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J Foland, J Fortenberry, B Warshaw,

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

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

8 Results 113 patients received CVVH Median 71% intubated
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= vs. Primary Renal Failure

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

13 Days in Hospital Prior to CVVH All Patients
* Survival *p<0.001

14 Days in ICU prior to CVVH All Patients
* Survival *p=0.03

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

16 Median % Fluid Overload MODS &  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 Analysis Factors Associated with Mortality

19 Multivariable Analysis Factors Associated with Mortality

20 Multivariable Analysis Factors 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?


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