1
|
Selewski DT, Barhight MF, Bjornstad EC, Ricci Z, de Sousa Tavares M, Akcan-Arikan A, Goldstein SL, Basu R, Bagshaw SM. Fluid assessment, fluid balance, and fluid overload in sick children: a report from the Pediatric Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2024; 39:955-979. [PMID: 37934274 PMCID: PMC10817849 DOI: 10.1007/s00467-023-06156-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The impact of disorders of fluid balance, including the pathologic state of fluid overload in sick children has become increasingly apparent. With this understanding, there has been a shift from application of absolute thresholds of fluid accumulation to an appreciation of the intricacies of fluid balance, including the impact of timing, trajectory, and disease pathophysiology. METHODS The 26th Acute Disease Quality Initiative was the first to be exclusively dedicated to pediatric and neonatal acute kidney injury (pADQI). As part of the consensus panel, a multidisciplinary working group dedicated to fluid balance, fluid accumulation, and fluid overload was created. Through a search, review, and appraisal of the literature, summative consensus statements, along with identification of knowledge gaps and recommendations for clinical practice and research were developed. CONCLUSIONS The 26th pADQI conference proposed harmonized terminology for fluid balance and for describing a pathologic state of fluid overload for clinical practice and research. Recommendations include that the terms daily fluid balance, cumulative fluid balance, and percent cumulative fluid balance be utilized to describe the fluid status of sick children. The term fluid overload is to be preserved for describing a pathologic state of positive fluid balance associated with adverse events. Several recommendations for research were proposed including focused validation of the definition of fluid balance, fluid overload, and proposed methodologic approaches and endpoints for clinical trials.
Collapse
Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Erica C Bjornstad
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zaccaria Ricci
- Department of Emergency and Intensive Care, Pediatric Intensive Care Unit, Azienda Ospedaliero Universitaria Meyer, Florence, Italy.
- Department of Health Science, University of Florence, Florence, Italy.
| | - Marcelo de Sousa Tavares
- Pediatric Nephrology Unit, Nephrology Center of Santa Casa de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | - Ayse Akcan-Arikan
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rajit Basu
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| |
Collapse
|
2
|
Ortmann LA, Nandi S, Li YL, Zheng H, Patel KP. Activation of renal epithelial Na + channels (ENaC) in infants with congenital heart disease. Front Pediatr 2024; 12:1338672. [PMID: 38379911 PMCID: PMC10876900 DOI: 10.3389/fped.2024.1338672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/25/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction This study was designed to measure the concentration and activity of urinary proteases that activate renal epithelial sodium channel (ENaC) mediated Na+ transport in infants with congenital heart disease, a potential mechanism for fluid retention. Methods Urine samples from infants undergoing cardiac surgery were collected at three time points: T1) pre-operatively, T2) 6-8 h after surgery, and T3) 24 h after diuretics. Urine was collected from five heathy infant controls. The urine was tested for four proteases and whole-cell patch-clamp testing was conducted in renal collecting duct M-1 cells to test whether patient urine increased Na+ currents consistent with ENaC activation. Results Heavy chain of plasminogen, furin, and prostasin were significantly higher in cardiac patients prior to surgery compared to controls. There was no difference in most proteases before and after surgery. Urine from cardiac patients produced a significantly greater increase in Na+ inward currents compared to healthy controls. Conclusion Urine from infants with congenital heart disease is richer in proteases and has the potential to increase activation of ENaC in the nephron to enhance Na+ reabsorption, which may lead to fluid retention in this population.
Collapse
Affiliation(s)
- Laura A. Ortmann
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, United States
| | - Shyam Nandi
- Department of Integrative and Cellular Physiology, University of Nebraska Medical Center, Omaha, NE, United States
| | - Yu-long Li
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Hong Zheng
- Basic Biomedical Sciences, Sanford School of Medicine, University of South Dakota, Vermillion, SD, United States
| | - Kaushik P. Patel
- Department of Integrative and Cellular Physiology, University of Nebraska Medical Center, Omaha, NE, United States
| |
Collapse
|
3
|
Raman S, Rahiman S, Kennedy M, Mattke A, Venugopal P, McBride C, Tu Q, Zapf F, Kuhlwein E, Woodgate J, Singh P, Schlapbach LJ, Gibbons KS. REstrictive versus StandarD FlUid Management in Mechanically Ventilated ChildrEn Admitted to PICU: study protocol for a pilot randomised controlled trial (REDUCE-1). BMJ Open 2023; 13:e076460. [PMID: 38030251 PMCID: PMC10689381 DOI: 10.1136/bmjopen-2023-076460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION Intravenous fluid therapy is the most common intervention in critically ill children. There is an increasing body of evidence questioning the safety of high-volume intravenous fluid administration in these patients. To date, the optimal fluid management strategy remains unclear. We aimed to test the feasibility of a pragmatic randomised controlled trial comparing a restrictive with a standard (liberal) fluid management strategy in critically ill children. METHODS AND ANALYSIS Multicentre, binational pilot, randomised, controlled, open-label, pragmatic trial. Patients <18 years admitted to paediatric intensive care unit and mechanically ventilated at the time of screening are eligible. Patients with tumour lysis syndrome, diabetic ketoacidosis or postorgan transplant are excluded. INTERVENTIONS 1:1 random assignment of 154 individual patients into two groups-restrictive versus standard, liberal, fluid strategy-stratified by primary diagnosis (cardiac/non-cardiac). The intervention consists of a restrictive fluid bundle, including lower maintenance fluid allowance, limiting fluid boluses, reducing volumes of drug delivery and initiating diuretics or peritoneal dialysis earlier. The intervention is applied for 48 hours postrandomisation or until discharge (whichever is earlier). ENDPOINTS The number of patients recruited per month and proportion of recruited to eligible patients are feasibility endpoints. New-onset acute kidney injury and the incidence of clinically relevant central venous thrombosis are safety endpoints. Fluid balance at 48 hours after randomisation is the efficacy endpoint. Survival free of paediatric intensive care censored at 28 days is the clinical endpoint. ETHICS AND DISSEMINATION Ethics approval was gained from the Children's Health Queensland Human Research Ethics Committee (HREC/21/QCHQ/77514, date: 1 September 2021), and University of Zurich (2021-02447, date: 17 March 2023). The trial is registered with the Australia New Zealand Clinical Trials Registry (ACTRN12621001311842). Open-access publication in high impact peer-reviewed journals will be sought. Modern information dissemination strategies will also be used including social media to disseminate the outcomes of the study. TRIAL REGISTRATION NUMBER ACTRN12621001311842. PROTOCOL VERSION/DATE V5/23 May 2023.
Collapse
Affiliation(s)
- Sainath Raman
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Sarfaraz Rahiman
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Melanie Kennedy
- Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Adrian Mattke
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Prem Venugopal
- Department for Cardiac Surgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Craig McBride
- General Surgery, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Quyen Tu
- Department of Pharmacy, Queensland Children's Hospital, Brisbane, Queensland, Australia
- UQ Centre for Clinical Research, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Florian Zapf
- Department of Intensive Care and Neonatology, University Children's Hospital Zürich, Zurich, Switzerland
| | - Eva Kuhlwein
- Department of Intensive Care and Neonatology, University Children's Hospital Zürich, Zurich, Switzerland
| | - Jemma Woodgate
- Department of Dietetics, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Puneet Singh
- Paediatric Intensive Care, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
| | - Luregn J Schlapbach
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care and Neonatology, University Children's Hospital Zürich, Zurich, Switzerland
| | - Kristen S Gibbons
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
4
|
Brandewie KL, Selewski DT, Bailly DK, Bhat PN, Diddle JW, Ghbeis M, Krawczeski CD, Mah KE, Neumayr TM, Raymond TT, Reichle G, Zang H, Alten JA. Early postoperative weight-based fluid overload is associated with worse outcomes after neonatal cardiac surgery. Pediatr Nephrol 2023; 38:3129-3137. [PMID: 36973562 DOI: 10.1007/s00467-023-05929-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/06/2023] [Accepted: 02/27/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVES Evaluate the association of postoperative day (POD) 2 weight-based fluid balance (FB-W) > 10% with outcomes after neonatal cardiac surgery. METHODS Retrospective cohort study of 22 hospitals in the NEonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) registry from September 2015 to January 2018. Of 2240 eligible patients, 997 neonates (cardiopulmonary bypass (CPB) n = 658, non-CPB n = 339) were weighed on POD2 and included. RESULTS Forty-five percent (n = 444) of patients had FB-W > 10%. Patients with POD2 FB-W > 10% had higher acuity of illness and worse outcomes. Hospital mortality was 2.8% (n = 28) and not independently associated with POD2 FB-W > 10% (OR 1.04; 95% CI 0.29-3.68). POD2 FB-W > 10% was associated with all utilization outcomes, including duration of mechanical ventilation (multiplicative rate of 1.19; 95% CI 1.04-1.36), respiratory support (1.28; 95% CI 1.07-1.54), inotropic support (1.38; 95% CI 1.10-1.73), and postoperative hospital length of stay (LOS 1.15; 95% CI 1.03-1.27). In secondary analyses, POD2 FB-W as a continuous variable demonstrated association with prolonged durations of mechanical ventilation (OR 1.04; 95% CI 1.02-1.06], respiratory support (1.03; 95% CI 1.01-1.05), inotropic support (1.03; 95% CI 1.00-1.05), and postoperative hospital LOS (1.02; 95% CI 1.00-1.04). POD2 intake-output based fluid balance (FB-IO) was not associated with any outcome. CONCLUSIONS POD2 weight-based fluid balance > 10% occurs frequently after neonatal cardiac surgery and is associated with longer cardiorespiratory support and postoperative hospital LOS. However, POD2 FB-IO was not associated with clinical outcomes. Mitigating early postoperative fluid accumulation may improve outcomes but requires safely weighing neonates in the early postoperative period. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Katie L Brandewie
- Department of Pediatrics, Division of Pediatric Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - David K Bailly
- Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Priya N Bhat
- Department of Pediatrics, Sections of Critical Care Medicine and Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - John W Diddle
- Division of Cardiac Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Muhammad Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Catherine D Krawczeski
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kenneth E Mah
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tara M Neumayr
- Divisions of Pediatric Critical Care Medicine and Pediatric Nephrology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Tia T Raymond
- Pediatric Cardiac Intensive Care, Medical City Children's Hospital, Dallas, TX, USA
| | - Garrett Reichle
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Huaiyu Zang
- Department of Pediatrics, Division of Pediatric Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Jeffrey A Alten
- Department of Pediatrics, Division of Pediatric Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| |
Collapse
|
5
|
Weld J, Kim E, Chandra P, Savorgnan F, Acosta S, Flores S, Loomba RS. Fluid Overload and AKI After the Norwood Operation: The Correlation and Characterization of Routine Clinical Markers. Pediatr Cardiol 2023:10.1007/s00246-023-03167-0. [PMID: 37129600 DOI: 10.1007/s00246-023-03167-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 04/16/2023] [Indexed: 05/03/2023]
Abstract
The purpose of this study was to determine the correlation of different methods of assessing fluid overload and determine which metrics are associated with development of acute kidney injury (AKI) in the period immediately following Norwood palliation. This was a retrospective single-center study of Norwood patients from January 2011 through January 2021. AKI was defined using the Kidney Disease Improving Global Outcomes (KDIGO). Patients were separated into two groups: those with AKI and those without. A logistic regression analysis was conducted with AKI at any point in the study period as the dependent variable and clinical and laboratory data as independent variables. Analysis was conducted as a stepwise regression. The coefficients from the logistic regression were then used to develop a cumulative AKI risk score. Spearman correlations were conducted to analyze the correlation of fluid markers. 116 patients were included, and 49 (42.4%) developed AKI. The duration of open chest, duration of mechanical ventilation, need for dialysis, need for extracorporeal membrane oxygenation, and inpatient mortality were associated with AKI (p ≤ 0.05). Stepwise logistic regression demonstrated the following significant independent associations AKI: age at Norwood in days (p < 0.01), blood urea nitrogen (p < 0.01), central venous pressure (p = 0.04), and renal oxygen extraction ratio (p < 0.01). The area under the receiver operating characteristic curve for the logistic regression was 0.74. The fluid markers had weak R-value. Urea, central venous pressure, and renal oxygen extraction ratio are associated with AKI after the Norwood operation. Common clinical metrics used to assess fluid overload are poorly correlated with each other for postoperative Norwood patients.
Collapse
Affiliation(s)
- Julia Weld
- Division of Cardiology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA.
| | - Erin Kim
- Division of Nephrology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Priya Chandra
- Division of Nephrology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Fabio Savorgnan
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Sebastian Acosta
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Saul Flores
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Rohit S Loomba
- Division of Cardiology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
| |
Collapse
|
6
|
Thompson EJ, Chamberlain RC, Hill KD, Sullenger RD, Graham EM, Gbadegesin RA, Hornik CP. Association of Urine Biomarkers With Acute Kidney Injury and Fluid Overload in Infants After Cardiac Surgery: A Single Center Ancillary Cohort of the Steroids to Reduce Systemic Inflammation After Infant Heart Surgery Trial. Crit Care Explor 2023; 5:e0910. [PMID: 37151894 PMCID: PMC10155890 DOI: 10.1097/cce.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
To examine the association between three perioperative urine biomarker concentrations (urine cystatin C [uCysC], urine neutrophil gelatinase-associated lipocalin [uNGAL], and urine kidney injury molecule 1 [uKIM-1]), and cardiac surgery-associated acute kidney injury (CS-AKI) and fluid overload (FO) in infants with congenital heart disease undergoing surgery on cardiopulmonary bypass. To explore how urine biomarkers are associated with distinct CS-AKI phenotypes based on FO status. DESIGN Ancillary prospective cohort study. SETTING Single U.S. pediatric cardiac ICU. PATIENTS Infants less than 1 year old enrolled in the Steroids to Reduce Systemic Inflammation after Infant Heart Surgery trial (NCT03229538) who underwent heart surgery from June 2019 to May 2020 and opted into biomarker collection at a single center. Infants with preoperative CS-AKI were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty infants met inclusion criteria. Median (interquartile) age at surgery was 103 days (5.5-161 d). Modified Kidney Disease Improving Global Outcomes-defined CS-AKI was diagnosed in 22 (55%) infants and 21 (53%) developed FO. UCysC and uNGAL peaked in the early postoperative period and uKIM-1 peaked later. In unadjusted analysis, bypass time was longer, and Vasoactive-Inotropic Score at 24 hours was higher in infants with CS-AKI. On multivariable analysis, higher uCysC (odds ratio [OR], 1.023; 95% CI, 1.004-1.042) and uNGAL (OR, 1.019; 95% CI, 1.004-1.035) at 0-8 hours post-bypass were associated with FO. UCysC, uNGAL, and uKIM-1 did not significantly correlate with CS-AKI. In exploratory analyses of CS-AKI phenotypes, uCysC and uNGAL were highest in CS-AKI+/FO+ infants. CONCLUSIONS In this study, uCysC and uNGAL in the early postoperative period were associated with FO at 48 hours. UCysC, uNGAL, and uKIM-1 were not associated with CS-AKI. Further studies should focus on defining expected concentrations of these biomarkers, exploring CS-AKI phenotypes and outcomes, and establishing clinically meaningful endpoints for infants post-cardiac surgery.
Collapse
Affiliation(s)
- Elizabeth J Thompson
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - Kevin D Hill
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - Eric M Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | | | - Christoph P Hornik
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
7
|
Luppes VAC, Willems A, Hazekamp MG, Blom NA, Ten Harkel ADJ. Fluid Overload in Pediatric Univentricular Patients Undergoing Fontan Completion. J Cardiovasc Dev Dis 2023; 10:jcdd10040156. [PMID: 37103035 PMCID: PMC10146974 DOI: 10.3390/jcdd10040156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Fluid overload (FO) is known to occur frequently after pediatric cardiac surgery and is associated with morbidity and mortality. Fontan patients are at risk to develop FO due to their critical fluid balance. Furthermore, they need an adequate preload in order to maintain adequate cardiac output. This study aimed to identify FO in patients undergoing Fontan completion and the impact of FO on pediatric intensive care unit (PICU) length of stay (LOS) and cardiac events, defined as death, cardiac re-surgery or PICU re-hospitalization during follow-up. METHODS In this retrospective single center study, the presence of FO was assessed in 43 consecutive children undergoing Fontan completion. RESULTS Patients with more than 5% maximum FO had an extended PICU LOS (3.9 [2.9-6.9] vs. 1.9 [1.0-2.6] days; p < 0.001) and an increased length of mechanical ventilation (21 [9-121] vs. 6 [5-10] h; p = 0.001). Regression analysis demonstrated that an increase of 1% maximum FO was associated with a prolonged PICU LOS of 13% (95% CI 1.042-1.227; p = 0.004). Furthermore, patients with FO were at higher risk to develop cardiac events. CONCLUSIONS FO is associated with short-term and long-term complications. Further studies are needed to determine the impact of FO on the outcome in this specific population.
Collapse
Affiliation(s)
- Victorien A C Luppes
- Department of Pediatric Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Nico A Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Arend D J Ten Harkel
- Department of Pediatric Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| |
Collapse
|
8
|
Neumayr TM, Alten JA, Bailly DK, Bhat PN, Brandewie KL, Diddle JW, Ghbeis M, Krawczeski CD, Mah KE, Raymond TT, Reichle G, Zang H, Selewski DT. Assessment of fluid balance after neonatal cardiac surgery: a description of intake/output vs. weight-based methods. Pediatr Nephrol 2023; 38:1355-1364. [PMID: 36066771 DOI: 10.1007/s00467-022-05697-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fluid overload associates with poor outcomes after neonatal cardiac surgery, but consensus does not exist for the most clinically relevant method of measuring fluid balance (FB). While weight change-based FB (FB-W) is standard in neonatal intensive care units, weighing infants after cardiac surgery may be challenging. We aimed to identify characteristics associated with obtaining weights and to understand how intake/output-based FB (FB-IO) and FB-W compare in the early postoperative period in this population. METHODS Observational retrospective study of 2235 neonates undergoing cardiac surgery from 22 hospitals comprising the NEonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) database. RESULTS Forty-five percent (n = 998) of patients were weighed on postoperative day (POD) 2, varying from 2 to 98% among centers. Odds of being weighed were lower for STAT categories 4 and 5 (OR 0.72; 95% CI 0.53-0.98), cardiopulmonary bypass (0.59; 0.42-0.83), delayed sternal closure (0.27; 0.19-0.38), prophylactic peritoneal dialysis use (0.58; 0.34-0.99), and mechanical ventilation on POD 2 (0.23; 0.16-0.33). Correlation between FB-IO and FB-W was weak for every POD 1-6 and within the entire cohort (correlation coefficient 0.15; 95% CI 0.12-0.17). FB-W measured higher than paired FB-IO (mean bias 12.5%; 95% CI 11.6-13.4%) with wide 95% limits of agreement (- 15.4-40.4%). CONCLUSIONS Weighing neonates early after cardiac surgery is uncommon, with significant practice variation among centers. Patients with increased severity of illness are less likely to be weighed. FB-W and FB-IO have weak correlation, and further study is needed to determine which cumulative FB metric most associates with adverse outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Tara M Neumayr
- Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Pediatric Nephrology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Jeffrey A Alten
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Priya N Bhat
- Department of Pediatrics, Sections of Critical Care Medicine and Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Katie L Brandewie
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Wesley Diddle
- Division of Cardiac Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Muhammad Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Catherine D Krawczeski
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kenneth E Mah
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tia T Raymond
- Pediatric Cardiac Intensive Care, Medical City Children's Hospital, Dallas, TX, USA
| | | | - Huaiyu Zang
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
9
|
SooHoo MM, Shah A, Mayen A, Williams MH, Hyslop R, Buckvold S, Basu RK, Kim JS, Brinton JT, Gist KM. Effect of a standardized fluid management algorithm on acute kidney injury and mortality in pediatric patients on extracorporeal support. Eur J Pediatr 2023; 182:581-590. [PMID: 36394647 DOI: 10.1007/s00431-022-04699-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/03/2022] [Accepted: 11/05/2022] [Indexed: 11/18/2022]
Abstract
Acute kidney injury (AKI), fluid overload (FO), and mortality are common in pediatric patients supported by extracorporeal membrane oxygenation (ECMO). The aim of this study is to evaluate if using a fluid management algorithm reduced AKI and mortality in children supported by ECMO. We performed a retrospective study of pediatric patients aged birth to 25 years requiring ECMO at a quaternary level children's hospital from 2007 to 2019 In October 2017, a fluid management algorithm was implemented for protocolized fluid removal after deriving a daily fluid goal using a combination of diuretics and ultrafiltration. Daily algorithm compliance was defined as ≥ 12 h on the algorithm each day. The primary and secondary outcomes were AKI and mortality, respectively, and were assessed in the entire cohort and the sub-analysis of children from the era in which the algorithm was implemented. Two hundred and ninety-nine (median age 5.3 months; IQR: 0.2, 62.3; 45% male) children required ECMO (venoarterial in 85%). The fluid algorithm was applied in 74 patients. The overall AKI rate during ECMO was 38% (26% severe-stage 2/3). Both AKI incidence and mortality were significantly lower in patients managed on the algorithm (p = 0.02 and p = 0.05). After adjusting for confounders, utilization of the algorithm was associated with lower odds of AKI (aOR: 0.40, 95%CI: 0.21, 0.76; p = 0.005) but was not associated with a reduction in mortality. In the sub-analysis, algorithm compliance of 80-100% was associated with a 54% reduction in mortality (ref: < 60% compliant; aOR:0.46, 95%CI:0.22-1.00; p = 0.05). Conclusion: Among the entire cohort, the use of a fluid management algorithm reduced the odds of AKI. Better compliance on the algorithm was associated with lower mortality. Multicenter studies that implement systematic fluid removal may represent an opportunity for improving ECMO-related outcomes. What is Known: • Acute kidney injury and fluid overload are associated with morbidity and mortality in children supported by extracorporeal membrane oxygenation. What is New: • A systematic and protocolized approach to fluid removal in children supported by extracorporeal membrane oxygenation reduces acute kidney injury incidence. • Greater adherence to a protocolized fluid removal algorithm is associated with a reduction in mortality.
Collapse
Affiliation(s)
- Megan M SooHoo
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA.
| | - Ananya Shah
- University of Colorado-Denver Campus, Denver, CO, 80045, USA
| | - Anthony Mayen
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - M Hank Williams
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA
| | - Robert Hyslop
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA
| | - Shannon Buckvold
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA
| | - Rajit K Basu
- Department of Pediatrics, Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John S Kim
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA
| | - John T Brinton
- Department of Biostatistics and Epidemiology, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Katja M Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
10
|
Fluid Accumulation in Mechanically Ventilated, Critically Ill Children: Retrospective Cohort Study of Prevalence and Outcome. Pediatr Crit Care Med 2022; 23:990-998. [PMID: 36454001 DOI: 10.1097/pcc.0000000000003047] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To describe the prevalence, patterns, explanatory variables, and outcomes associated with fluid accumulation (FA) in mechanically ventilated children. DESIGN Retrospective cohort study. SETTING Tertiary PICU. PATIENTS Children mechanically ventilated for greater than or equal to 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Between July 2016 and July 2021, 1,636 children met eligibility criteria. Median age was 5.5 months (interquartile range [IQR], 0.7-46.5 mo), and congenital heart disease was the most common diagnosis. Overall, by day 7 of admission, the median maximum cumulative FA, as a percentage of estimated admission weight, was 7.5% (IQR, 3.3-15.1) occurring at a median of 4 days after admission. Overall, higher FA was associated with greater duration of mechanical ventilation (MV) (mean difference, 1.17 [95% CI, 1.13-1.22]; p < 0.001]), longer intensive care length of stay (LOS) (mean difference, 1.16 [95% CI, 1.12-1.21]; p < 0.001]), longer hospital LOS (mean difference, 1.19 [95% CI, 1.13-1.26]; p < 0.001]), and increased mortality (odds ratio, 1.31 [95% CI, 1.08-1.59]; p = 0.005). However, these associations depended on the effects of children with extreme values, and there was no increase in risk up to 20% FA, overall, in children following cardiopulmonary bypass and in children in the general ICU. When excluding children with maximum FA of >10%, there was no association with duration of MV (mean difference, 0.99 [95% CI, 0.94-1.04]; p = 0.64) and intensive care or hospital LOS (mean difference, 1.01 [95% CI, 0.96-1.06]; p = 0.70 and 1.01 [95% CI, 0.95-1.08]; 0.79, respectively) but an association with reduced mortality 0.71 (95% CI, 0.53-0.97; p = 0.03). CONCLUSIONS In mechanically ventilated critically ill children, greater maximum FA was associated with longer duration of MV, intensive care LOS, hospital LOS, and mortality. However, these findings were driven by extreme values of FA of greater than 20%, and up to 10%, there was reduced mortality and no signal of harm.
Collapse
|
11
|
Risk Factors for Postoperative Acute Kidney Injury in Patients Undergoing Redo Cardiac Surgery Using Cardiopulmonary Bypass. J Cardiovasc Dev Dis 2022; 9:jcdd9080244. [PMID: 36005408 PMCID: PMC9409715 DOI: 10.3390/jcdd9080244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 02/04/2023] Open
Abstract
Objective: This paper aimed to investigate the incidence and risk factors of postoperative acute kidney injury (AKI) in adult patients undergoing redo cardiac surgery with cardiopulmonary bypass (CPB), and explore the impact of AKI on early outcomes. Methods: A total of 116 patients undergoing redo cardiac surgery with CPB between November 2017 and May 2021 were included. Patients were divided into two groups, AKI group and non-AKI group, according to the Kidney Disease Improving Global Outcomes criteria. Perioperative variables were retrospectively collected and analyzed. Risk factors for the development of AKI were investigated by univariate and multiple logistic regression models. Clinical outcomes were also compared between the groups. Results: Postoperative AKI occurred in 63 patients (54.3%), among whom renal replacement therapy was required in 12 patients (19.0%). The mechanical ventilation time (AKI: 43.00 (19.00, 72.00) hours; non-AKI: 18.00 (15.00, 20.00) hours; p < 0.001), ICU length of stay (AKI: 4.00 (2.00, 6.00) days; non-AKI: 3.00 (2.00, 4.00) days; p = 0.010), hospital length of stay since operation (AKI: 12.00 (8.00, 18.00) days; non-AKI: 9.00 (7.00, 12.50) days; p = 0.024), dialysis (AKI: 12.00 (19.05%); non-AKI: 0 (0%); p = 0.001), reintubation (AKI: 7.00 (11.11%); non-AKI: 0 (0%); p = 0.035), and hospital mortality (AKI: 8.00 (12.70%); non-AKI: 0 (0%); p = 0.020) were all higher in the AKI group than in the non-AKI group. Multivariate analysis revealed that high aspartate aminotransferase (OR, 1.028, 95% CI, 1.003 to 1.053, p = 0.025), coronary angiogram within 2 weeks before surgery (OR, 3.209, 95% CI, 1.307 to 7.878, p = 0.011) and CPB time (OR, 1.012, 95% CI, 1.005 to 1.019, p = 0.001) were independent risk factors for postoperative AKI. Conclusions: High aspartate aminotransferase, coronary angiogram within 2 weeks before surgery and CPB time seem to be associated with an increased incidence of postoperative AKI in patients with redo cardiac surgery.
Collapse
|
12
|
Hamdy YH, Aboelela AH, Madkour MAE, Abdelmassih A, Mahrous R, Kareem A. The effect of fluids flushed in pediatric cardiac catheterization procedures on lung ultrasound score. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2082050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Yasmeen H. Hamdy
- Department of Anesthesia, Surgical ICU, and Pain Management, Cairo University, Cairo, Egypt
| | - Amel H Aboelela
- Department of Anesthesia, Surgical ICU, and Pain Management, Cairo University, Cairo, Egypt
| | | | - Antoine Abdelmassih
- Pediatric Cardiology Unit, Pediatrics’ Department, Faculty of Medicine, Cairo University, Cairo, Egypt
- Department, Cancer Children Hospital of Egypt, Cairo, Egypt
| | - Reham Mahrous
- Department of Anesthesia, Surgical ICU, and Pain Management, Cairo University, Cairo, Egypt
| | - Ahmed Kareem
- Department of Anesthesia, Surgical ICU, and Pain Management, Cairo University, Cairo, Egypt
| |
Collapse
|
13
|
Evaluation of postoperative renal functions and its effect on body perfusion in patients with double aortic cannulation. Cardiol Young 2022; 33:733-740. [PMID: 35635193 DOI: 10.1017/s1047951122001627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The optimal visceral preservation method during aortic arch reconstruction is still controversial. It has been thought that double aortic cannulation is effective. Herein, it was aimed to evaluate this technique in providing distal perfusion. METHODS A total of 74 patients who underwent arch reconstruction between 2011 and 2019 were included. Patients were grouped according to ventricular physiology and cannulation strategies. Group 1 were univentricle patients, and all had double aortic cannulation. Group 2 were biventricular patients. Group 2A double aortic cannulation-done and Group 2B non-double aortic cannulation were included. Lactate, urea, creatinine values, renal functions, and need for peritoneal dialysis of patients were evaluated. RESULTS There were no complications observed due to descending aortic cannulation in any of the patients. A delayed sternal closure and the need for peritoneal dialysis were more common in the Group 1 (p < 0.01). The preoperative and postoperative 1st- and 2nd-day lactate, urea, and creatinine values in the Group 1 were higher (p < 0.05) when compared with the Group 2A and 2B. The same values were higher in Group 2A than the Group 2B (p < 0.05). CONCLUSION The positive effect of double aortic cannulation on renal dysfunction could not be demonstrated. This may be associated with a <1 month of age, low weight, complex surgical procedure, and high preoperative lactate, urea, and creatinine values in patients with double aortic cannulation.
Collapse
|
14
|
Jacquet-Lagrèze M, Acker A, Hentzen J, Didier C, De Lamer S, Chardonnal L, Bouhamri N, Portran P, Schweizer R, Lilot M, Fellahi JL. Preload Dependence Fails to Predict Hemodynamic Instability During a Fluid Removal Challenge in Children. Pediatr Crit Care Med 2022; 23:296-305. [PMID: 35190504 DOI: 10.1097/pcc.0000000000002906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Fluid overload increases morbidity and mortality in PICU patients. Active fluid removal improves the prognosis but may worsen organ dysfunction. Preload dependence in adults does predict hemodynamic instability induced by a fluid removal challenge (FRC). We sought to investigate the diagnostic accuracy of dynamic and static markers of preload in predicting hemodynamic instability and reduction of stroke volume during an FRC in children. We followed the Standards for Reporting of Diagnostic Accuracy statement to design conduct and report this study. DESIGN Prospective noninterventional cohort study. SETTINGS From June 2017 to April 2019 in a pediatric cardiac ICU in a tertiary hospital. PATIENTS Patients 8 years old or younger, with symptoms of fluid overload after cardiac surgery, were studied. INTERVENTIONS We confirmed preload dependence by echocardiography before and during a calibrated abdominal compression test. We then performed a challenge to remove 10-mL/kg fluid in less than 120 minutes with an infusion of diuretics. Hemodynamic instability was defined as a decrease of 10% of mean arterial pressure. MEASUREMENT AND MAIN RESULTS We compared patients showing hemodynamic instability with patients remaining stable, and we built receiver operative characteristic (ROC) curves. Among 58 patients studied, 10 showed hemodynamic instability. The area under the ROC curve was 0.55 for the preload dependence test (95% CI, 0.34-0.75). Using a threshold of 10% increase in stroke volume index (SVi) during calibrated abdominal compression, the specificity was 0.30 (95% CI, 0.00-0.60) and the sensitivity was 0.77 (95% CI, 0.65-0.88). Mean arterial pressure variation and SVi variation were not correlated during fluid removal; r = 0.19; 95% CI -0.07 to 0.43; p = 0.139. CONCLUSIONS Preload dependence is not accurate to predict hemodynamic instability during an FRC. Our data do not support a reduction in intravascular volume being mainly responsible for the reduction in arterial pressure during an FRC in children.
Collapse
Affiliation(s)
- Matthias Jacquet-Lagrèze
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
- Laboratoire de recherche en Cardiovasculaire, Métabolisme, diabétologie et Nutrition (CarMeN), Inserm U1060, Lyon, France
- Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Est, Lyon, France
| | - Amélie Acker
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
| | - Julie Hentzen
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
| | - Capucine Didier
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
| | - Sabine De Lamer
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
| | - Laurent Chardonnal
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
| | - Noureddine Bouhamri
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
| | - Philippe Portran
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
| | - Rémi Schweizer
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
| | - Marc Lilot
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
- Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Est, Lyon, France
| | - Jean-Luc Fellahi
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
- Laboratoire de recherche en Cardiovasculaire, Métabolisme, diabétologie et Nutrition (CarMeN), Inserm U1060, Lyon, France
- Université Claude Bernard Lyon 1, Faculté de médecine Lyon-Est, Lyon, France
| |
Collapse
|
15
|
|
16
|
Chen Z, Wang H, Wu Z, Jin M, Chen Y, Li J, Wei Q, Tao S, Zeng Q. Continuous Renal-Replacement Therapy in Critically Ill Children: Practice Changes and Association With Outcome. Pediatr Crit Care Med 2021; 22:e605-e612. [PMID: 33965990 DOI: 10.1097/pcc.0000000000002751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study was designed to evaluate practice changes and outcomes over a 10-year period in a large single-center PICU cohort that received continuous renal-replacement therapy. DESIGN Retrospective study design. SETTING A multidisciplinary tertiary PICU of a university-affiliated hospital in Guangzhou, China. PATIENTS All critically ill children who were admitted to our PICU from January 2010 to December 2019 and received continuous renal-replacement therapy were included in this study. MEASUREMENTS AND MAIN RESULTS A total of 289 patients were included in the study. Of the two study periods, 2010-2014 and 2015-2019, the proportion of continuous renal-replacement therapy initiation time greater than 24 hours was significantly reduced ([73/223] 32.73% vs. [40/66] 60.60%, p < 0.001), the percentage of fluid overload at continuous renal-replacement therapy initiation was lower (3.8% [1.6-7.2%] vs. 12.1% [6.6-23.3%], p < 0.001), the percentage of regional citrate anticoagulation protocol was increased ([223/223] 100% vs. [15/66] 22.7%, p < 0.001), and the ICU survival rate was significantly improved ([24/66] 36.4% vs. [131/223] 58.7%, p = 0.001) in the latter period compared with the former. In addition, subgroup analysis found that survival were higher in patients with continuous renal-replacement therapy initiation time less than 24 hours, regional citrate anticoagulation protocol, and fluid overload less than 10%. CONCLUSIONS The survival rate of patients received continuous renal-replacement therapy treatment in our center has improved over past 10 years, and some changes have taken place during these periods. Among them, early initiation of continuous renal-replacement therapy, lower fluid overload, and regional citrate anticoagulation method seems to be related to the improvement of outcome. Ongoing evaluation of the practice changes and quality improvement of continuous renal-replacement therapy for critically ill pediatric patients still need attention.
Collapse
Affiliation(s)
- ZhiJiang Chen
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - HuiLi Wang
- Department of Laboratory, Guangdong Women and Children Hospital, Guangzhou, China
| | - Zhu Wu
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ming Jin
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - YiTing Chen
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Li
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - QiuJu Wei
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - ShaoHua Tao
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Qiyi Zeng
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| |
Collapse
|
17
|
Anderson NM, Bond GY, Joffe AR, MacDonald C, Robertson C, Urschel S, Morgan CJ. Post-operative fluid overload as a predictor of hospital and long-term outcomes in a pediatric heart transplant population. Pediatr Transplant 2021; 25:e13897. [PMID: 33131128 DOI: 10.1111/petr.13897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 09/27/2020] [Accepted: 10/02/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pediatric patients undergoing heart transplant have a number of factors predisposing them to become fluid-overloaded, including capillary leak syndrome. Capillary leak and FO are associated with organ injury and may influence both short- and long-term outcomes. This study aimed to 1) determine the extent, timing, and predictors of post-operative FO and 2) investigate the association of FO with clinically important outcomes. METHODS Between 2000 and 2012, 70 children less than 6 years old had a heart transplant at our institution. This was a secondary analysis of data from an ongoing prospective cohort study. RESULTS FO, defined as cumulative fluid balance greater than 10% of body weight in the first 5 post-operative days, occurred in 16/70 patients (23%); 7 of these had more than 20% FO. Shorter donor ischemic time and longer cardiopulmonary bypass time were independently associated with increased risk of FO. FO >20% was a statistically significant independent predictor of mortality (P = .005), ventilation time, and PICU length of stay. There was no statistically significant association between identified neurodevelopment domains and FO. CONCLUSIONS Our single-center experience demonstrates that FO was common after pediatric heart transplant and was associated with worse clinical outcomes. FO is a potentially modifiable factor, and research is needed to better determine risk factors and whether intervention to reduce FO can improve outcomes in pediatric heart transplant patients.
Collapse
Affiliation(s)
- Nicole M Anderson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Gwen Y Bond
- Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | | | - Charlene Robertson
- Glenrose Rehabilitation Hospital, Edmonton, AB, Canada.,Division of Developmental Pediatrics, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Simon Urschel
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | | | | |
Collapse
|
18
|
A systematic review of the evidence supporting post-operative diuretic use following cardiopulmonary bypass in children with Congenital Heart Disease. Cardiol Young 2021; 31:699-706. [PMID: 33942711 DOI: 10.1017/s1047951121001451] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Paediatric cardiac surgery on cardiopulmonary bypass induces substantial physiologic changes that contribute to post-operative morbidity and mortality. Fluid overload and oedema are prevalent complications, routinely treated with diuretics. The optimal diuretic choice, timing of initiation, dose, and interval remain largely unknown. METHODS To guide clinical practice and future studies, we used PubMed and EMBASE to systematically review the existing literature of clinical trials involving diuretics following cardiac surgery from 2000 to 2020 in children aged 0-18 years. Studies were assessed by two reviewers to ensure that they met eligibility criteria. RESULTS We identified nine studies of 430 children across four medication classes. Five studies were retrospective, and four were prospective, two of which included randomisation. All were single centre. There were five primary endpoints - urine output, acute kidney injury, fluid balance, change in serum bicarbonate level, and required dose of diuretic. Included studies showed early post-operative diuretic resistance, suggesting higher initial doses. Two studies of ethacrynic acid showed increased urine output and lower diuretic requirement compared to furosemide. Children receiving peritoneal dialysis were less likely to develop fluid overload than those receiving furosemide. Chlorothiazide, acetazolamide, and tolvaptan demonstrated potential benefit as adjuncts to traditional diuretic regimens. CONCLUSIONS Early diuretic resistance is seen in children following cardiopulmonary bypass. Ethacrynic acid appears superior to furosemide. Adjunct diuretic therapies may provide additional benefit. Study populations were heterogeneous and endpoints varied. Standardised, validated endpoints and pragmatic trial designs may allow investigators to determine the optimal diuretic, timing of initiation, dose, and interval to improve post-operative outcomes.
Collapse
|
19
|
Abdel-Rahman EM, Turgut F, Gautam JK, Gautam SC. Determinants of Outcomes of Acute Kidney Injury: Clinical Predictors and Beyond. J Clin Med 2021; 10:jcm10061175. [PMID: 33799741 PMCID: PMC7999959 DOI: 10.3390/jcm10061175] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 12/24/2022] Open
Abstract
Acute kidney injury (AKI) is a common clinical syndrome characterized by rapid impairment of kidney function. The incidence of AKI and its severe form AKI requiring dialysis (AKI-D) has been increasing over the years. AKI etiology may be multifactorial and is substantially associated with increased morbidity and mortality. The outcome of AKI-D can vary from partial or complete recovery to transitioning to chronic kidney disease, end stage kidney disease, or even death. Predicting outcomes of patients with AKI is crucial as it may allow clinicians to guide policy regarding adequate management of this problem and offer the best long-term options to their patients in advance. In this manuscript, we will review the current evidence regarding the determinants of AKI outcomes, focusing on AKI-D.
Collapse
Affiliation(s)
- Emaad M. Abdel-Rahman
- Division of Nephrology, University of Virginia, Charlottesville, VA 22908, USA;
- Correspondence: ; Tel.: +1-(434)-243-2671
| | - Faruk Turgut
- Internal Medicine/Nephrology, Faculty of Medicine, Mustafa Kemal University, Antakya/Hatay 31100, Turkey;
| | - Jitendra K. Gautam
- Division of Nephrology, University of Virginia, Charlottesville, VA 22908, USA;
| | | |
Collapse
|
20
|
Gist KM, Henry BM, Borasino S, Rahman AF, Webb T, Hock KM, Kim JS, Smood B, Mosher Z, Alten JA. Prophylactic Peritoneal Dialysis After the Arterial Switch Operation: A Retrospective Cohort Study. Ann Thorac Surg 2021; 111:655-661. [DOI: 10.1016/j.athoracsur.2020.04.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/28/2022]
|
21
|
Persson JN, Holstein J, Silveira L, Irons A, Rajab TK, Jaggers J, Twite MD, Scahill C, Kohn M, Gold C, Davidson JA. Validation of Point-of-Care Ultrasound to Measure Perioperative Edema in Infants With Congenital Heart Disease. Front Pediatr 2021; 9:727571. [PMID: 34497787 PMCID: PMC8419458 DOI: 10.3389/fped.2021.727571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/30/2021] [Indexed: 01/16/2023] Open
Abstract
Purpose: Fluid overload is a common post-operative issue in children following cardiac surgery and is associated with increased morbidity and mortality. There is currently no gold standard for evaluating fluid status. We sought to validate the use of point-of-care ultrasound to measure skin edema in infants and assess the intra- and inter-user variability. Methods: Prospective cohort study of neonates (≤30 d/o) and infants (31 d/o to 12 m/o) undergoing cardiac surgery and neonatal controls. Skin ultrasound was performed on four body sites at baseline and daily post-operatively through post-operative day (POD) 3. Subcutaneous tissue depth was manually measured. Intra- and inter-user variability was assessed using intraclass correlation coefficient (ICC). Results: Fifty control and 22 surgical subjects underwent skin ultrasound. There was no difference between baseline surgical and control neonates. Subcutaneous tissue increased in neonates starting POD 1 with minimal improvement by POD 3. In infants, this pattern was less pronounced with near resolution by POD 3. Intra-user variability was excellent (ICC 0.95). Inter-user variability was very good (ICC 0.82). Conclusion: Point-of-care skin ultrasound is a reproducible and reliable method to measure subcutaneous tissue in infants with and without congenital heart disease. Acute increases in subcutaneous tissue suggests development of skin edema, consistent with extravascular fluid overload. There is evidence of skin edema starting POD 1 in all subjects with no substantial improvement by POD 3 in neonates. Point-of-care ultrasound could be an objective way to measure extravascular fluid overload in infants. Further research is needed to determine how extravascular fluid overload correlates to clinical outcomes.
Collapse
Affiliation(s)
- Jessica N Persson
- Department of Pediatrics, University of Colorado Anschutz, Aurora, CO, United States.,Heart Institute, Children's Hospital Colorado, Aurora, CO, United States
| | | | - Lori Silveira
- Department of Pediatrics, University of Colorado Anschutz, Aurora, CO, United States
| | - Aimee Irons
- Heart Institute, Children's Hospital Colorado, Aurora, CO, United States
| | - Taufiek Konrad Rajab
- Heart Institute, Children's Hospital Colorado, Aurora, CO, United States.,Section of Congenital Heart Surgery, University of Colorado Anschutz, Aurora, CO, United States
| | - James Jaggers
- Heart Institute, Children's Hospital Colorado, Aurora, CO, United States.,Section of Congenital Heart Surgery, University of Colorado Anschutz, Aurora, CO, United States
| | - Mark D Twite
- Department of Anesthesiology, University of Colorado Anschutz and Children's Hospital Colorado, Aurora, CO, United States
| | - Carly Scahill
- Department of Pediatrics, University of Colorado Anschutz, Aurora, CO, United States.,Heart Institute, Children's Hospital Colorado, Aurora, CO, United States
| | - Mary Kohn
- Department of Pediatrics, University of Colorado Anschutz, Aurora, CO, United States
| | - Christine Gold
- Department of Pediatrics, University of Colorado Anschutz, Aurora, CO, United States
| | - Jesse A Davidson
- Department of Pediatrics, University of Colorado Anschutz, Aurora, CO, United States.,Heart Institute, Children's Hospital Colorado, Aurora, CO, United States
| |
Collapse
|
22
|
Abstract
OBJECTIVES Fluid overload is common in the PICU and has been associated with increased morbidity and mortality. It remains unclear whether fluid overload is a surrogate marker for severity of illness and need for increased support, an iatrogenic modifiable risk factor, or a sign of oliguria. The proportions of various fluid intake contributing to fluid overload and its recognition have not been adequately examined. We aimed to: 1) describe the types and amounts of fluid exposure in the PICU and 2) identify the clinicians' recognition of fluid overload. SETTING Noncardiac PICU in a quaternary care hospital. PATIENTS Pediatric patients admitted for more than 24 hours. DESIGN Prospective observational study over 28 days. INTERVENTIONS Data were collected on the amount and type of fluid exposure-resuscitative boluses, blood products, enteral intake, parenteral nutrition (total parenteral nutrition), or modifiable fluids (IV fluids and medications) indexed to the patients' admission body surface area on days 1 and 3. Charts of patients admitted for 3 days who developed 15% fluid overload were reviewed to assess clinicians' recognition of fluid overload. MEASUREMENTS AND MAIN RESULTS One hundred two patients were included. Day 1 median fluid exposure was 2,318 mL/m (1,831-3,037 mL/m; 1,646 mL/m [1,296-2,086 mL/m] modifiable fluids). Forty-seven patients (46%) received fluid boluses, and 16 (16%) received blood products. Day 3 median fluid exposure was 2,233 mL/m (1,904-2,556 mL/m; 750 mL/m [375-1,816 mL/m] modifiable fluids). Of the 54 patients, one patient (1.9%) received a fluid bolus and two (3.7%) received blood products. In our cohort, 47 of 54 (87%) had fluid exposure greater than 1,600 mL/m on day 3. Fluid overload was not recognized by the clinicians in 30% of the patients who developed more than 15% fluid overload. CONCLUSIONS Although resuscitation fluids contributed more to fluid exposure on day 1 compared with day 3, fluid exposure frequently exceeded maintenance requirements on day 3. Fluid overload was not always recognized by PICU practitioners. Further studies to correlate modifiable fluid exposure to fluid overload and explore modifiable practice improvement opportunities are needed.
Collapse
|
23
|
Ricci Z, Benegni S, Cies JJ, Marinari E, Haiberger R, Garisto C, Rizza A, Giorni C, Di Chiara L, Arpicco S, Muntoni E, Ferrari F, Milla P. Population Pharmacokinetics of Cefoxitin Administered for Pediatric Cardiac Surgery Prophylaxis. Pediatr Infect Dis J 2020; 39:609-614. [PMID: 32221166 DOI: 10.1097/inf.0000000000002635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Available data about pharmacokinetics (PK) of antimicrobials administered as surgical prophylaxis to children undergoing cardiac surgery with cardiopulmonary bypass (CPB) showed that drug concentrations during CPB may be supra or subtherapeutic. The aim of this study was to determine the population PK and pharmacodynamic target attainment (PTA) of cefoxitin during pediatric CPB surgery. METHODS A prospective interventional study was conducted. Cefoxitin (40 mg/kg, up to max 1000 mg) was administered before skin incision. Blood samples were obtained in the operatory room throughout surgery. Population PK, PTA, and safety of cefoxitin were evaluated in neonates, infants, children <10 and >10 years old. RESULTS Forty patients were enrolled. Cefoxitin levels correlated with time from bolus administration (r = -0.6, P = 0.0001) and, after 240 minutes from bolus, drug values below the target (8 mg/L) were shown. Cefoxitin concentrations were best described by a one-compartment model with first order elimination. A significant relationship was identified between body weight, age, body mass index, and serum creatinine on drug clearance and age, body weight, and body mass index on cefoxitin volume of distribution. The PTA for free drug concentration being above the minimum inhibitory concentration of 8 mg/L for at least 240 minutes was >90% in all age groups except in patients >10 years of age (PTA = 62%). CONCLUSIONS Cefoxitin PK appears to be significantly influenced by CPB with generally reduced drug clearance. The PTA was adequately achieved in the majority of patients except in patients >10 years old or longer surgeries.
Collapse
Affiliation(s)
- Zaccaria Ricci
- From the Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Benegni
- From the Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Eleonora Marinari
- From the Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Roberta Haiberger
- From the Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Cristiana Garisto
- From the Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandra Rizza
- From the Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Giorni
- From the Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Luca Di Chiara
- From the Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Silvia Arpicco
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Elisabetta Muntoni
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Fiorenza Ferrari
- Department of Anesthesiology and Intensive Care, Intensive Care Unit, I.R.C.C.S. Policlinico San Matteo, Viale Golgi, Pavia, Italy
| | - Paola Milla
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| |
Collapse
|
24
|
Association of postoperative fluid overload with adverse outcomes after congenital heart surgery: a systematic review and dose-response meta-analysis. Pediatr Nephrol 2020; 35:1109-1119. [PMID: 32040627 DOI: 10.1007/s00467-020-04489-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/07/2019] [Accepted: 01/23/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pediatric cardiac surgery is commonly associated with acute kidney injury (AKI) and significant fluid retention, which complicate postoperative management and lead to increased rates of morbidity. This meta-analysis aimed to accumulate current literature evidence and evaluate the correlation of fluid overload degree with adverse outcome in patients undergoing congenital heart surgery. METHODS Medline, Scopus, CENTRAL, Clinicaltrials.gov, and Google Scholar were systematically searched from inception. All studies reporting the effects of fluid overload on postoperative clinical outcomes were selected. A dose-response meta-analytic method using restricted cubic splines was implemented in R-3.6.1. RESULTS Twelve studies were included, with a total of 3111 pediatric patients. Qualitative synthesis indicated that fluid overload was linked to significantly higher risk of mortality, AKI, prolonged hospital, and intensive care unit (ICU) stay, as well as with increased duration of mechanical ventilation, inotrope need, and infection rate. Meta-analysis demonstrated a linear correlation between fluid overload and the risk of mortality (χ2 = 6.22, p value = 0.01) and AKI (χ2 = 35.84, p value < 0.001), while a positive curvilinear relationship was estimated for the outcomes of hospital (χ2 = 18.84, p value = 0.0001) and ICU stay (χ2 = 63.69, p value = 0.0001). CONCLUSIONS The present meta-analysis supports that postoperative fluid overload is significantly linked to elevated risk of prolonged hospital stay, AKI development, and mortality in pediatric patients undergoing cardiac surgery. These findings warrant replication by future prospective studies, which should define the optimal cutoff values and assess the effectiveness of therapeutic strategies to limit fluid overload in the postoperative setting.
Collapse
|
25
|
El-Nawawy A, Moustafa AA, Antonios MAM, Atta MM. Clinical Outcomes Associated with Fluid Overload in Critically Ill Pediatric Patients. J Trop Pediatr 2020; 66:152-162. [PMID: 31280298 DOI: 10.1093/tropej/fmz045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Fluid overload (FO) has been accused as being one of the ICU problems affecting morbidity and mortality. The aim of the study was to assess the effect and critical threshold of FO that is related to mortality. METHODS This prospective observational study was conducted in a pediatric ICU. All patients admitted (n = 203) during 12 months with a length of stay more than 48 h were recruited. RESULTS FO was found to be related to mortality (p = 0.025) but was not proved to be an independent risk factor of fatal outcome by the logistic regression model. This raises the suspicion about any cause-effect relationship between FO and mortality. Even though, FO was statistically a fair discriminator of death (AUC = 0.655, p = 0.0008) and a cutoff level of FO was set at 7%. Kaplan-Meier curve showed that cumulative of survival differed significantly between groups of patients with FO more and less than 7% (p = 0.002). CONCLUSION Frequent and accurate monitoring of FO is crucial among critically ill patients. The present study suggested a threshold of 7% FO beyond which a more conservative regimen of fluid administration might improve patients' outcome.
Collapse
Affiliation(s)
- Ahmed El-Nawawy
- Department of Pediatrics, Faculty of Medicine, El-Shatby Hospital, Alexandria University, Alexandria, Egypt
| | - Azza A Moustafa
- Department of Pediatrics, Faculty of Medicine, El-Shatby Hospital, Alexandria University, Alexandria, Egypt
| | - Manal A M Antonios
- Department of Pediatrics, Faculty of Medicine, El-Shatby Hospital, Alexandria University, Alexandria, Egypt
| | - May M Atta
- Resident of Pediatric Intensive Care Unit, El-Shatby Hospital, affiliated to the Department of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| |
Collapse
|
26
|
Sumbel L, Wats A, Salameh M, Appachi E, Bhalala U. Thoracic Fluid Content (TFC) Measurement Using Impedance Cardiography Predicts Outcomes in Critically Ill Children. Front Pediatr 2020; 8:564902. [PMID: 33718292 PMCID: PMC7947197 DOI: 10.3389/fped.2020.564902] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/09/2020] [Indexed: 01/03/2023] Open
Abstract
Objective: Conventional methods of fluid assessment in critically ill children are difficult and/or inaccurate. Impedance cardiography has capability of measuring thoracic fluid content (TFC). There is an insufficient literature reporting correlation between TFC and conventional methods of fluid balance and whether TFC predicts outcomes in critically ill children. We hypothesized that TFC correlates with indices of fluid balance [FIMO (Fluid Intake Minus Output) and AFIMO (Adjusted Fluid Intake Minus Output)] and is a predictor of outcomes in critically ill children. Design: Retrospective chart review. Setting: Pediatric intensive care unit of a tertiary care teaching hospital. Patients: Children <21 years, admitted to our Pediatric Intensive Care Unit (PICU) between July- November 2018 with acute respiratory failure and/or shock and who were monitored for fluid status using ICON® monitor. Interventions: None. Measurements and Main Results: We collected demographic information, data on daily and cumulative fluid balance (CFB), ventilator, PICU and hospital days, occurrence of multi-organ dysfunction syndrome (MODS), and mortality. We calculated AFIMO using insensible fluid loss. We analyzed data using correlation coefficient, chi-square test and multiple linear regression analysis. We analyzed a total 327 recordings of TFC, FIMO and AFIMO as daily records of fluid balance in 61 critically ill children during the study period. The initial TFC, FIMO, and AFIMO in ml [median (IQR)] were 30(23, 44), 300(268, 325), and 21.05(-171.3, 240.2), respectively. The peak TFC, FIMO, and AFIMO in ml were 36(26, 24), 322(286, 334), and 108.8(-143.6, 324.4) respectively. The initial CFB was 1134.2(325.6, 2774.4). TFC did not correlate well with FIMO or AFIMO (correlation coefficient of 0.02 and -0.03, respectively), but a significant proportion of patients with high TFC exhibited pulmonary plethora on x-ray chest (as defined by increased bronchovascular markings and/or presence of pleural effusion) (p = 0.015). The multiple linear regression analysis revealed that initial and peak TFC and peak and mean FIMO and AFIMO predicted outcomes (ventilator days, length of PICU, and hospital days) in critically ill children (p < 0.05). Conclusions: In our cohort of critically ill children with respiratory failure and/or shock, TFC did not correlate with conventional measures of fluid balance (FIMO/AFIMO), but a significant proportion of patients with high TFC had pulmonary plethora on chest x-ray. Both initial and peak TFC predicted outcomes in critically ill children.
Collapse
Affiliation(s)
- Lydia Sumbel
- Department of Pediatrics, The Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Aanchal Wats
- Department of Pediatrics, The Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Mohammed Salameh
- Department of Pediatrics, The Children's Hospital of San Antonio, San Antonio, TX, United States.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Elumalai Appachi
- Department of Pediatrics, The Children's Hospital of San Antonio, San Antonio, TX, United States.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Utpal Bhalala
- Department of Pediatrics, The Children's Hospital of San Antonio, San Antonio, TX, United States.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| |
Collapse
|
27
|
Carpenter RJ, Kouyoumjian S, Moromisato DY, Lieu P, Amirnovin R. Lower-Dose, Intravenous Chlorothiazide Is an Effective Adjunct Diuretic to Furosemide Following Pediatric Cardiac Surgery. J Pediatr Pharmacol Ther 2020; 25:31-38. [PMID: 31897073 DOI: 10.5863/1551-6776-25.1.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Postoperative fluid overload is ubiquitous in neonates and infants following operative intervention for congenital heart defects; ineffective diuresis is associated with poor outcomes. Diuresis with furosemide is widely used, yet there is often resistance at higher doses. In theory, furosemide resistance may be overcome with chlorothiazide; however, its efficacy is unclear, especially in lower doses and in this population. We hypothesized the addition of lower-dose, intravenous chlorothiazide following surgery in patients on high-dose furosemide would induce meaningful diuresis with minimal side effects. METHODS This was a retrospective, cohort study. Postoperative infants younger than 6 months, receiving high-dose furosemide, and given lower-dose chlorothiazide (1-2 mg/kg every 6-12 hours) were identified. Diuretic doses, urine output, fluid balance, vasoactive-inotropic scores, total fluid intake, and electrolyte levels were recorded. RESULTS There were 73 patients included. The addition of lower-dose chlorothiazide was associated with a significant increase in urine output (3.8 ± 0.18 vs 5.6 ± 0.27 mL/kg/hr, p < 0.001), more negative fluid balance (16.1 ± 4.2 vs -25.0 ± 6.3 mL/kg/day, p < 0.001), and marginal changes in electrolytes. Multivariate analysis was performed, demonstrating that increased urine output and more negative fluid balance were independently associated with addition of chlorothiazide. Subgroup analysis of 21 patients without a change in furosemide dose demonstrated the addition of chlorothiazide significantly increased urine output (p = 0.03) and reduced fluid balance (p < 0.01), further validating the adjunct effects of chlorothiazide. CONCLUSION Lower-dose, intravenous chlorothiazide is an effective adjunct treatment in postoperative neonates and infants younger than 6 months following cardiothoracic surgery.
Collapse
|
28
|
Perry T, Bora K, Bakar A, Meyer DB, Sweberg T. Non-surgical Risk Factors for the Development of Chylothorax in Children after Cardiac Surgery-Does Fluid Matter? Pediatr Cardiol 2020; 41:194-200. [PMID: 31720782 DOI: 10.1007/s00246-019-02255-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/05/2019] [Indexed: 01/30/2023]
Abstract
We hypothesize that there are post-operative, non-surgical risk factors that could be modified to prevent the occurrence of chylothorax, and we seek to determine those factors. Retrospective chart review of 285 consecutive patients < 18 years who underwent cardiac surgery from 2015 to 2017 at a single institution pediatric intensive care unit. Data was collected on patient demographics, cardiac lesion, surgical and post-operative characteristics. Primary outcome was development of chylothorax. Of 285 patients, median age was 189 days, median weight was 6.6 kg, 48% were female, and 10% had trisomy 21. 3.5% of patients developed upper extremity DVTs, and 8% developed chylothorax. At 24 h following surgery, a majority were in the 0-10% fluid overload category or had a negative fluid balance (63% and 34%, respectively), and a positive fluid balance was rare at 72 h (16%). In univariate analysis, age, weight, bypass time, DVT, arrhythmia, and trisomy 21 were significantly associated with chylothorax and adjusted for in logistic regression. Presence of an upper extremity DVT (OR 49.8, p < 0.001) and trisomy 21 (OR 5.8, p < 0.001) remained associated with chylothorax on regression modeling. The presence of an upper extremity DVT and trisomy 21 were associated with the development of chylothorax. Fluid overload was rare in our population. The presence of positive fluid balance, fluid overload, elevated central venous pressure, and early initiation of fat containing feeds were not associated with chylothorax.
Collapse
Affiliation(s)
- Tanya Perry
- Division of Cardiology, Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Kelly Bora
- Division of Pediatric Critical Care, Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Adnan Bakar
- Division of Pediatric Critical Care, Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, NY, USA.,Division of Cardiology, Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - David B Meyer
- Division of Cardiothoracic Surgery, Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Todd Sweberg
- Division of Pediatric Critical Care, Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, NY, USA
| |
Collapse
|
29
|
Carlisle MA, Soranno DE, Basu RK, Gist KM. Acute Kidney Injury and Fluid Overload in Pediatric Cardiac Surgery. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2019; 5:326-342. [PMID: 33282633 PMCID: PMC7717109 DOI: 10.1007/s40746-019-00171-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) and fluid overload affect a large number of children undergoing cardiac surgery, and confers an increased risk for adverse complications and outcomes including death. Survivors of AKI suffer long-term sequelae. The purpose of this narrative review is to discuss the short and long-term impact of cardiac surgery associated AKI and fluid overload, currently available tools for diagnosis and risk stratification, existing management strategies, and future management considerations. RECENT FINDINGS Improved risk stratification, diagnostic prediction tools and clinically available early markers of tubular injury have the ability to improve AKI-associated outcomes. One of the major challenges in diagnosing AKI is the diagnostic imprecision in serum creatinine, which is impacted by a variety of factors unrelated to renal disease. In addition, many of the pharmacologic interventions for either AKI prevention or treatment have failed to show any benefit, while peritoneal dialysis catheters, either for passive drainage or prophylactic dialysis may be able to mitigate the detrimental effects of fluid overload. SUMMARY Until novel risk stratification and diagnostics tools are integrated into routine practice, supportive care will continue to be the mainstay of therapy for those affected by AKI and fluid overload after pediatric cardiac surgery. A viable series of preventative measures can be taken to mitigate the risk and severity of AKI and fluid overload following cardiac surgery, and improve care.
Collapse
Affiliation(s)
- Michael A Carlisle
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
| | - Danielle E. Soranno
- Department of Pediatrics, Division of Pediatric Nephrology, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
| | - Rajit K Basu
- Department of Pediatrics, Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta GA
| | - Katja M Gist
- Department of Pediatrics, Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
| |
Collapse
|
30
|
Wang J, Wang C, Wang Y, Gao Y, Tian Y, Wang S, Li J, Yang L, Peng YG, Yan F. Fluid Overload in Special Pediatric Cohorts With Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery Following Surgical Repair. J Cardiothorac Vasc Anesth 2019; 34:1565-1572. [PMID: 31780357 DOI: 10.1053/j.jvca.2019.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/22/2019] [Accepted: 10/07/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the prevalence, risk factors, and clinical outcomes associated with early fluid overload (FO) in a special group of pediatric patients undergoing repair of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). DESIGN It was a retrospective study performed with multiple variable regression analysis. SETTING A single cardiac surgical institution. PARTICIPANTS Eighty-eight patients younger than 18 years of age undergoing ALCAPA surgical repair with cardiopulmonary bypass were recruited at the authors' institution from June 2010 to September 2017. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Of 88 pediatric patients with ALCAPA after surgical repair, 37.5% developed early FO, defined as fluid accumulation ≥5% within the period from surgery until midnight of postoperative day 1. Patients with early FO were younger, weighed less, and had worse preoperative cardiac dysfunction. With logistic regression analysis, being underweight was confirmed to be a risk factor for FO development (odds ratio, 8.66; 95% confidence interval, 2.83-26.52; p < 0.001). Early FO also predicted severe acute kidney injury, respiratory morbidity, and low cardiac output syndrome after reimplantation procedure. Patients with early FO also had significantly longer mechanical ventilation hours (p < 0.001), intensive care unit length of stay (p = 0.003), and hospital length of stay (p = 0.009). CONCLUSION Early FO ≥5% has been linked to adverse postoperative outcomes in pediatric patients undergoing repair for ALCAPA. The use of restrictive fluid management is crucial for patients who have lower weight and poor myocardial function before and after complex surgical procedures such as in ALCAPA settings.
Collapse
Affiliation(s)
- Jianhui Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunrong Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuefu Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yuchen Gao
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tian
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sudena Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Li
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lijing Yang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong G Peng
- Department of Anesthesiology, UF Health Shands Hospital, University of Florida, Gainesville, FL
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
31
|
Abstract
OBJECTIVES To determine common practice for fluid management after cardiac surgery for congenital heart disease among pediatric cardiac intensivists. DESIGN A survey consisting of 17 questions about fluid management practices after pediatric cardiac surgery. Distribution was done by email, social media, World Federation of Pediatric Intensive and Critical Care Societies website, and World Federation of Pediatric Intensive and Critical Care Societies newsletter using the electronic survey distribution and collection system Research Electronic Data Capture. SETTING PICUs around the world. SUBJECTS Pediatric intensivists managing children after surgery for congenital heart disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One-hundred eight responses from 18 countries and six continents were received. The most common prescribed fluids for IV maintenance are isotonic solutions, mainly NaCl 0.9% (42%); followed by hypotonic fluids (33%) and balanced crystalloids solutions (14%). The majority of the respondents limit total fluid intake to 50% during the first 24 hours after cardiac surgery. The most frequently used fluid as first choice for resuscitation is NaCl 0.9% (44%), the second most frequent choice are colloids (27%). Furthermore, 64% of respondents switch to a second fluid for ongoing resuscitation, 76% of these choose a colloid. Albumin 5% is the most commonly used colloid (61%). Almost all respondents (96%) agree there is a need for research on this topic. CONCLUSIONS Our survey demonstrates great variation in fluid management practices, not only for maintenance fluids but also for volume resuscitation. Despite the lack of evidence, colloids are frequently administered. The results highlight the need for further research and evidence-based guidelines on this topic.
Collapse
|
32
|
Neonatal and Paediatric Heart and Renal Outcomes Network: design of a multi-centre retrospective cohort study. Cardiol Young 2019; 29:511-518. [PMID: 31107196 DOI: 10.1017/s1047951119000210] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury is common. In order to improve our understanding of acute kidney injury, we formed the multi-centre Neonatal and Pediatric Heart and Renal Outcomes Network. Our main goals are to describe neonatal kidney injury epidemiology, evaluate variability in diagnosis and management, identify risk factors, investigate the impact of fluid overload, and explore associations with outcomes. METHODS The Neonatal and Pediatric Heart and Renal Outcomes Network collaborative includes representatives from paediatric cardiac critical care, cardiology, nephrology, and cardiac surgery. The collaborative sites and infrastructure are part of the Pediatric Cardiac Critical Care Consortium. An acute kidney injury module was developed and merged into the existing infrastructure. A total of twenty-two participating centres provided data on 100-150 consecutive neonates who underwent cardiac surgery within the first 30 post-natal days. Additional acute kidney injury variables were abstracted by chart review and merged with the corresponding record in the quality improvement database. Exclusion criteria included >1 operation in the 7-day study period, pre-operative renal replacement therapy, pre-operative serum creatinine >1.5 mg/dl, and need for extracorporeal support in the operating room or within 24 hours after the index operation. RESULTS A total of 2240 neonatal patients were enrolled across 22 centres. The incidence of acute kidney injury was 54% (stage 1 = 31%, stage 2 = 13%, and stage 3 = 9%). CONCLUSIONS Neonatal and Pediatric Heart and Renal Outcomes Network represents the largest multi-centre study of neonatal kidney injury. This new network will enhance our understanding of kidney injury and its complications.
Collapse
|
33
|
IV Fluids After Pediatric Cardiac Surgery. Pediatr Crit Care Med 2019; 20:385-387. [PMID: 30950992 DOI: 10.1097/pcc.0000000000001851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
Yuan SM. Acute kidney injury after pediatric cardiac surgery. Pediatr Neonatol 2019; 60:3-11. [PMID: 29891225 DOI: 10.1016/j.pedneo.2018.03.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 09/11/2017] [Accepted: 03/27/2018] [Indexed: 01/11/2023] Open
Abstract
Acute kidney injury (AKI) is a common complication of pediatric cardiac surgery and is associated with increased morbidity and mortality. Literature of AKI after pediatric cardiac surgery is comprehensively reviewed in terms of incidence, risk factors, biomarkers, treatment and prognosis. The novel RIFLE (pediatric RIFLE for pediatrics), Acute Kidney Injury Network (AKIN) and Kidney Disease Improving Global Outcomes (KDIGO) criteria have brought about unified diagnostic standards and comparable results for AKI after cardiac surgery. Numerous risk factors, either renal or extrarenal, can be responsible for the development of AKI after cardiac surgery, with low cardiac output syndrome being the most pronounced predictor. Early fluid overload is also crucial for the occurrence of AKI and prognosis in pediatric patients. Three sensitive biomarkers, neutrophil gelatinase-associated lipocalin, cystatin C (CysC) and liver fatty acid-binding protein, are regarded as the earliest (increase at 2-4 h), and another two, kidney injury molecule-1 and interleukin-18 represent the intermediate respondents (increase at 6-12 h after surgery). To ameliorate the cardiopulmonary bypass techniques, improve renal perfusion and eradicate the causative risk factors are imperative for the prevention of AKI in pediatric patients. The early and intermediate biomarkers are helpful for an early judgment of occurrence of postoperative AKI. Improved survival has been achieved by prevention, renal support and modifications of hemofiltration techniques. Further development is anticipated in small children.
Collapse
Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, 389 Longdejing Street, Chengxiang District, Putian 351100, Fujian Province, People's Republic of China.
| |
Collapse
|
35
|
Klinkner DB, Siddiqui S. Renal dysfunction in the pediatric surgical patient: When to intervene. Semin Pediatr Surg 2019; 28:57-60. [PMID: 30824136 DOI: 10.1053/j.sempedsurg.2019.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Renal dysfunction is very common in the pediatric surgical critical care patient, with an estimated incidence of up to 35% in the PICU population. It impacts multiple other organ systems, particularly ventilation, and adds to the morbidity and mortality in children with multisystem organ dysfunction. In this article, we review the definitions and stages of renal failure in the pediatric population, identify which of these are more likely to require renal replacement therapy, and identify the indications for the different types of intervention. In addition, the complications of each form of therapy, along with management options, will be discussed. Finally, we will discuss the immediate and long-term outcomes for pediatric patients from neonates to adolescents.
Collapse
Affiliation(s)
- Denise B Klinkner
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, United States.
| | - Sabina Siddiqui
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, United States.
| | | |
Collapse
|
36
|
Rizza A, Ricci Z. Fluid and Electrolyte Balance. CONGENIT HEART DIS 2019. [DOI: 10.1007/978-3-319-78423-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
37
|
Selewski DT, Akcan-Arikan A, Bonachea EM, Gist KM, Goldstein SL, Hanna M, Joseph C, Mahan JD, Nada A, Nathan AT, Reidy K, Staples A, Wintermark P, Boohaker LJ, Griffin R, Askenazi DJ, Guillet R. The impact of fluid balance on outcomes in critically ill near-term/term neonates: a report from the AWAKEN study group. Pediatr Res 2019; 85:79-85. [PMID: 30237572 PMCID: PMC6941736 DOI: 10.1038/s41390-018-0183-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/17/2018] [Accepted: 07/23/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND In sick neonates admitted to the NICU, improper fluid balance can lead to fluid overload. We report the impact of fluid balance in the first postnatal week on outcomes in critically ill near-term/term neonates. METHODS This analysis includes infants ≥36 weeks gestational age from the Assessment of Worldwide Acute Kidney injury Epidemiology in Neonates (AWAKEN) study (N = 645). Fluid balance: percent weight change from birthweight. PRIMARY OUTCOME mechanical ventilation (MV) on postnatal day 7. RESULTS The median peak fluid balance was 1.0% (IQR: -0.5, 4.6) and occurred on postnatal day 3 (IQR: 1, 5). Nine percent required MV at postnatal day 7. Multivariable models showed the peak fluid balance (aOR 1.12, 95%CI 1.08-1.17), lowest fluid balance in 1st postnatal week (aOR 1.14, 95%CI 1.07-1.22), fluid balance on postnatal day 7 (aOR 1.12, 95%CI 1.07-1.17), and negative fluid balance at postnatal day 7 (aOR 0.3, 95%CI 0.16-0.67) were independently associated with MV on postnatal day 7. CONCLUSIONS We describe the impact of fluid balance in critically ill near-term/term neonates over the first postnatal week. Higher peak fluid balance during the first postnatal week and higher fluid balance on postnatal day 7 were independently associated with MV at postnatal day 7.
Collapse
Affiliation(s)
- David T. Selewski
- Division of Nephrology, Department of Pediatrics & Communicable Diseases, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | - Ayse Akcan-Arikan
- Sections of Pediatric Critical Care Medicine and Renal, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Elizabeth M. Bonachea
- Department of Pediatrics, The Ohio State University, Section of Neonatology, Nationwide Children’s Hospital, Columbus, OH
| | - Katja M. Gist
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO
| | - Stuart L. Goldstein
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital and Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Mina Hanna
- Department Pediatrics, University of Kentucky, Lexington, KY
| | - Catherine Joseph
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - John D. Mahan
- Nationwide Children’s Hospital, The Ohio State University, College of Medicine, Columbus, OH
| | - Arwa Nada
- Department of Pediatrics, Division of Nephrology, LeBonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Amy T. Nathan
- Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Kimberly Reidy
- Department of Pediatrics, Division of Nephrology, Children’s Hospital at Montefiore/ Albert Einstein College of Medicine, Bronx, NY
| | - Amy Staples
- University of New Mexico, Department of Pediatrics, Albuquerque, NM
| | - Pia Wintermark
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Louis J. Boohaker
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL
| | - Russell Griffin
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL
| | - David J. Askenazi
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL
| | - Ronnie Guillet
- Department of Pediatrics, Division of Neonatology, Golisano Children’s Hospital, University of Rochester, NY
| | | |
Collapse
|
38
|
Raina R, Sethi SK, Wadhwani N, Vemuganti M, Krishnappa V, Bansal SB. Fluid Overload in Critically Ill Children. Front Pediatr 2018; 6:306. [PMID: 30420946 PMCID: PMC6215821 DOI: 10.3389/fped.2018.00306] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/28/2018] [Indexed: 12/16/2022] Open
Abstract
Background: A common practice in the management of critically ill patients is fluid resuscitation. An excessive administration of fluids can lead to an imbalance in fluid homeostasis and cause fluid overload (FO). In pediatric critical care patients, FO can lead to a multitude of adverse effects and increased risk of morbidity. Objectives: To review the literature highlighting impact of FO on a multitude of outcomes in critically-ill children, causative vs. associative relationship of FO with critical illness and current pediatric fluid management guidelines. Data Sources: A literature search was conducted using PubMed/Medline and Embase databases from the earliest available date until June 2017. Data Extraction: Two authors independently reviewed the titles and abstracts of all articles which were assessed for inclusion. The manuscripts of studies deemed relevant to the objectives of this review were then retrieved and associated reference lists hand-searched. Data Synthesis: Articles were segregated into various categories namely pathophysiology and sequelae of fluid overload, assessment techniques, epidemiology and fluid management. Each author reviewed the selected articles in categories assigned to them. All authors participated in the final review process. Conclusions: Recent evidence has purported a relationship between mortality and FO, which can be validated by prospective RCTs (randomized controlled trials). The current literature demonstrates that "clinically significant" degree of FO could be below 10%. The lack of a standardized method to assess FB (fluid balance) and a universal definition of FO are issues that need to be addressed. To date, the impact of early goal directed therapy and utility of hemodynamic parameters in predicting fluid responsiveness remains underexplored in pediatric resuscitation.
Collapse
Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital and Cleveland Clinic Akron General, Akron, OH, United States
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, United States
| | - Sidharth Kumar Sethi
- Department of Nephrology, Kidney & Urology Institute, Medanta, The Medicity, Gurgaon, India
| | - Nikita Wadhwani
- Department of Nephrology, Kidney & Urology Institute, Medanta, The Medicity, Gurgaon, India
| | - Meghana Vemuganti
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Vinod Krishnappa
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, United States
- College of Graduate Studies, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Shyam B. Bansal
- Department of Nephrology, Kidney & Urology Institute, Medanta, The Medicity, Gurgaon, India
| |
Collapse
|
39
|
SooHoo MM, Patel SS, Jaggers J, Faubel S, Gist KM. Acute Kidney Injury Defined by Fluid Corrected Creatinine in Neonates After the Norwood Procedure. World J Pediatr Congenit Heart Surg 2018; 9:513-521. [DOI: 10.1177/2150135118775413] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background: Both the Norwood procedure and acute kidney injury (AKI) are associated with significant morbidity and mortality. The impact of AKI by measured and fluid corrected serum creatinine on outcomes after the Norwood procedure has not been previously studied. The purpose of this study was to (1) identify the incidence of AKI, (2) determine AKI risk factors, and (3) evaluate outcomes in patients with AKI using both measured and fluid corrected serum creatinine. Methods: Single-center retrospective chart review from 2009 to 2015 including neonates who underwent the Norwood procedure. Acute kidney injury was defined by the Kidney Disease Improving Global Outcomes staging criteria using both measured and fluid corrected serum creatinine. Multivariable logistic regression analysis was performed to determine the risk factors associated with AKI. Results: Ninety-five neonates underwent the Norwood procedure. Correcting for fluid overload increased the incidence of AKI from 40% to 44%, increased AKI severity in 15 patients, and improved the identification of adverse outcomes associated with AKI. Patients palliated with the modified Blalock-Taussig shunt (mBTS) had a 9.4 greater odds of fluid corrected AKI compared to those palliated with a right ventricle to pulmonary artery conduit (95% confidence interval [95% CI]: 1.68-52.26, P = .01). A higher vasoactive inotrope score (VIS) on postoperative day (POD) 0 was associated with fluid corrected AKI (odds ratio: 1.20, 95% CI: 1.06-1.35; P = .003). Conclusions: Acute kidney injury is common after the Norwood procedure. Correcting creatinine for fluid balance revealed new cases of AKI. Use of an mBTS and higher VIS on POD 0 were associated with increased risk of AKI.
Collapse
Affiliation(s)
- Megan McFerson SooHoo
- Department of Pediatrics, The Heart Institute, Children’s Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Sonali S. Patel
- Department of Pediatrics, The Heart Institute, Children’s Hospital Colorado, University of Colorado, Denver, CO, USA
| | - James Jaggers
- Section of Pediatric Cardiac Surgery, Department of Pediatric Surgery, Children’s Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Sarah Faubel
- Renal Division, Department of Medicine, University of Colorado, Denver, CO, USA
- Department of Pediatrics, The Kidney Center, Children’s Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Katja M. Gist
- Department of Pediatrics, The Heart Institute, Children’s Hospital Colorado, University of Colorado, Denver, CO, USA
| |
Collapse
|
40
|
Abstract
The implications and management of fluid overload in pediatric critical care remain areas of ongoing controversy. Consensus definitions and methods of quantitating fluid overload continue to evolve, paralleling our growing understanding of fluid dynamics in critically ill patients. Fluid overload has been associated with adverse outcomes in some patient populations; guidelines for fluid management therapies are sparse and have little supporting data. Conflicting data for efficacy of therapies such as diuretic medications and renal replacement therapy are likely reflective of an incomplete understanding of the dynamic relationship between critical illness and fluid overload. Although some guidance regarding diuresis, continuous renal replacement therapy, and fluid balance goals is elucidated in the following chapters, it is important to recognize that further research into these management strategies is required before standardized approaches to management can be established.
Collapse
Affiliation(s)
| | - Kevin M. Valentine
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN USA
| |
Collapse
|
41
|
Pan T, Li D, Li S, Yan J, Wang X. Early initiation of peritoneal dialysis improves postoperative recovery in children with right ventricular outflow tract obstructive lesions at high risk of fluid overload: a propensity score-matched analysis. Interact Cardiovasc Thorac Surg 2018. [PMID: 29534186 DOI: 10.1093/icvts/ivy048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tuo Pan
- Department of Pediatric Intensive Care Unit, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Dan Li
- Department of Pediatric Intensive Care Unit, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shoujun Li
- Department of Pediatric Cardiac Surgery, National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jun Yan
- Department of Pediatric Cardiac Surgery, National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xu Wang
- Department of Pediatric Intensive Care Unit, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| |
Collapse
|
42
|
Alobaidi R, Morgan C, Basu RK, Stenson E, Featherstone R, Majumdar SR, Bagshaw SM. Association Between Fluid Balance and Outcomes in Critically Ill Children: A Systematic Review and Meta-analysis. JAMA Pediatr 2018; 172:257-268. [PMID: 29356810 PMCID: PMC5885847 DOI: 10.1001/jamapediatrics.2017.4540] [Citation(s) in RCA: 223] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE After initial resuscitation, critically ill children may accumulate fluid and develop fluid overload. Accruing evidence suggests that fluid overload contributes to greater complexity of care and worse outcomes. OBJECTIVE To describe the methods to measure fluid balance, define fluid overload, and evaluate the association between fluid balance and outcomes in critically ill children. DATA SOURCES Systematic search of MEDLINE, EMBASE, Cochrane Library, trial registries, and selected gray literature from inception to March 2017. STUDY SELECTION Studies of children admitted to pediatric intensive care units that described fluid balance or fluid overload and reported outcomes of interest were included. No language restrictions were applied. DATA EXTRACTION AND SYNTHESIS All stages were conducted independently by 2 reviewers. Data extracted included study characteristics, population, fluid metrics, and outcomes. Risk of bias was assessed using the Newcastle-Ottawa Scale. Narrative description of fluid assessment methods and fluid overload definitions was done. When feasible, pooled analyses were performed using random-effects models. MAIN OUTCOMES AND MEASURES Mortality was the primary outcome. Secondary outcomes included treatment intensity, organ failure, and resource use. RESULTS A total of 44 studies (7507 children) were included in this systematic review and meta-analysis. Of those, 27 (61%) were retrospective cohort studies, 13 (30%) were prospective cohort studies, 3 (7%) were case-control studies, and 1 study (2%) was a secondary analysis of a randomized trial. The proportion of children with fluid overload varied by case mix and fluid overload definition (median, 33%; range, 10%-83%). Fluid overload, however defined, was associated with increased in-hospital mortality (17 studies [n = 2853]; odds ratio [OR], 4.34 [95% CI, 3.01-6.26]; I2 = 61%). Survivors had lower percentage fluid overload than nonsurvivors (22 studies [n = 2848]; mean difference, -5.62 [95% CI, -7.28 to -3.97]; I2 = 76%). After adjustment for illness severity, there was a 6% increase in odds of mortality for every 1% increase in percentage fluid overload (11 studies [n = 3200]; adjusted OR, 1.06 [95% CI, 1.03-1.10]; I2 = 66%). Fluid overload was associated with increased risk for prolonged mechanical ventilation (>48 hours) (3 studies [n = 631]; OR, 2.14 [95% CI, 1.25-3.66]; I2 = 0%) and acute kidney injury (7 studies [n = 1833]; OR, 2.36 [95% CI, 1.27-4.38]; I2 = 78%). CONCLUSIONS AND RELEVANCE Fluid overload is common and is associated with substantial morbidity and mortality in critically ill children. Additional research should now ideally focus on interventions aimed to mitigate the potential for harm associated with fluid overload.
Collapse
Affiliation(s)
- Rashid Alobaidi
- Division of Pediatric Critical Care, Department of Pediatrics, Stollery Children’s Hospital, Edmonton, Alberta, Canada
| | - Catherine Morgan
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Rajit K. Basu
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Erin Stenson
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Robin Featherstone
- Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, Alberta Research Center for Health Evidence (ARCHE), Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Sumit R. Majumdar
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| |
Collapse
|
43
|
De Cloedt L, Emeriaud G, Lefebvre É, Kleiber N, Robitaille N, Jarlot C, Lacroix J, Gauvin F. Transfusion-associated circulatory overload in a pediatric intensive care unit: different incidences with different diagnostic criteria. Transfusion 2018; 58:1037-1044. [PMID: 29388216 DOI: 10.1111/trf.14504] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/19/2017] [Accepted: 12/20/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND The incidence of transfusion-associated circulatory overload (TACO) is not well known in children, especially in pediatric intensive care unit (PICU) patients. STUDY DESIGN AND METHODS All consecutive patients admitted over 1 year to the PICU of CHU Sainte-Justine were included after they received their first red blood cell transfusion. TACO was diagnosed using the criteria of the International Society of Blood Transfusion, with two different ways of defining abnormal values: 1) using normal pediatric values published in the Nelson Textbook of Pediatrics and 2) by using the patient as its own control and comparing pre- and posttransfusion values with either 10 or 20% difference threshold. We monitored for TACO up to 24 hours posttransfusion. RESULTS A total of 136 patients were included. Using the "normal pediatric values" definition, we diagnosed 63, 88, and 104 patients with TACO at 6, 12, and 24 hours posttransfusion, respectively. Using the "10% threshold" definition we detected 4, 15, and 27 TACO cases in the same periods, respectively; using the "20% threshold" definition, the number of TACO cases was 2, 6, and 17, respectively. Chest radiograph was the most frequent missing item, especially at 6 and 12 hours posttransfusion. Overall, the incidence of TACO varied from 1.5% to 76% depending on the definition. CONCLUSION A more operational definition of TACO is needed in PICU patients. Using a threshold could be more optimal but more studies are needed to confirm the best threshold.
Collapse
Affiliation(s)
- Lise De Cloedt
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Guillaume Emeriaud
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Émilie Lefebvre
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Niina Kleiber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Nancy Robitaille
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Christine Jarlot
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - France Gauvin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| |
Collapse
|
44
|
Selewski DT, Goldstein SL. The role of fluid overload in the prediction of outcome in acute kidney injury. Pediatr Nephrol 2018; 33:13-24. [PMID: 27900473 DOI: 10.1007/s00467-016-3539-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 01/11/2023]
Abstract
Our understanding of the epidemiology and the impact of acute kidney injury (AKI) and fluid overload on outcomes has improved significantly over the past several decades. Fluid overload occurs commonly in critically ill children with and without associated AKI. Researchers in pediatric AKI have been at the forefront of describing the impact of fluid overload on outcomes in a variety of populations. A full understanding of this topic is important as fluid overload represents a potentially modifiable risk factor and a target for intervention. In this state-of-the-art review, we comprehensively describe the definition of fluid overload, the impact of fluid overload on kidney function, the impact of fluid overload on the diagnosis of AKI, the association of fluid overload with outcomes, the targeted therapy of fluid overload, and the impact of the timing of renal replacement therapy on outcomes.
Collapse
Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics & Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital and Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
45
|
|
46
|
Selewski DT, Askenazi DJ, Bridges BC, Cooper DS, Fleming GM, Paden ML, Verway M, Sahay R, King E, Zappitelli M. The Impact of Fluid Overload on Outcomes in Children Treated With Extracorporeal Membrane Oxygenation: A Multicenter Retrospective Cohort Study. Pediatr Crit Care Med 2017; 18:1126-1135. [PMID: 28937504 PMCID: PMC5716912 DOI: 10.1097/pcc.0000000000001349] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To characterize the epidemiology of fluid overload and its association with mortality and duration of extracorporeal membrane oxygenation in children treated with extracorporeal membrane oxygenation. DESIGN Retrospective cohort study. SETTING Six tertiary children's hospital ICUs. PATIENTS Seven hundred fifty-six children younger than 18 years old treated with extracorporeal membrane oxygenation for greater than or equal to 24 hours from January 1, 2007, to December 31, 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall survival to extracorporeal membrane oxygenation decannulation and hospital discharge was 74.9% (n = 566) and 57.7% (n = 436), respectively. Median fluid overload at extracorporeal membrane oxygenation initiation was 8.8% (interquartile range, 0.3-19.2), and it differed between hospital survivors and non survival, though not between extracorporeal membrane oxygenation survivors and non survivors. Median peak fluid overload on extracorporeal membrane oxygenation was 30.9% (interquartile range, 15.4-54.8). During extracorporeal membrane oxygenation, 84.8% had a peak fluid overload greater than or equal to 10%; 67.2% of patients had a peak fluid overload of greater than or equal to 20% and 29% of patients had a peak fluid overload of greater than or equal to 50%. The median peak fluid overload was lower in patients who survived on extracorporeal membrane oxygenation (27.2% vs 44.4%; p < 0.0001) and survived to hospital discharge (24.8% vs 43.3%; p < 0.0001). After adjusting for acute kidney injury, pH at extracorporeal membrane oxygenation initiation, nonrenal complications, extracorporeal membrane oxygenation mode, support type, center and patient age, the degree of fluid overload at extracorporeal membrane oxygenation initiation (p = 0.05), and the peak fluid overload on extracorporeal membrane oxygenation (p < 0.0001) predicted duration of extracorporeal membrane oxygenation in survivors. Multivariable analysis showed that peak fluid overload on extracorporeal membrane oxygenation (adjusted odds ratio, 1.09; 95% CI, 1.04-1.15) predicted mortality on extracorporeal membrane oxygenation; fluid overload at extracorporeal membrane oxygenation initiation (adjusted odds ratio, 1.13; 95% CI, 1.05-1.22) and peak fluid overload (adjusted odds ratio, 1.18; 95% CI, 1.12-1.24) both predicted hospital morality. CONCLUSIONS Fluid overload occurs commonly and is independently associated with adverse outcomes including increased mortality and increased duration of extracorporeal membrane oxygenation in a broad pediatric extracorporeal membrane oxygenation population. These results suggest that fluid overload is a potential target for intervention to improve outcomes in children on extracorporeal membrane oxygenation.
Collapse
Affiliation(s)
- David T Selewski
- Department of Pediatrics & Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - David S Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | | | - Mark Verway
- Department of Pediatrics, McGill University Health Centre, Montreal, QC, Canada
| | - Rashmi Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Eileen King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael Zappitelli
- Department of Pediatrics, McGill University Health Centre, Montreal, QC, Canada
| |
Collapse
|
47
|
Kim-Campbell N, Gretchen C, Callaway C, Felmet K, Kochanek PM, Maul T, Wearden P, Sharma M, Viegas M, Munoz R, Gladwin MT, Bayir H. Cell-Free Plasma Hemoglobin and Male Gender Are Risk Factors for Acute Kidney Injury in Low Risk Children Undergoing Cardiopulmonary Bypass. Crit Care Med 2017; 45:e1123-e1130. [PMID: 28863013 PMCID: PMC5657595 DOI: 10.1097/ccm.0000000000002703] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To determine the relationship between the production of cell-free plasma hemoglobin and acute kidney injury in infants and children undergoing cardiopulmonary bypass for cardiac surgery. DESIGN Prospective observational study. SETTING Twelve-bed cardiac ICU in a university-affiliated children's hospital. PATIENTS Children were prospectively enrolled during their preoperative outpatient appointment with the following criteria: greater than 1 month to less than 18 years old, procedures requiring cardiopulmonary bypass, no preexisting renal dysfunction. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma and urine were collected at baseline (in a subset), the beginning and end of cardiopulmonary bypass, and 2 hours and 24 hours after cardiopulmonary bypass in 60 subjects. Levels of plasma hemoglobin increased during cardiopulmonary bypass and were associated (p < 0.01) with cardiopulmonary bypass duration (R = 0.22), depletion of haptoglobin at end and 24 hours after cardiopulmonary bypass (R = 0.12 and 0.15, respectively), lactate dehydrogenase levels at end cardiopulmonary bypass (R = 0.27), and change in creatinine (R = 0.12). Forty-three percent of patients developed acute kidney injury. There was an association between plasma hemoglobin level and change in creatinine that varied by age (overall [R = 0.12; p < 0.01]; in age > 2 yr [R = 0.22; p < 0.01]; and in < 2 yr [R = 0.03; p = 0.42]). Change in plasma hemoglobin and male gender were found to be risk factors for acute kidney injury (odds ratio, 1.02 and 3.78, respectively; p < 0.05). CONCLUSIONS Generation of plasma hemoglobin during cardiopulmonary bypass and male gender are associated with subsequent renal dysfunction in low-risk pediatric patients, especially in those older than 2 years. Further studies are needed to determine whether specific subgroups of pediatric patients undergoing cardiopulmonary bypass would benefit from potential treatments for hemolysis and plasma hemoglobin-associated renal dysfunction.
Collapse
Affiliation(s)
- Nahmah Kim-Campbell
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Catherine Gretchen
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Clifton Callaway
- Department of Emergency Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Kathryn Felmet
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
| | - Timothy Maul
- Department of Cardiothoracic Surgery, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Peter Wearden
- Department of Cardiothoracic Surgery, UPMC and University of Pittsburgh, Pittsburgh, PA
- Nemours Cardiac Center –Florida, Orlando, FL
| | - Mahesh Sharma
- Department of Cardiothoracic Surgery, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Melita Viegas
- Department of Cardiothoracic Surgery, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Ricardo Munoz
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Mark T. Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA
- Division of Pulmonary, Allergy and Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
| | - Hülya Bayir
- Department of Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
48
|
Factors Associated With Pediatric Ventilator-Associated Conditions in Six U.S. Hospitals: A Nested Case-Control Study. Pediatr Crit Care Med 2017; 18:e536-e545. [PMID: 28914722 DOI: 10.1097/pcc.0000000000001328] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES A newly proposed surveillance definition for ventilator-associated conditions among neonatal and pediatric patients has been associated with increased morbidity and mortality among ventilated patients in cardiac ICU, neonatal ICU, and PICU. This study aimed to identify potential risk factors associated with pediatric ventilator-associated conditions. DESIGN Retrospective cohort. SETTING Six U.S. hospitals PATIENTS:: Children less than or equal to 18 years old ventilated for greater than or equal to 1 day. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified children with pediatric ventilator-associated conditions and matched them to children without ventilator-associated conditions. Medical records were reviewed for comorbidities and acute care factors. We used bivariate and multivariate conditional logistic regression models to identify factors associated with ventilator-associated conditions. We studied 192 pairs of ventilator-associated conditions cases and matched controls (113 in the PICU and cardiac ICU combined; 79 in the neonatal ICU). In the PICU/cardiac ICU, potential risk factors for ventilator-associated conditions included neuromuscular blockade (odds ratio, 2.29; 95% CI, 1.08-4.87), positive fluid balance (highest quartile compared with the lowest, odds ratio, 7.76; 95% CI, 2.10-28.6), and blood product use (odds ratio, 1.52; 95% CI, 0.70-3.28). Weaning from sedation (i.e., decreasing sedation) or interruption of sedation may be protective (odds ratio, 0.44; 95% CI, 0.18-1.11). In the neonatal ICU, potential risk factors included blood product use (odds ratio, 2.99; 95% CI, 1.02-8.78), neuromuscular blockade use (odds ratio, 3.96; 95% CI, 0.93-16.9), and recent surgical procedures (odds ratio, 2.19; 95% CI, 0.77-6.28). Weaning or interrupting sedation was protective (odds ratio, 0.07; 95% CI, 0.01-0.79). CONCLUSIONS In mechanically ventilated neonates and children, we identified several possible risk factors associated with ventilator-associated conditions. Next steps include studying propensity-matched cohorts and prospectively testing whether changes in sedation management, transfusion thresholds, and fluid management can decrease pediatric ventilator-associated conditions rates and improve patient outcomes.
Collapse
|
49
|
Zappitelli M, Ambalavanan N, Askenazi DJ, Moxey-Mims MM, Kimmel PL, Star RA, Abitbol CL, Brophy PD, Hidalgo G, Hanna M, Morgan CM, Raju TN, Ray P, Reyes-Bou Z, Roushdi A, Goldstein SL. Developing a neonatal acute kidney injury research definition: a report from the NIDDK neonatal AKI workshop. Pediatr Res 2017; 82:569-573. [PMID: 28604760 PMCID: PMC9673450 DOI: 10.1038/pr.2017.136] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 02/26/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Michael Zappitelli
- Division of Nephrology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Namasivayam Ambalavanan
- Departments of Pediatrics, Molecular and Cellular Pathology, and Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama
| | - David J. Askenazi
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marva M. Moxey-Mims
- Division of Kidney Urologic and Hematologic Diseases, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul L. Kimmel
- Division of Kidney Urologic and Hematologic Diseases, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Robert A. Star
- Division of Kidney Urologic and Hematologic Diseases, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Carolyn L. Abitbol
- Department of Pediatric Nephrology, Holtz Children’s Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Patrick D. Brophy
- Department of Pediatrics, University of Iowa Children’s Hospital, Pediatric Nephrology, Dialysis and Transplantation, University of Iowa Healthcare, University of Iowa Health System, Iowa City, Iowa
| | - Guillermo Hidalgo
- Department of Pediatrics, East Carolina University, East Carolina University School of Medicine, Greenville, North Carolina
| | - Mina Hanna
- Department of Pediatrics, University of Kentucky, Lexington, Kentucky
| | | | - Tonse N.K. Raju
- National Institute of Child Health and Human Development, National Institutes of Health, Pregnancy and Perinatology Branch, Bethesda, Maryland
| | - Patricio Ray
- Department of Nephrology, Main Hospital, Children’s National Health System, Washington, DC
| | - Zayhara Reyes-Bou
- Department of Pediatrics, University of Puerto Rico, Medical Sciences Campus, Neonatal Perinatal Medicine Section, San Juan, Puerto Rico
| | - Amani Roushdi
- Department of Pediatrics, Mackenzie Health Hospital, Richmond Hill, Ontario, Canada
| | - Stuart L. Goldstein
- Department of Pediatrics, Cincinnati Children’s Hospital and Medical Center, Cincinnati, USA
| |
Collapse
|
50
|
Glassford NJ, Gelbart B, Bellomo R. Coming full circle: thirty years of paediatric fluid resuscitation. Anaesth Intensive Care 2017; 45:308-319. [PMID: 28486889 DOI: 10.1177/0310057x1704500306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization-recommended approach to FBT in resource-poor settings. Trials in the intensive care unit (ICU) and emergency department settings post-FEAST have continued to explore liberal FBT strategies as the norm, despite a strong signal associating fluid accumulation with pulmonary pathology in the paediatric population. Modern clinical trial methodology may ameliorate the traditional challenges of performing randomised interventional trials in critically ill children. Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted.
Collapse
Affiliation(s)
- N J Glassford
- Registrar and Clinical Research Fellow, Department of Intensive Care, Austin Hospital, PhD Candidate, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Melbourne, Victoria
| | - B Gelbart
- Staff Specialist, Department of Intensive Care, Royal Children's Hospital, Honorary Fellow, Murdoch Childrens Research Institute, Melbourne, Victoria
| | - R Bellomo
- Director of Intensive Care Research, Department of Intensive Care, Austin Hospital, Co-director and Honorary Professor, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Professor of Intensive Care, School of Medicine, The University of Melbourne, Melbourne, Victoria
| |
Collapse
|