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Early Cumulative Fluid Balance and Outcomes in Pediatric Allogeneic Hematopoietic Cell Transplant Recipients With
Colin J Sallee1, Lincoln S Smith1, Courtney M Rowan2
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, United States.
Insights
Positive early fluid overload in pediatric hematopoietic cell transplant patients with respiratory failure is linked to worse outcomes. Higher cumulative fluid balance (CFB) increases mortality risk and decreases extubation rates.
Area of Science:
- Pediatric critical care medicine
- Hematopoietic stem cell transplantation (HCT)
- Acute respiratory failure management
Background:
- Critically ill pediatric HCT recipients with acute respiratory failure face high mortality.
- Fluid balance is a key management parameter in critical care.
- The impact of early fluid accumulation on outcomes in this specific population is not well understood.
Purpose of the Study:
- To investigate the association between early cumulative fluid balance (CFB) and patient outcomes.
- To determine if renal replacement therapy (RRT) modifies this association.
- To analyze CFB's impact on mortality and extubation rates in pediatric HCT patients with respiratory failure.
Main Methods:
- Secondary analysis of a multicenter retrospective cohort (2009-2014).
- Included pediatric patients (1mo-21yrs) post-allogeneic HCT with acute respiratory failure on invasive mechanical ventilation (IMV).
- Calculated day 3 CFB and assessed its association with PICU mortality and 28/60-day extubation rates using regression models.
Main Results:
- Positive day 3 CFB was associated with increased PICU mortality (aOR 3.42) and lower extubation rates at 28 and 60 days (aSHR 0.30).
- Each 1% increase in day 3 CFB correlated with a 3% higher mortality risk and a 3% lower extubation rate.
- The association between positive day 3 CFB and mortality was significantly stronger in patients not receiving RRT.
Conclusions:
- Early positive and increasing cumulative fluid balance is independently linked to adverse outcomes in pediatric HCT patients with acute respiratory failure.
- Fluid management strategies may be crucial for improving outcomes in this vulnerable population.
- The protective effect of RRT against fluid overload complications warrants further investigation.
Objectives:
To evaluate the associations between early cumulative fluid balance (CFB) and outcomes among critically ill pediatric allogeneic hematopoietic cell transplant (HCT) recipients with acute respiratory failure, and determine if these associations vary by treatment with renal replacement therapy (RRT).
Methods:
We performed a secondary analysis of a multicenter retrospective cohort of patients (1mo - 21yrs) post-allogeneic HCT with acute respiratory failure treated with invasive mechanical ventilation (IMV) from 2009 to 2014. Fluid intake and output were measured daily for the first week of IMV (day 0 = day of intubation). The exposure, day 3 CFB (CFB from day 0 through day 3 of IMV), was calculated using the equation [Fluid in - Fluid out] (liters)/[PICU admission weight](kg)*100. We measured the association between day 3 CFB and PICU mortality with logistic regression, and the rate of extubation at 28 and 60 days with competing risk regression (PICU mortality = competing risk).
Results:
198 patients were included in the study. Mean % CFB for the cohort was positive on day 0 of IMV, and increased further on days 1-7 of IMV. For each 1% increase in day 3 CFB, the odds of PICU mortality were 3% higher (adjusted odds ratio (aOR) 1.03, 95% CI 1.00-1.07), and the rate of extubation was 3% lower at 28 days (adjusted subdistribution hazard ratio (aSHR) 0.97, 95% CI 0.95-0.98) and 3% lower at 60 days (aSHR 0.97, 95% CI 0.95-0.98). When day 3 CFB was dichotomized, 161 (81%) had positive and 37 (19%) had negative day 3 CFB. Positive day 3 CFB was associated with higher PICU mortality (aOR 3.42, 95% CI 1.48-7.87) and a lower rate of extubation at 28 days (aSHR 0.30, 95% CI 0.18-0.48) and 60 days (aSHR 0.30, 95% 0.19-0.48). On stratified analysis, the association between positive day 3 CFB and PICU mortality was significantly stronger in those not treated with RRT (no RRT: aOR 9.11, 95% CI 2.29-36.22; RRT: aOR 1.40, 95% CI 0.42-4.74).
Conclusions:
Among critically ill pediatric allogeneic HCT recipients with acute respiratory failure, positive and increasing early CFB were independently associated with adverse outcomes.
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