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Published on: January 17, 2025
Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous
Stephen M Gorga1, Rashmi D Sahay2, David J Askenazi3
1Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA.
Insights
Fluid overload (FO) is common when initiating continuous renal replacement therapy (CRRT) in children on extracorporeal membrane oxygenation (ECMO). Higher FO at CRRT initiation and discontinuation is linked to increased mortality and longer ECMO duration.
Area of Science:
- Pediatric critical care medicine
- Nephrology
- Cardiovascular surgery
Background:
- Continuous renal replacement therapy (CRRT) is frequently used in critically ill children supported by extracorporeal membrane oxygenation (ECMO).
- Fluid overload (FO) is a common complication in these patients, potentially impacting outcomes.
Purpose of the Study:
- To characterize CRRT utilization in pediatric ECMO patients.
- To determine the association of FO at CRRT initiation and fluid removal during CRRT with mortality.
Main Methods:
- Retrospective chart review of pediatric patients (<18 years) treated with concurrent ECMO and CRRT.
- Analysis of FO at CRRT initiation and discontinuation in relation to survival and ECMO duration.
Main Results:
- Of 357 patients analyzed, 47.2% received CRRT. Survival to ECMO decannulation was 66.4%, and to hospital discharge was 44.3%.
- Median FO at CRRT initiation (20.1%) and discontinuation was significantly lower in survivors.
- FO at CRRT initiation and discontinuation were independently associated with increased hospital mortality and longer ECMO duration.
Conclusions:
- Severe FO is prevalent at CRRT initiation in pediatric ECMO patients.
- The degree of FO is independently associated with adverse outcomes, including mortality.
- Early intervention to manage FO may be a critical therapeutic target in this population.
Objective:
The aim of this study was to characterize continuous renal replacement therapy (CRRT) utilization on extracorporeal membrane oxygenation (ECMO) and to determine the association of both fluid overload (FO) at CRRT initiation and fluid removal during CRRT with mortality in a large multicenter cohort.
Methods:
Retrospective chart review of all children < 18 years of age concurrently treated with ECMO and CRRT from January 1, 2007, to December 31, 2011, at six tertiary care children's hospital. Children treated with hemodialysis or peritoneal dialysis were excluded from the FO analysis.
Measurements And Main Results:
A total of 756 of the 1009 children supported with ECMO during the study period had complete FO data. Of these, 357 (47.2%) received either CRRT or were treated with an in-line filter and thus entered into the final analysis. Survival to ECMO decannulation was 66.4% and survival to hospital discharge was 44.3%. CRRT initiation occurred at median of 1 day (IQR 0, 2) after ECMO initiation. Median FO at CRRT initiation was 20.1% (IQR 5, 40) and was significantly lower in ECMO survivors vs. non-survivors (15.3% vs. 30.5% p = 0.005) and in hospital survivors vs. non-survivors (13.5% vs. 25.9%, p = 0.004). Median FO at CRRT discontinuation was significantly lower in ECMO survivors (23% vs. 37.6% p = 0.002) and hospital survivors vs. non-survivors (22.6% vs. 36.1%, p = 0.002). In ECMO survivors, after adjusting for pH at CRRT initiation, non-renal complications, ECMO mode, support type, center, patient age and AKI, FO at CRRT initiation (p = 0.01), and FO at CRRT discontinuation (p = 0.0002) were independently associated with duration of ECMO. In a similar multivariable analysis, FO at CRRT initiation (adjusted adds ratio [aOR] 1.09, 95% CI 1.00-1.18, p = 0.045) and at CRRT discontinuation (aOR 1.11, 95% CI 1.03-1.19, p = 0.01) were independently associated with hospital mortality.
Conclusions:
In a multicenter pediatric ECMO cohort, this study demonstrates that severe FO was very common at CRRT initiation. We found an independent association between the degree of FO at CRRT initiation with adverse outcomes including mortality and increased duration of ECMO support. The results suggest that intervening prior to the development of significant FO may be a clinical therapeutic target and warrants further evaluation.
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