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

1. Fluid Overload Prior To Continuous Hemofiltration and Survival in Critically Ill Children J Foland, J Fortenberry, B Warshaw, R Pettignano, R Merritt, M Heard, K Rogers, C Reid, A Tanner, K Easley Children’s Healthcare of Atlanta at Egleston Emory University School of Medicine Atlanta, Georgia Accepted for publication in Critical Care Medicine, August 2004

2. Background • Renal replacement therapy is used for primary and secondary renal failure • Continuous venovenous hemofiltration (CVVH) is the preferred modality in our ICUs

3. Background • Goldstein et al. (Pediatrics, 2000) • 21 ICU children on CVVH(D) •  Survival associated with  ICU fluid overload prior to CVVH • GFR had no association with survival • Lane et al. (Bone Marrow Transplant, 1994) • 30 pediatric BMT recipients • Survival associated with < 10% weight gain from baseline

4. Hypotheses • CVVH survivors have less fluid overload than non-survivors prior to CVVH • Increasing fluid overload prior to CVVH is associated with decreasing survival

5. Methods • Database of all Egleston patients receiving CVVH from Nov ‘97 to Dec ‘02 (excluding ECMO) • Review of • Demographics • Diagnoses • Clinical & laboratory findings • Indication for CVVH

6. Definitions Total Input - Total Output (L)* Ideal Body Weight (kg) • Total fluid overload (%) • For 7 days prior to CVVH • GFR: Schwartz Formula X 100

7. Definitions Total Input - Total Output (L)* Ideal Body Weight (kg) • ICU fluid overload (%) • From ICU admission to CVVH initiation X 100

8. Results • 113 patients received CVVH • Median • Age: 9.6 years (2.5, 14.3) • Number of days on CVVH: 4 (2.0, 10.0) • PRISM III: 13 (9.0, 17.0) • %Fluid Overload: 10.9 (2.8, 22.1) • Creatinine: 3.1 (1.7, 4.9) mg/dL • 71% intubated • 70% vasoactive infusions

9. Patient Diagnoses

10. CVVH Indications

11. Patient Survival *  *p=0.0002 vs. Primary Renal Failure

12. Severity of IllnessSurvival ‡ † * PRISM III Intubated Vasoactive Infusions * p<0.001 † p<0.001 ‡ p=0.009

13. Days in Hospital Prior to CVVHAll Patients Days * Survival *p<0.001

14. Days in ICU prior to CVVHAll Patients Days * Survival *p=0.03

15. Median % Fluid OverloadAll Patients Total % Fluid Overload * Survival *p=0.02

16. Median % Fluid OverloadMODS &  3 Organ Involvement Total % Fluid Overload * Survival *p=0.01

17. Patient Outcomes • No survival difference seen with... • Duration of CVVH • Ultrafiltration rates • Membrane Type • Estimated GFR • Age adjusted serum creatinine • P/F ratios

18. Multivariable AnalysisFactors Associated with Mortality

19. Multivariable AnalysisFactors Associated with Mortality

20. Multivariable AnalysisFactors Associated with Mortality

21. Conclusions • CVVH survivors had • Less fluid overload prior to CVVH • Less cardiovascular support • Less respiratory support

22. Conclusion: Fluid Overload Our review suggests that increasing fluid overload is associated with decreased survival in pediatric patients receiving CVVH, particularly those with  3 organ MODS

23. Speculation Total percent fluid overload prior to CVVH may be a better predictor of survival than other indicators of severity of illness in select patients

24. Speculation Earlier use of CVVH, prior to excessive fluid overload, in critically ill children may be associated with increased survival

25. Questions?