Risk factors for in-hospital mortality and acute kidney injury in neonatal-pediatric patients receiving extracorporeal membrane oxygenation

Risk factors for mortality in patients receiving extracorporeal membrane oxygenation

OBJECTIVE

Patients on extracorporeal membrane oxygenation (ECMO) are often complex and have a high mortality rate. Currently, risk assessment and treatment decisions for patients receiving ECMO are controversial. Therefore, we sought to identify risk factors for mortality in patients receiving ECMO and provide a reference for patient management.

METHODS

We retrospectively analyzed the clinical data of 199 patients who received ECMO support from December 2013 to April 2023. Univariate and multivariable logistic regression analyses were used to identify risk factors. The cutoff value was determined by receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 199 patients were selected for this study, and the mortality rate was 76.38%. More than half of the patients underwent surgery during hospitalization. Multivariable logistic regression analysis revealed that continuous renal replacement therapy (CRRT) implantation (OR = 2.994; 95% CI, 1.405-6.167; p = 0.004) and age (OR = 1.021; 95% CI, 1.002-1.040; p = 0.032) were the independent risk factors for mortality. In the ROC curve analysis, age had the best predictive effect (AUC 0.646, 95% CI 0.559-0.732, p = 0.003) for death when the cutoff value was 48.5 years. Furthermore, in patients receiving combined CRRT and ECMO, lack of congenital heart disease and previous surgical history were the independent risk factors for mortality.

CONCLUSIONS

CRRT implantation and age were independent risk factors for patients with ECMO implantation in a predominantly surgical cohort. In patients receiving a combination of CRRT and ECMO, lack of congenital heart disease and previous surgical history were independent risk factors for mortality.

Managing the kidney - The role of continuous renal replacement therapy in neonatal and pediatric ECMO

Extracorporeal membrane oxygenation (ECMO) represents a lifesaving therapy utilized in in the most critically ill neonates and children with reversible cardiopulmonary failure. As a result of the severity of their critical illness these patients are among the highest risk populations for developing acute kidney injury (AKI) and disorders of fluid balance including the pathologic state of fluid overload (FO). In multiple studies AKI has been shown to occur commonly in 60-80% children treated with ECMO and is associated with adverse outcomes. In early studies evaluating ECMO in neonatal respiratory populations, the importance of fluid balance and the development of FO was recognized as an important contributor to adverse outcomes. Multiple single center studies and multicenter work have confirmed that FO occurs commonly across ECMO populations and is consistently associated with adverse outcomes. As a result of the high rates of AKI and the high rates of FO, continuous renal replacement therapy (CRRT) is increasingly utilized in neonatal and pediatric ECMO. In this state-of-the-art review, we cover the definitions, pathophysiology, incidence, and impact of AKI and FO in neonates and children supported with ECMO and summarize and appraise the evidence regarding the use of CRRT concurrently with ECMO. This review will cover the appropriate timing of this initiation, the options for providing CRRT with ECMO, overview of CRRT prescription, and the long-term implications of kidney support therapy in this population.

Low-Cost SpO2 Integrated Neonatal CPAP Device for Low Resource Setting

Introduction

More than 60% of preterm births take place in South Asia and sub-Saharan Africa, making prematurity a primary cause of neonatal mortality. Even though continuous positive airway pressure (CPAP) is a popular treatment for respiratory distress syndrome (RDS) and is safe, practicable, and efficient for use in LMICs, it is crucial to ensure that neonates receive the full benefits of the therapy by monitoring their blood oxygen level.

Methods

A centrifugal fan, power source, control system, and sensors are all included in our design. A centrifugal fan was created to provide air at positive pressure in the range of approximately 4 cmH2O to 20 cmH2O utilizing revolving blades (impeller), a DC motor, and a fixed component. The control unit contains a microcontroller to handle sensor data. The proportional-integral (PI) controller board's external potentiometer is used to set the pressure level.

Results

To ascertain whether the prototype satisfies the design requirements, it was constructed and put through several iterations and testing. The proposed device's prototype was tested for accuracy, affordability, and usability. The centrifugal fan speed measurement was accurate to within 94.5%, while the oxygen concentration sensor reading was accurate to within 98.5%.

Conclusion

The design investigates viability of a straightforward, inexpensive, portable SpO2 integrated neonatal CPAP device for use in the delivery room in low-resource countries and to evaluates methods for measuring flows during CPAP treatment by monitoring the level of oxygen in the blood and pressure level delivered by the device using the lowest and safest setting that yields useful results.

Independent risk factors of acute kidney injury among patients receiving extracorporeal membrane oxygenation

OBJECTIVE

Acute kidney injury (AKI) is one of the most frequent complications in patients treated with extracorporeal membrane oxygenation (ECMO) support. The aim of this study was to investigate the risk factors of AKI in patients undergoing ECMO support.

METHODS

We performed a retrospective cohort study which included 84 patients treated with ECMO support at intensive care unit in the People's Hospital of Guangxi Zhuang Autonomous Region from June 2019 to December 2020. AKI was defined as per the standard definition proposed by the Kidney Disease Improving Global Outcome (KDIGO). Independent risk factors for AKI were evaluated through multivariable logistic regression analysis with stepwise backward approach.

RESULTS

Among the 84 adult patients, 53.6% presented AKI within 48 h after initiation of ECMO support. Three independent risk factors of AKI were identified. The final logistic regression model included: left ventricular ejection fraction (LVEF) before ECMO initiation (OR, 0.80; 95% CI, 0.70-0.90), sequential organ failure assessment (SOFA) score before ECMO initiation (OR, 1.41; 95% CI, 1.16-1.71), and serum lactate at 24 h after ECMO initiation (OR, 1.27; 95% CI, 1.09-1.47). The area under receiver operating characteristics of the model was 0.879.

CONCLUSION

Severity of underlying disease, cardiac dysfunction before ECMO initiation and the blood lactate level at 24 h after ECMO initiation were independent risk factors of AKI in patients who received ECMO support.

Risk factors and outcomes associated with acute kidney injury following extracardiac total cavopulmonary connection: a retrospective observational study

BACKGROUND

Total cavopulmonary connection (TCPC) is an important operation for the treatment of complex congenital heart disease. Epidemiology and outcomes for pediatric patients with acute kidney injury (AKI) following extracardiac TCPC have not been well documented. This study investigates the prevalence, risk factors, and outcomes of AKI in children after extracardiac TCPC surgery.

METHODS

We retrospectively evaluated patients (age at surgery <18 years) who underwent extracardiac TCPC surgery between January 2008 and January 2020 in the Pediatric Cardiac Surgical Center of Fuwai Hospital, Beijing, China. AKI was defined according to the pediatric-modified risk, injury, failure, loss of function, and end-stage renal disease criteria.

RESULTS

A total of 377 pediatric patients were included in this study; 123 patients (32.6%) had some degree of AKI. Among the patients with AKI, 101 (82.1%) were diagnosed with AKI-risk (AKI-R), while 22 (17.9%) were diagnosed with acute kidney injury/failure (AKI/F) (16 with AKI, and 6 with AKF). Preoperative estimated creatinine clearance (OR: 1.039, 95% CI: 1.024-1.055, P<0.001), neutrophil-to-lymphocyte ratio (OR: 1.208, 95% CI: 1.128-1.294, P<0.001), and renal perfusion pressure (OR: 0.962, 95% CI: 0.938-0.986, P=0.002) on postoperative day (POD) 0 were significantly associated with AKI after TCPC. Having previously undergone a bidirectional Glenn was significantly associated with the severity of postoperative AKI (OR: 0.253, 95% CI: 0.088-0.731, P=0.011). Furthermore, AKI was associated with prolonged mechanical ventilation time, prolonged intensive care unit stay, and composite adverse outcome. Compared with non-AKI patients, the 10-year survival rate of patients with severe AKI was significantly lower (95.5% vs. 65.9%, P=0.009).

CONCLUSIONS

Although the incidence of AKI was high in patients undergoing TCPC surgery, most cases were AKI-R. Severe AKI was significantly associated with early adverse outcomes and poor long-term survival.