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The Impact of Fluid Overload on Outcomes in Children Treated With Extracorporeal Membrane Oxygenation: A Multicenter Retrospective Cohort Study*

Selewski, David T. MD, MS1; Askenazi, David J. MD, MSPH2; Bridges, Brian C. MD3; Cooper, David S. MD, MPH4; Fleming, Geoffrey M. MD3; Paden, Matthew L. MD5; Verway, Mark PhD6; Sahay, Rashmi MD, MS7; King, Eileen PhD7; Zappitelli, Michael MD, MSc6

doi: 10.1097/PCC.0000000000001349
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Objective: To characterize the epidemiology of fluid overload and its association with mortality and duration of extracorporeal membrane oxygenation in children treated with extracorporeal membrane oxygenation.

Design: Retrospective cohort study.

Setting: Six tertiary children’s hospital ICUs.

Patients: Seven hundred fifty-six children younger than 18 years old treated with extracorporeal membrane oxygenation for greater than or equal to 24 hours from January 1, 2007, to December 31, 2011.

Interventions: None.

Measurements and Main Results: Overall survival to extracorporeal membrane oxygenation decannulation and hospital discharge was 74.9% (n = 566) and 57.7% (n = 436), respectively. Median fluid overload at extracorporeal membrane oxygenation initiation was 8.8% (interquartile range, 0.3–19.2), and it differed between hospital survivors and non survival, though not between extracorporeal membrane oxygenation survivors and non survivors. Median peak fluid overload on extracorporeal membrane oxygenation was 30.9% (interquartile range, 15.4–54.8). During extracorporeal membrane oxygenation, 84.8% had a peak fluid overload greater than or equal to 10%; 67.2% of patients had a peak fluid overload of greater than or equal to 20% and 29% of patients had a peak fluid overload of greater than or equal to 50%. The median peak fluid overload was lower in patients who survived on extracorporeal membrane oxygenation (27.2% vs 44.4%; p < 0.0001) and survived to hospital discharge (24.8% vs 43.3%; p < 0.0001). After adjusting for acute kidney injury, pH at extracorporeal membrane oxygenation initiation, nonrenal complications, extracorporeal membrane oxygenation mode, support type, center and patient age, the degree of fluid overload at extracorporeal membrane oxygenation initiation (p = 0.05), and the peak fluid overload on extracorporeal membrane oxygenation (p < 0.0001) predicted duration of extracorporeal membrane oxygenation in survivors. Multivariable analysis showed that peak fluid overload on extracorporeal membrane oxygenation (adjusted odds ratio, 1.09; 95% CI, 1.04–1.15) predicted mortality on extracorporeal membrane oxygenation; fluid overload at extracorporeal membrane oxygenation initiation (adjusted odds ratio, 1.13; 95% CI, 1.05–1.22) and peak fluid overload (adjusted odds ratio, 1.18; 95% CI, 1.12–1.24) both predicted hospital morality.

Conclusions: Fluid overload occurs commonly and is independently associated with adverse outcomes including increased mortality and increased duration of extracorporeal membrane oxygenation in a broad pediatric extracorporeal membrane oxygenation population. These results suggest that fluid overload is a potential target for intervention to improve outcomes in children on extracorporeal membrane oxygenation.

Supplemental Digital Content is available in the text.

1Department of Pediatrics & Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI.

2Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL.

3Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.

4Department of Pediatrics, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

5Department of Pediatrics, Emory University, Atlanta, GA.

6Department of Pediatrics, McGill University Health Centre, Montreal, QC, Canada.

7Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

*See also p. 1181.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Dr. Askenazi received funding from Baxter and acute kidney injury Foundation; he disclosed off-label product use in that acute continuous renal replacement therapy (CRRT) is not U.S. Food and Drug Administration-approved in the United States for children lower than 20 kg with any device; and he receives funding from the National Institutes of Health (NIH) (R01 DK13608-01) and the Pediatric and Infant Center for Acute Nephrology, which is sponsored by Children’s of Alabama and the University of Alabama at Birmingham School of Medicine, as well as by the Department of Pediatrics, and Center for Clinical and Translational Science under award number UL1TR00165. Dr. Fleming’s institution received funding from the National Center for Advancing Translational Sciences/NIH; he received funding from Society of Critical Care Medicine (faculty at Pediatric Board Review Course July 2016); and he received support for article research from the NIH. Dr. Paden disclosed off-label product use in that all extracorporeal membrane oxygenation and CRRT use is off label in children. RedCap is supported by UL1 TR000445 from National Center for Advancing Translational Sciences/NIH. Dr. Zappitelli receives research salary support from the Fonds de Recherche de Québec-Santé. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: dselewsk@med.umich.edu

©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies