Early Cumulative Fluid Balance and Outcomes in Pediatric Allogeneic Hematopoietic Cell Transplant Recipients With Acute Respiratory Failure: A Multicenter Study.

Courtney M Rowan,Megan C Daniel,Shira J Gertz,Colin J Sallee,Julie C Fitzgerald,Susan R Heckbert,Jennifer A Mcarthur,Joseph R Angelo,Kris M Mahadeo,Lincoln S Smith,Deyin D Hsing

doi:10.3389/fonc.2021.705602

Abstract

ObjectivesTo 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).MethodsWe 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).Results198 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).ConclusionsAmong critically ill pediatric allogeneic HCT recipients with acute respiratory failure, positive and increasing early CFB were independently associated with adverse outcomes.

Highlights

Pediatric patients post-allogeneic hematopoietic cell transplantation (HCT) are high utilizers of pediatric intensive care unit (PICU) resources [1], invasive mechanical ventilation (IMV) [2]
Positive day 3 cumulative fluid balance (CFB) was associated with higher PICU mortality and a lower rate of extubation at 28 days and 60 days
The association between positive day 3 CFB and PICU mortality was significantly stronger in those not treated with renal replacement therapy (RRT)

Summary

Introduction

Pediatric patients post-allogeneic hematopoietic cell transplantation (HCT) are high utilizers of pediatric intensive care unit (PICU) resources [1], invasive mechanical ventilation (IMV) [2]. Valentine et al [16] showed that fluid balance patterns in a pediatric cohort with ARF were similar to the liberal fluid management arm, rather than the conservative arm of the FACTT trial. This suggested that known associations between positive fluid balance and poor outcomes in patients with ARF had not influenced pediatric practice.

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