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Fluid Overload Prior To Continuous Hemofiltration and Survival in Critically Ill Children
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Transcript of Fluid Overload Prior To Continuous Hemofiltration and Survival in Critically Ill Children
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Fluid Overload Prior To Continuous Hemofiltration and Survival in Critically Ill ChildrenJ Foland, J Fortenberry, B Warshaw, R Pettignano, R Merritt, M Heard, K Rogers, C Reid, A Tanner, K Easley
Children’s Healthcare of Atlanta at EglestonEmory University School of MedicineAtlanta, Georgia
Accepted for publication in Critical Care Medicine, August 2004
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Backgroundo Renal replacement therapy is used for
primary and secondary renal failure
o Continuous venovenous hemofiltration
(CVVH) is the preferred modality in
our ICUs
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Backgroundo Goldstein et al. (Pediatrics, 2000)
o 21 ICU children on CVVH(D) Survival associated with ICU fluid
overload prior to CVVHo GFR had no association with survival
o Lane et al. (Bone Marrow Transplant, 1994)o 30 pediatric BMT recipientso Survival associated with < 10% weight gain
from baseline
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Hypotheseso CVVH survivors have less fluid
overload than non-survivors prior to
CVVH
o Increasing fluid overload prior to CVVH
is associated with decreasing survival
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Methodso Database of all Egleston patients
receiving CVVH from Nov ‘97 to Dec ‘02 (excluding ECMO)
o Review of o Demographicso Diagnoseso Clinical & laboratory findingso Indication for CVVH
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Total Input - Total
Output (L)*Ideal Body Weight (kg)
Definitionso Total fluid overload (%)
* For 7 days prior to CVVH
o GFR: Schwartz Formula
X 100
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Definitionso ICU fluid overload (%)
* From ICU admission to CVVH initiation
X 100Total Input - Total
Output (L)*Ideal Body Weight (kg)
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Resultso 113 patients received CVVHo Median
o Age: 9.6 years (2.5, 14.3)o Number of days on CVVH: 4 (2.0,
10.0)o PRISM III: 13 (9.0, 17.0)o %Fluid Overload: 10.9 (2.8, 22.1)o Creatinine: 3.1 (1.7, 4.9) mg/dL
o 71% intubated o 70% vasoactive infusions
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Patient Diagnoses
25%
75%
PrimaryRenalFailure
SecondaryRenalFailure
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CVVH Indications
37%
30%
25%
6% 2% Acute Fluid Overload
Acute Renal Failure
Electrolyte Imbalance
Acute on Chronic RenalFailureHyperammonemia
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Patient Survival
61%
90%
51%57%
52%
0%
25%
50%
75%
100%
All PrimaryRenal
Failure
SecondaryRenal
Failure
MODS 3 OrganMODS
*p=0.0002 vs. Primary Renal Failure
*
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Severity of IllnessSurvival
* p<0.001
*
15.5
12
0
5
10
15
20
Died Lived
91%
58%
0%
25%
50%
75%
100%
Died Lived
84%
61%
0%
25%
50%
75%
100%
Died Lived
PRISM III Intubated Vasoactive
Infusions†
p<0.001‡
p=0.009
† ‡
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Day
s
Survival *p<0.001
*
15
3
0
5
10
15
20
Died Lived
Days in Hospital Prior to CVVH
All Patients
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Days in ICU prior to CVVHAll PatientsD
ays
Survival *p=0.03
*
3
1
0
1
2
3
4
Died Lived
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Tota
l % F
luid
O
verl
oad
Survival *p=0.02
*
15.1%
7.8%
0%
5%
10%
15%
20%
Died Lived
Median % Fluid OverloadAll Patients
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Tota
l % F
luid
O
verl
oad
Survival *p=0.01
*
15.5%
9.2%
0%
5%
10%
15%
20%
Died Lived
Median % Fluid OverloadMODS & 3 Organ
Involvement
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Patient Outcomeso No survival difference seen with...
o Duration of CVVH
o Ultrafiltration rates
o Membrane Type
o Estimated GFR
o Age adjusted serum creatinine
o P/F ratios
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Multivariable AnalysisFactors Associated with Mortality
All patients, n=94
Effect Odds Ratio 95% CI p
PRISM III (per 10) 1.24 1.02, 1.50 0.03
% FO (per 10%) 1.37 0.97, 1.94 0.07
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Multivariable AnalysisFactors Associated with Mortality
MODS patients, n=88
Effect Odds Ratio 95% CI p
PRISM III (per 10) 1.21 0.99, 1.47 0.06
% FO (per 10%) 1.30 0.92, 1.84 .013
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Multivariable AnalysisFactors Associated with Mortality
3 Organ MODS, n=70
Effect Odds Ratio 95% CI p
PRISM III (per 10%) 1.10 0.88, 1.39 0.4
% FO (per 10%) 1.78 1.13, 2.82 0.01
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Conclusions
o CVVH survivors had
o Less fluid overload prior to CVVH
o Less cardiovascular support
o Less respiratory support
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Conclusion: Fluid OverloadOur review suggests that increasing increasing
fluid overloadfluid overload is associated with
decreased survivaldecreased survival in pediatric
patients receiving CVVH, particularly
those with 3 organ MODS
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Speculation
Total percent fluid overloadpercent fluid overload prior to
CVVH may be a better predictor of
survival than other indicators of
severity of illness in select patients
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Speculation
Earlier use of CVVH, prior to excessive prior to excessive
fluid overloadfluid overload, in critically ill children
may be associated with increased
survival
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Questions?