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FLUID OVERLOAD MODIFIES HEMODYNAMIC IMPACT OF CONTINUOUS RENAL REPLACEMENT THERAPY: EVIDENCE OF A COVERT CARDIORENAL
Sameer Thadani, Anna Lang1, Christin Silos2
1Baylor College of Medicine, Houston, Texas.
Insights
Fluid overload in critically ill children receiving continuous renal replacement therapy (CRRT) significantly impacts hemodynamics. Children with over 15% fluid overload exhibit increased systemic vascular resistance and decreased cardiac index, highlighting the need for hemodynamic monitoring.
Area of Science:
- Pediatric Critical Care Medicine
- Nephrology
- Cardiovascular Physiology
Background:
- Fluid overload (FO) is a significant concern in critically ill children, associated with increased morbidity and mortality.
- Continuous renal replacement therapy (CRRT) is a common treatment for fluid overload in this population.
- Adverse cardiovascular effects of FO and CRRT are known in adults, but pediatric data are limited.
Purpose of the Study:
- To investigate the impact of fluid overload (>15%) on hemodynamic parameters in children undergoing CRRT.
- To assess the feasibility and utility of electrocardiometry for hemodynamic monitoring in pediatric CRRT patients.
Main Methods:
- An observational, single-center study included children (<18 years) receiving CRRT.
- Electrocardiometry, a noninvasive bioimpedance technique, was used to collect hemodynamic data within the first 48 hours of CRRT.
- Patients with specific conditions (ESRD, ECMO, VADs, etc.) or without arterial lines were excluded.
Main Results:
- Of 17 included children, 9 (53%) had fluid overload >15%.
- Children with FO >15% demonstrated a significantly higher systemic vascular resistance index (P < 0.01) and a lower cardiac index (P < 0.01) compared to those without.
- No significant differences were observed in heart rate or mean arterial pressure between groups.
Conclusions:
- Fluid overload significantly alters the hemodynamic profile in children treated with CRRT.
- Higher fluid overload is associated with increased systemic vascular resistance and reduced cardiac output, independent of heart rate and mean arterial pressure.
- Electrocardiometry is a feasible tool for monitoring hemodynamics in pediatric CRRT patients, warranting further research.
Abstract:
Background: Fluid overload (FO) in critically ill children correlates with higher morbidity and mortality rates. Continuous renal replacement therapy (CRRT) is commonly employed to manage FO. In adults, both FO and CRRT adversely affect myocardial function. It remains unclear if children experience similar cardiovascular effects. Methods: Observational single-center study on children (<18 years) receiving CRRT at Texas Children's Hospital from 11/2019 to 3/2021. Excluded were those with end-stage renal disease, pacemakers, extracorporeal membrane oxygenation, ventricular assist devices, apheresis, or without an arterial line. Electrocardiometry (ICON Osypka Medical GmbH, Berlin, Germany) which is noninvasive and utilizes bioimpedance, was applied to obtain hemodynamic data over the first 48 h of CRRT. Our aim was to identify how FO >15% affects hemodynamics in children receiving CRRT. Results: Seventeen children, median age 43 months (interquartile range [IQR] 12-124), were included. The median FO at CRRT initiation was 14.4% (2.4%-25.6%), with 9 (53%) patients having FO >15%. Differences were noted in systemic vascular resistance index (1,277 [IQR 1088-1,666] vs. 1,030 [IQR 868-1,181] dynes/s/cm 5 /m 2 , P < 0.01), and cardiac index (3.90 [IQR 3.23-4.75] vs. 5.68 [IQR 4.65-6.32] L/min/m 2 , P < 0.01), with no differences in heart rate or mean arterial pressure between children with and without FO. Conclusion: FO affects the hemodynamic profile of children on CRRT, with those having FO >15% showing higher systemic vascular resistance index and lower cardiac index, despite heart rate and mean arterial pressure remaining unchanged. Our study illustrates the feasibility and utility of electrocardiometry in these patients, suggesting future research employ this technology to further explore the hemodynamic effects of dialysis in children.
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