Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy

Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
Intensive Care Medicine (Impact Factor: 7.21). 04/2011; 37(7):1166-73. DOI: 10.1007/s00134-011-2231-3
Source: PubMed

ABSTRACT In pediatric intensive care unit (PICU) patients, fluid overload (FO) at initiation of continuous renal replacement therapy (CRRT) has been reported to be an independent risk factor for mortality. Previous studies have calculated FO based on daily fluid balance during ICU admission, which is labor intensive and error prone. We hypothesized that a weight-based definition of FO at CRRT initiation would correlate with the fluid balance method and prove predictive of outcome.
This is a retrospective single-center review of PICU patients requiring CRRT from July 2006 through February 2010 (n = 113). We compared the degree of FO at CRRT initiation using the standard fluid balance method versus methods based on patient weight changes assessed by both univariate and multivariate analyses.
The degree of fluid overload at CRRT initiation was significantly greater in nonsurvivors, irrespective of which method was used. The univariate odds ratio for PICU mortality per 1% increase in FO was 1.056 [95% confidence interval (CI) 1.025, 1.087] by the fluid balance method, 1.044 (95% CI 1.019, 1.069) by the weight-based method using PICU admission weight, and 1.045 (95% CI 1.022, 1.07) by the weight-based method using hospital admission weight. On multivariate analyses, all three methods approached significance in predicting PICU survival.
Our findings suggest that weight-based definitions of FO are useful in defining FO at CRRT initiation and are associated with increased mortality in a broad PICU patient population. This study provides evidence for a more practical weight-based definition of FO that can be used at the bedside.

Download full-text


Available from: David T Selewski, Sep 01, 2015
  • Source
    • "Fluid overload has repeatedly been shown to be associated with mortality in critically ill children, and there are 7 pediatric studies that demonstrate the initiation of continuous renal replacement therapy (CRRT) before the accrual of greater than 10 to 20% fluid overload is associated with greater survival [3] [4] [5] [6] [7] [8] [9]. In each of these studies, percent fluid overload was defined by the formula described in the 2001 article by Goldstein et al., ([Fluid in − fluid out]/PICU admission weight) * 100 [3]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: We present three cases of pediatric patients with thrombocytopenia-associated multiple organ failure and the evidence for providing extracorporeal organ support. All three patients had severe cardiac dysfunction, respiratory failure, and acute kidney injury treated with venoarterial extracorporeal membrane oxygenation, continuous renal replacement therapy, and plasma exchange. Despite the presence of multiple organ failure and high risk of mortality, all three patients survived with minimal long-term sequelae.
    Journal of Pediatric Surgery 05/2013; 48(5):1114-1117. DOI:10.1016/j.jpedsurg.2013.02.061 · 1.31 Impact Factor
  • Source
    • "An inverse relationship between fluid accumulation and survival has been reported in several other conditions, such as in the perioperative period [21-23], acute pulmonary edema [8,24], pulmonary injury [25], sepsis [18,23,26] and acute kidney injury (AKI) [27], chronic renal failure [28,29] and decompensated heart failure [30]. When we studied the impact of all the adjusted variables on combined events, we found that the changes in serum creatinine (≥0.3 mg/dL) and fluid accumulation (≥10%) were the variables most significantly associated with mortality (Table 2). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Fluid overload is a clinical problem frequently related to cardiac and renal dysfunction. The aim of this study was to evaluate fluid overload and changes in serum creatinine as predictors of cardiovascular mortality and morbidity after cardiac surgery. Methods Patients submitted to heart surgery were prospectively enrolled in this study from September 2010 through August 2011. Clinical and laboratory data were collected from each patient at preoperative and trans-operative moments and fluid overload and creatinine levels were recorded daily after cardiac surgery during their ICU stay. Fluid overload was calculated according to the following formula: (Sum of daily fluid received (L) - total amount of fluid eliminated (L)/preoperative weight (kg) × 100). Preoperative demographic and risk indicators, intra-operative parameters and postoperative information were obtained from medical records. Patients were monitored from surgery until death or discharge from the ICU. We also evaluated the survival status at discharge from the ICU and the length of ICU stay (days) of each patient. Results A total of 502 patients were enrolled in this study. Both fluid overload and changes in serum creatinine correlated with mortality (odds ratio (OR) 1.59; confidence interval (CI): 95% 1.18 to 2.14, P = 0.002 and OR 2.91; CI: 95% 1.92 to 4.40, P <0.001, respectively). Fluid overload played a more important role in the length of intensive care stay than changes in serum creatinine. Fluid overload (%): b coefficient = 0.17; beta coefficient = 0.55, P <0.001); change in creatinine (mg/dL): b coefficient = 0.01; beta coefficient = 0.11, P = 0.003). Conclusions Although both fluid overload and changes in serum creatinine are prognostic markers after cardiac surgery, it seems that progressive fluid overload may be an earlier and more sensitive marker of renal dysfunction affecting heart function and, as such, it would allow earlier intervention and more effective control in post cardiac surgery patients.
    Critical care (London, England) 05/2012; 16(3):R99. DOI:10.1186/cc11368
  • [Show abstract] [Hide abstract]
    ABSTRACT: In critically ill pediatric patients, fluid overload (FO) >10% has been identified as a threshold for possible interventions, including initiation of continuous renal replacement therapy (CRRT). However, multiple definitions have been reported, and there remains no consensus method for FO calculation. The goal of this study was to compare different methods of FO determination and to assess their relative value in predicting outcomes. This is a retrospective single-center review of 21 pediatric stem cell transplant patients (PSCT) that required CRRT from 2004 to 2009. We compared eight definitions (4 weight-based and 4 fluid-balance based) that varied by baseline weights. Outcome measures were pediatric intensive care unit (PICU) mortality and pediatric logistic organ dysfunction (PELOD) scores. The number of patients identified as having >10% FO varied significantly according to the definition used, from 14 to 48% (p = 0.002). Significant intra-subject variability was observed; the median difference between individual minimum and maximum %FO scores was 11.4% (IQR 6.8, 17.1%). %FO was not significantly associated with PICU mortality, but five of eight FO definitions were predictive of higher subsequent PELOD scores. Our study is one of the first to compare different FO definitions and the impact on predicting outcomes. Our findings suggest that depending on the FO definition used, there is significant variability in the calculated %FO in PSCT patients, and this has important implications for clinical decision-making. Further studies are necessary to determine an optimal FO definition that is clinically relevant and predictive of important outcomes.
    Intensive Care Medicine 02/2012; 38(4):663-9. DOI:10.1007/s00134-012-2503-6 · 7.21 Impact Factor
Show more