III (per 10) 1.24 1.02, 1.50 0.03

% FO (per 10%) 1.37 0.97, 1.94 0.07

Multivariable AnalysisFactors Associated with Mortality

MODS patients, n=88

Effect Odds Ratio 95% CI p

PRISM III (per 10) 1.21 0.99, 1.47 0.06

% FO (per 10%) 1.30 0.92, 1.84 .013

Multivariable AnalysisFactors Associated with Mortality

3 Organ MODS, n=70

Effect Odds Ratio 95% CI p

PRISM III (per 10%) 1.10 0.88, 1.39 0.4

% FO (per 10%) 1.78 1.13, 2.82 0.01

Conclusions

o CVVH survivors had

o Less fluid overload prior to CVVH

o Less cardiovascular support

o Less respiratory support

Conclusion: Fluid OverloadOur review suggests that increasing increasing

fluid overloadfluid overload is associated with

decreased survivaldecreased survival in pediatric

patients receiving CVVH, particularly

those with 3 organ MODS

Speculation

Total percent fluid overloadpercent fluid overload prior to

CVVH may be a better predictor of

survival than other indicators of

severity of illness in select patients

Speculation

Earlier use of CVVH, prior to excessive prior to excessive

fluid overloadfluid overload, in critically ill children

may be associated with increased

survival

Questions?