Fluid Overload and Renal Angina Index at Admission Are Associated With Worse Outcomes in Critically Ill Children.

Sidharth K Sethi,Veena Raghunathan,Pranaw Jha,Maneesh Kumar,Maninder Dhaliwal,Shilpi Shah,Maroun J Mhanna,Sravanthi Paluri,Shyam Bansal,Rupesh Raina

doi:10.3389/fped.2018.00118

Abstract

Objectives: We investigated the association of fluid overload and oxygenation in critically sick children, and their correlation with various outcomes (duration of ventilation, ICU stay, and mortality). We also assessed whether renal angina index (RAI) at admission can predict mortality or acute kidney injury (AKI) on day 3 after admission.Design and setting: Prospective study, pediatric intensive care in a tertiary hospital.Duration: June 2013-June 2014.Patients: Patients were included if they needed invasive mechanical ventilation for >24 h and had an indwelling arterial catheter. Patients with congenital heart disease or those who received renal replacement therapy (RRT) were excluded.Methods: Oxygenation index, fluid overload percent (daily, cumulative), RAI at admission and pediatric logistic organ dysfunction (PELOD) score were obtained in all critically ill children. KDIGO classification was used to define AKI, using both creatinine and urine output criteria. Admission data for determination of RAI included the use of vasopressors, invasive mechanical ventilation, percent fluid overload, and change in kidney function (estimated creatinine clearance). Univariable and multivariable approaches were used to assess the relations between fluid overload, oxygenation index and clinical outcomes. An RAI cutoff >8 was used to predict AKI on day 3 of admission and mortality.Results: One hundred and two patients were recruited. Fluid overload predicted oxygenation index in all patients, independent of age, gender and PELOD score (p < 0.05). Fluid overload was associated with longer duration of ventilation (p < 0.05), controlled for age, gender, and PELOD score. Day-3 AKI rates were higher in patients with a RAI of 8 or more, and higher areas under the RAI curve had better prediction rates for Day-3 AKI. An RAI <8 had high negative predictive values (80–95%) for Day-3 AKI. RAI was better than traditional markers of pediatric severity of illness (PELOD) score for prediction of AKI on day 3.Conclusions: This study emphasizes that positive fluid balance adversely affects intensive care in critically ill children. Further, the RAI prediction model may help optimize treatment and improve clinical prediction of AKI.

Highlights

There are multiple reports of observational studies demonstrating a strong, independent association between fluid accumulation and poor clinical outcomes in children [1,2,3,4,5,6,7] and adults [8,9,10,11,12,13]
The collective pediatric experience from multiple studies on critically ill children reveals that 10–20% fluid overload (FO) at continuous renal replacement therapy (CRRT) initiation confers a three- to eight-fold increased odds for mortality, after adjustment for illness severity, multi-organ failure, and age [14]
The largest study of pediatric populations included 297 patients from the Prospective Pediatric CRRT Registry Group, and showed that >20% FO is associated with higher odds of mortality compared with the presence of multiorgan failure (MOF) or oncological diagnosis at CRRT initiation [4]

Summary

Introduction

There are multiple reports of observational studies demonstrating a strong, independent association between fluid accumulation and poor clinical outcomes in children [1,2,3,4,5,6,7] and adults [8,9,10,11,12,13]. The collective pediatric experience from multiple studies on critically ill children reveals that 10–20% fluid overload (FO) at continuous renal replacement therapy (CRRT) initiation confers a three- to eight-fold increased odds for mortality, after adjustment for illness severity, multi-organ failure, and age (from infants to young adults) [14]. The multicentre Program to Improve Care for Acute Renal Disease study showed an association between mortality and >10% fluid accumulation at RRT initiation [8]. Another observational study on 212 adult patients with sepsis showed increased survival in sick patients who received both adequate initial fluid resuscitation and late conservative fluid management [10]. The Fluid And Catheter Treatment Trial (FACTT) showed that a conservative fluid management strategy [using fluid restriction and diuretics to maintain lower central venous pressure and pulmonary capillary wedge pressure (PCWP)] led to fewer ventilator days, and suggested diuretic-induced negative fluid balance may improve survival in patients with acute kidney injury (AKI) [15]

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