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Fluid Overload Prior To Continuous Hemofiltration and Survival in Critically Ill Children. J 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 Egleston Emory University School of Medicine - PowerPoint PPT Presentation
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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
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