Related Experiment Video
Updated: May 20, 2026
Bedside Ultrasound for Guiding Fluid Removal in Patients with Pulmonary Edema: The Reverse-FALLS Protocol
Published on: July 28, 2018
Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous
David T Selewski1, Timothy T Cornell, Neal B Blatt
1Division of Nephrology, Department of Pediatrics & Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA. dselewsk@med.umich.edu
Insights
Fluid overload at continuous renal replacement therapy (CRRT) initiation is linked to higher mortality in pediatric extracorporeal membrane oxygenation (ECMO) patients. Early intervention before significant fluid overload develops may improve survival rates.
Area of Science:
- Pediatric critical care medicine
- Nephrology
- Extracorporeal life support
Background:
- Fluid overload at the initiation of continuous renal replacement therapy (CRRT) is a known risk factor for mortality in pediatric intensive care units.
- Pediatric patients on extracorporeal membrane oxygenation (ECMO) are particularly vulnerable to fluid imbalances.
- Understanding the relationship between fluid overload, CRRT, and ECMO is crucial for improving patient outcomes.
Purpose of the Study:
- To investigate the association between fluid overload at CRRT initiation and mortality in pediatric patients undergoing ECMO.
- To analyze the impact of fluid removal during CRRT and the kinetics of fluid removal on survival.
- To identify key predictors of mortality in this high-risk population.
Main Methods:
- Retrospective chart review of pediatric patients requiring CRRT while on ECMO.
- Data collected from a tertiary children's hospital between July 2006 and September 2010.
- Analysis of fluid overload at CRRT initiation and discontinuation, and its correlation with survival.
Main Results:
- Overall intensive care unit survival was 34% for the 53 patients studied.
- Lower median fluid overload at CRRT initiation (24.5% vs. 38%) and discontinuation (7.1% vs. 17.5%) was observed in survivors compared to nonsurvivors.
- Fluid overload at CRRT initiation was the most consistent predictor of survival, even after adjusting for other factors.
Conclusions:
- Fluid overload at CRRT initiation is significantly associated with mortality in pediatric ECMO patients.
- While fluid overload at CRRT discontinuation is also linked to mortality, it appears to be a consequence of initial overload.
- Intervention before significant fluid overload develops, potentially through earlier CRRT initiation, may be more effective than aggressive fluid removal post-overload.
Objective:
In pediatric patients, fluid overload at continuous renal replacement therapy initiation is associated with increased mortality. The aim of this study was to characterize the association between fluid overload at continuous renal replacement therapy initiation, fluid removal during continuous renal replacement therapy, the kinetics of fluid removal and mortality in a large pediatric population receiving continuous renal replacement therapy while on extracorporeal membrane oxygenation.
Design:
Retrospective chart review.
Setting:
Tertiary children's hospital.
Patients:
Extracorporeal membrane oxygenation patients requiring continuous renal replacement therapy from July 2006 to September 2010.
Interventions:
None.
Measurements And Main Results:
Overall intensive care unit survival was 34% for 53 patients that were initiated on continuous renal replacement therapy while on extracorporeal membrane oxygenation during the study period. Median fluid overload at continuous renal replacement therapy initiation was significantly lower in survivors compared to nonsurvivors (24.5% vs. 38%, p = .006). Median fluid overload at continuous renal replacement therapy discontinuation was significantly lower in survivors compared to nonsurvivors (7.1% vs. 17.5%, p = .035). After adjusting for percent fluid overload at continuous renal replacement therapy initiation, age, and severity of illness, the change in fluid overload at continuous renal replacement therapy discontinuation was not significantly associated with mortality (p = .212). Models investigating the rates of fluid removal in different periods, age, severity of illness, and fluid overload at continuous renal replacement therapy initiation found that fluid overload at continuous renal replacement therapy initiation was the most consistent predictor of survival.
Conclusions:
Our data demonstrate an association between fluid overload at continuous renal replacement therapy initiation and mortality in pediatric patients receiving extracorporeal membrane oxygenation. The degree of fluid overload at continuous renal replacement therapy discontinuation is also associated with mortality, but appears to reflect the effect of fluid overload at initiation. Furthermore, correction of fluid overload to ≤ 10% was not associated with improved survival. These results suggest that intervening prior to the development of significant fluid overload may be more clinically effective than attempting fluid removal after significant fluid overload has developed. Our findings suggest a role for earlier initiation of continuous renal replacement therapy in this population, and warrant further clinical studies.
Related Concept Videos
01:26Extracorporeal Removal of Drugs: Continuous Renal Replacement Therapy
01:30Continuous Renal Replacement Therapy
01:20Acute Kidney Injury V: Interprofessional Care
01:30Extracorporeal Removal of Drugs: Peritoneal Dialysis and Hemodialysis
01:25Extracorporeal Removal of Drugs: Hemoperfusion and Hemofiltration
01:25Hemodialysis III: Nursing Management