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Effect of a standardized fluid management algorithm on acute kidney injury and mortality in pediatric patients on
Megan M SooHoo1, Ananya Shah2, Anthony Mayen3
1Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, 13123 E 16th Avenue, CO, B100, Aurora, USA. Megan.SooHoo@childrenscolorado.org.
Insights
A fluid management algorithm reduced acute kidney injury (AKI) in pediatric patients on extracorporeal membrane oxygenation (ECMO). Higher compliance with the algorithm also correlated with decreased mortality, suggesting improved outcomes with systematic fluid removal.
Area of Science:
- Pediatric Critical Care Medicine
- Nephrology
- Cardiopulmonary Support
Background:
- Acute kidney injury (AKI) and fluid overload (FO) are prevalent complications in pediatric patients requiring extracorporeal membrane oxygenation (ECMO).
- These conditions are associated with increased morbidity and mortality in this vulnerable population.
- Effective fluid management strategies are crucial for improving outcomes in ECMO patients.
Purpose of the Study:
- To evaluate the impact of a fluid management algorithm on reducing AKI and mortality in pediatric ECMO patients.
- To assess the association between algorithm compliance and patient outcomes.
- To determine if protocolized fluid removal improves survival and reduces kidney injury in children on ECMO.
Main Methods:
- A retrospective study was conducted on pediatric patients (birth to 25 years) supported by ECMO between 2007 and 2019.
- A fluid management algorithm for protocolized fluid removal was implemented in October 2017.
- Outcomes (AKI and mortality) were compared between patients managed with and without the algorithm, with a focus on algorithm compliance.
Main Results:
- The fluid management algorithm was used in 74 patients, with an overall AKI rate of 38% during ECMO.
- Patients managed on the algorithm showed significantly lower AKI incidence and mortality compared to those not on the algorithm (p=0.02 and p=0.05, respectively).
- High algorithm compliance (80-100%) was associated with a 54% reduction in mortality (aOR: 0.46, 95%CI: 0.22-1.00; p=0.05).
Conclusions:
- The implementation of a fluid management algorithm significantly reduced the odds of AKI in pediatric ECMO patients.
- Greater adherence to the fluid management protocol was associated with a notable reduction in mortality.
- Multicenter studies focusing on systematic fluid removal protocols are recommended to further enhance ECMO-related outcomes.
Abstract:
Acute kidney injury (AKI), fluid overload (FO), and mortality are common in pediatric patients supported by extracorporeal membrane oxygenation (ECMO). The aim of this study is to evaluate if using a fluid management algorithm reduced AKI and mortality in children supported by ECMO. We performed a retrospective study of pediatric patients aged birth to 25 years requiring ECMO at a quaternary level children's hospital from 2007 to 2019 In October 2017, a fluid management algorithm was implemented for protocolized fluid removal after deriving a daily fluid goal using a combination of diuretics and ultrafiltration. Daily algorithm compliance was defined as ≥ 12 h on the algorithm each day. The primary and secondary outcomes were AKI and mortality, respectively, and were assessed in the entire cohort and the sub-analysis of children from the era in which the algorithm was implemented. Two hundred and ninety-nine (median age 5.3 months; IQR: 0.2, 62.3; 45% male) children required ECMO (venoarterial in 85%). The fluid algorithm was applied in 74 patients. The overall AKI rate during ECMO was 38% (26% severe-stage 2/3). Both AKI incidence and mortality were significantly lower in patients managed on the algorithm (p = 0.02 and p = 0.05). After adjusting for confounders, utilization of the algorithm was associated with lower odds of AKI (aOR: 0.40, 95%CI: 0.21, 0.76; p = 0.005) but was not associated with a reduction in mortality. In the sub-analysis, algorithm compliance of 80-100% was associated with a 54% reduction in mortality (ref: < 60% compliant; aOR:0.46, 95%CI:0.22-1.00; p = 0.05). Conclusion: Among the entire cohort, the use of a fluid management algorithm reduced the odds of AKI. Better compliance on the algorithm was associated with lower mortality. Multicenter studies that implement systematic fluid removal may represent an opportunity for improving ECMO-related outcomes. What is Known: • Acute kidney injury and fluid overload are associated with morbidity and mortality in children supported by extracorporeal membrane oxygenation. What is New: • A systematic and protocolized approach to fluid removal in children supported by extracorporeal membrane oxygenation reduces acute kidney injury incidence. • Greater adherence to a protocolized fluid removal algorithm is associated with a reduction in mortality.
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