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Hypertension and Health Outcomes in the PICU

Ehrmann, Brett J. MS; Selewski, David T. MD; Troost, Jonathan P. BS; Hieber, Susan M. BA; Gipson, Debbie S. MS, MD

Pediatric Critical Care Medicine: June 2014 - Volume 15 - Issue 5 - p 417–427
doi: 10.1097/PCC.0000000000000126
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Objectives: Reports of the burden of hypertension in hospitalized children are emerging, but the prevalence and significance of this condition within the PICU are not well understood. The aims of this study were to validate a definition of hypertension in the PICU and assess the associations between hypertension and acute kidney injury, PICU length of stay, and mortality.

Design and Setting: Single-center retrospective study using a database of PICU discharges between July 2011 and February 2013.

Patients: All children discharged from the PICU with length of stay more than 6 hours, aged 1 month through 17 years. Exclusions were traumatic brain injury, incident renal transplant, or hypotension.

Interventions: None.

Measurements and Main Results: Potential definitions of hypertension utilizing combinations of standardized cutoff percentiles, durations, initiation or dose escalation of antihypertensives, and/or billing diagnosis codes for hypertension were compared using receiver operator characteristic curves against a manual medical record review. Multivariable logistic and linear regression analyses were conducted using the selected definition of hypertension to assess its independent association with acute kidney injury and PICU length of stay, respectively. A definition requiring three systolic and/or diastolic readings above standardized 99th percentiles plus 5 mm Hg over 1 day was selected (area under the curve, 0.91; sensitivity, 94%; specificity, 87%). Among the 1,215 patients in this analysis, the prevalence of hypertension was 25%. Hypertension was independently associated with acute kidney injury (odds ratio, 2.89; 95% CI, 1.64–5.09; p < 0.01) and increased PICU length of stay (1.50 d; 95% CI, 0.94–2.05; p < 0.01) in multivariable analyses. Deaths were rare—0 in the normotension group and 3 (1%) in the hypertension group—but were statistically different (p = 0.02).

Conclusions: Hypertension is common in the PICU and is associated with worse clinical outcomes. Future studies are needed to confirm these results.

Division of Pediatric Nephrology, Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI.

This study was performed at the C.S. Mott Children’s Hospital.

Supported, in part, by a grant from the Renal Research Institute and Clinical and Translational Science Award 2TL1TR000435-06 from the National Center for Advancing Translational Studies and the National Institutes of Health.

Dr. Ehrmann and his institution received grant support. This work was supported by Clinical and Translational Science Award 2TL1TR000435-06, from the National Center for Advancing Translational Studies and the National Institutes of Health (NIH). This funding was awarded as a stipend for full-time participation in a predoctoral Master's degree program including didactics and conduction of a clinical research project (this manuscript being one of the end products). Dr. Ehrmann received support for article research from the NIH. Dr. Selewski’s institution received grant support from the Renal Research Institute (Support database manager. No faculty support). Dr. Troost received support for article research from the NIH. His institution received grant support from the National Center for Advancing Translational Studies. Dr. Gipson consulted for GSK. Her institution received grant support from the NIH, PCORI, Renal Research Institute, UK British Council (RRI grant role is as mentor to junior faculty PI. Grant paid for a portion of the data management activity to establish an electronic medical record extract of all children admitted to the ICU. This data base, but not the funding, was subsequently used for this project. No other grants are related to AKI). Dr. Hieber disclosed that she does not have any potential conflicts of interest.

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©2014The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies