Fluid overload: clinical outcomes in pediatric intensive care unit

Abstract Objective The aim of this study was to analyze the effects of fluid overload related to mechanical ventilation, renal replacement therapy, and evolution to discharge or death in critically ill children. Methods A retrospective study in a Pediatric Intensive Care Unit for two years. Patients who required invasive ventilatory support and vasopressor and/or inotropic medications were considered critically ill. Results 70 patients were included. The mean age was 6.8 ± 6 years. There was a tolerable increase in fluid overload during hospitalization, with a median of 2.45% on the first day, 5.10% on the third day, and 8.39% on the tenth day. The median fluid overload on the third day among those patients in pressure support ventilation mode was 4.80% while the median of those who remained on controlled ventilation was 8.45% (p = 0.039). Statistical significance was observed in the correlations between fluid overload measurements on the first, third, and tenth days of hospitalization and the beginning of renal replacement therapy (p = 0.049) and between renal replacement therapy and death (p = 0.01). The median fluid overload was 7.50% in patients who died versus 4.90% in those who did not die on the third day of hospitalization (p = 0.064). There was no statistically significant association between death and the variables sex or age. Conclusions The fluid overload on the third day of hospitalization proved to be a determinant for the clinical outcomes of weaning from mechanical ventilation, initiation of renal replacement therapy, discharge from the intensive care unit, or death among these children.

Application of abdominal venous Doppler flow pattern in volume management / 中华危重病急救医学

Accurate assessment of hemodynamic status is crucial for volume management. Venous congestion caused by volume overload can cause organ damage and poor prognosis. Traditional critical ultrasound, including inferior vena cava ultrasound, echocardiography, and lung ultrasound, is widely used in volume management. However, it is unable to evaluate the organ blood flow. The blood flow pattern of abdominal vein changes dynamically with venous congestion, which is an index for evaluating the blood flow of hepatic vein, portal vein and internal renal vein by Doppler ultrasound. This article reviews the acquisition and grading standards of abdominal venous blood flow patterns, their application and limitations in volume management, with a view to providing help for early clinical identification of terminal organ congestion, implementation of fluid negative balance intervention and individualized volume management.

Volume assessment and management for pediatric patients with heart failure / 中国小儿急救医学

Fluid overload is frequently found in critically ill patients with pediatric heart failure.Volume management is one of the important therapeutic measures for pediatric patients with heart failure, the aim of which is to achieve the best individual volume homeostasis.Assessment of volume status is the premise and foundation of volume management.The comprehensive evaluation and effective management of volume status leave clinical doctors a great challenge.In order to provide guidance and evidence for clinicians, this review elucidated the methods for assessment and management of volume status for pediatric patients with heart failure.

Fluid overload as a predictor of morbidity and mortality in pediatric patients following congenital heart surgery / Sobrecarga hídrica como predictor de morbilidad y mortalidad en pacientes pediátricos operados de corazón

Abstract Background: Patients undergoing congenital heart surgery with cardiopulmonary bypass frequently require the administration of intravenous fluids and blood products due to hemodynamic instability. Correctly performed fluid resuscitation can revert the state of tissue hypoperfusion in the different organs. However, excessive fluid administration and acute kidney injury may promote fluid overload (FO) and increase the risk of complications, hospital stay, and mortality. Methods: We conducted a prospective longitudinal study of pediatric patients with congenital heart surgery and cardiopulmonary bypass in the Pediatric Cardiac Intensive Care Unit (PCICU), Instituto Nacional de Pediatría, from July 2018 to December 2019. Fluid overload was quantified every 24 hours during the first 3 days of stay at the PCICU and expressed as a percentage. We recorded PCICU stay, days of mechanical ventilation, and mortality as outcome variables. Results: We included 130 patients. The main factors associated with fluid overload were age < 1 year (p < 0.001), weight < 5 kg (p < 0.001), and longer cardiopulmonary bypass time (p = 0.003). Patients with fluid overload ≥ 5% had higher inotropic score (p < 0.001), higher oxygenation index (p < 0.001), and longer mechanical ventilation time (p < 0.001). Fluid overload ≥ 5% was associated with higher postoperative mortality (odds ratio 89, p = 0.004). Conclusions: Fluid overload can be used as a prognostic factor in the evolution of pediatric patients undergoing congenital heart surgery since it is associated with increased morbidity and mortality.

Resumen Introducción: Los pacientes con cirugía cardiaca congénita en la que se emplea una bomba de circulación extracorpórea frecuentemente requieren la administración de líquidos intravenosos y hemoderivados por inestabilidad hemodinámica. La resucitación con volumen realizada adecuadamente puede revertir el estado de hipoperfusión tisular en los diferentes órganos. Sin embargo, el ingreso excesivo de líquidos y la falla renal aguda pueden favorecer la sobrecarga hídrica (SH) e incrementar el riesgo de complicaciones, la estancia hospitalaria y la mortalidad. Métodos: Se llevó a cabo un estudio prospectivo longitudinal de pacientes pediátricos con cirugía del corazón y empleo de bomba de circulación extracorpórea en la Unidad de Cuidados Intensivos Cardiovasculares (UCICV), Instituto Nacional de Pediatría, de julio 2018 a diciembre 2019. La SH, registrada como porcentaje, fue cuantificada cada 24 horas durante los primeros 3 días de estancia en UCICV. Como variables de desenlace se registraron la estancia en UCICV, el tiempo de ventilación mecánica y la mortalidad. Resultados: Se incluyeron 130 pacientes. Los principales factores asociados con la SH fueron la edad < 1 año (p < 0.001), peso < 5 kg (p < 0.001) y mayor tiempo de circulación extracorpórea (p = 0.003). Los pacientes con SH ≥ 5% presentaron mayor puntaje inotrópico (p < 0.001), mayor índice de oxigenación (p < 0.001) y mayor tiempo de ventilación mecánica (p < 0.001). La SH ≥ 5% se asoció con una mayor probabilidad de muerte en el periodo posoperatorio (razón de momios: 89, p = 0.004). Conclusiones: La SH puede utilizarse como factor pronóstico en la evolución de los pacientes pediátricos operados de corazón, ya que se asocia con una mayor morbimortalidad.

Threshold and risk factors of fluid overload in neonatal septic shock / 中国新生儿科杂志

Objective:To study the threshold of fluid overload (FO) and its risk factors in neonatal septic shock.Methods:From January 2019 to November 2020, clinical data of infants with septic shock hospitalized in the neonatal department of our hospital were reviewed. With poor prognosis as the outcome, ROC curve was drawn based on 24 h (from the beginning of septic shock), 48 h and 72 h FO value. FO cutoff value was determined as area under curve (AUC) reached maximum. Risk factors of FO were analyzed between FO<cutoff value group and FO≥cutoff value group.Results:A total of 152 eligible cases were included and the cutoff value of 48 h FO was determined as 43.3%. 116 cases were in FO<43.3% group and 36 cases were in FO≥43.3% group. FO≥43.3% group had smaller gestational age (GA), birth weight (BW), 1 min Apgar score, 5 min Apgar score and lower PLT, PCT, pH, and ALB level compared with FO<43.3% group. Meanwhile, FO≥43.3% group had significantly higher shock score, bedside septic shock scores (bSSS), lactic acid level, higher incidences of WBC <5×10 9/L and albumin infusion compared with FO<43.3% group. As for prognostic outcome, FO≥43.3% group had significantly higher incidences of neonatal persistent pulmonary hypertension, severe cerebral hemorrhage, periventricular leukomalacia, acute kidney injury, severe brain injury, multiple organ dysfunction syndrome, disseminated intravascular coagulation and 28 d all-cause mortality rate than FO<43.3% group ( P<0.05). Logistic regression analysis showed risk factors associated with FO≥43.3% were BW ( OR=0.998, 95% CI 0.998~0.999, P<0.05), pH ( OR=0.018, 95% CI 0.000~0.990, P<0.05) and bSSS ( OR=1.619, 95% CI 1.134~2.311, P<0.05). The cutoff values were BW 1 830 g, pH 7.15 and bSSS 0.5. Conclusions:The 48 h FO with cutoff value of 43.3% has the highest predictive value for prognostic outcome in neonates with septic shock. FO≥43.3% is associated with more adverse outcomes. Infants with septic shock who have lower BW, lower pH and higher bSSS are more likely to develop FO≥43.3%.

Fluid overload in critically ill children and advances in its treatment / 国际儿科学杂志

Fluid overload(FO)is significantly associated with survival in critically ill children.Excessive fluid accumulation in the body causes tissue oedema, which may lead to heart failure, acute kidney injury(AKI)and acute pulmonary oedema, affecting length of hospital stay, readmission rates and prognosis.According to the cause of the FO, the main treatments are fluid restriction, diuretics, and ultrafiltration.Diuretics are often used clinically to treat patients with FO.International guidelines recommend ultrafiltration to remove excess water when diuretic therapy is not effective or when diuretic resistance occurs, or when life-threatening complications arise.However, there is no conclusion on the setting for the net ultrafiltration intensity in ultrafiltration, particularly in critically ill children.With the development of ultrafiltration technology, the application of ultrafiltration in the treatment of FO patients will be further carried out.This article provides a review of the FO and its treatment in critically ill children.

Diagnostic performance of brain Natriuretic Peptide, Bioelectrical Impedance Analysis, and Left Ventricular End-Diastolic Diameter in the Determination of Fluid Overload and Mortality In Pediatric Sepsis

Objective@#This pilot study investigated whether serum B-type Natriuretic Peptide (BNP), bioelectrical impedance analysis (BIA), and left ventricular end-diastolic diameter (LVEDD) can be used to predict fluid overload and clinical outcomes in pediatric sepsis. @*Methods@#Pediatric sepsis patients were enrolled. BNP, BIA, and LVEDD were obtained on admission and on Day 3. Diagnostic performances of BNP, BIA, LVEDD and correlation with fluid status were obtained.@*Results@#Twenty-two patients were enrolled. Day 3 BNP was higher in non-survivors (9241 vs. 682.2 pg/mL, p=0.04) and day 3 LVEDD Z-score was lower in non-survivors (-3.51 vs. -0.01, p=0.023). There was no difference in the fluid balance between survivors and non-survivors. Admission BNP >670.34pg/mL predicted vasopressor use with a sensitivity of 85.71% and specificity of 86.67% while ΔBNP>5388.13pg/mL predicted mortality with 100% sensitivity. Day 3 LVEDD <22mm predicted mortality with a sensitivity of 94.74%. Cumulative fluid balance was strongly correlated with BIA and LVEDD (r=0.65, p=0.001; r=0.74, p<0.001 respectively). The median length of stay in hospital days for non-survivors was not significantly different from survivors (4 [1-12] vs. 8 [6-12] days,p=0.21). @*Conclusion@#Rise in BNP levels appear to be independent of fluid status and is a good predictor of mortality, vasopressor, and mechanical ventilator use but not of length of hospital stay. LVEDD and BIA are good estimates of cumulative fluid balance but not as predictors of mortality, vasopressor, mechanical ventilator use, and length of hospital stay. Significance of the outcomes of the study was limited due to the small sample size.

Asociación del signo de Godet con la medición por ultrasonido del edema periférico y balance de líquidos. El resurgir de la clínica / Association of the Godet's sign with ultrasound measurement of peripheral edema and fluid balance. The resurrection of the clinic / Associação do sinal de Godet com medida de ultrassom de edema periférico e equilíbrio hidrográfico. O ressurgimento da clínica

Resumen: Introducción: la administración de líquidos representa una intervención terapéutica de primera línea. Sin embargo, con frecuencia esto conduce a sobrecarga de líquidos, lo que se asocia con alta mortalidad. Objetivo: describir la asociación del edema periférico medido por ultrasonido con el balance hídrico acumulado diario y comparar su correlación con el signo de Godet. Material y métodos: pacientes adultos que ingresaron a la unidad de terapia intensiva (UTI) con más de 24 h de estancia y datos clínicos de sobrecarga hídrica. Diseño: es un estudio observacional, prospectivo, longitudinal, simple ciego, piloto. Cálculo de muestra n = 72 pacientes. Resultados: la mediana de edad fue de 45 años, 96.6% estuvo con ventilación mecánica, todos los pacientes presentaron desenlace en el análisis multivariado ajustado y se detectó que hay asociación del signo de Godet con la medición del edema por ultrasonido, observando una fuerte correlación explicada por una R2 87% p = 0.0001. Por último, se realizó otra regresión de los mililitros del balance hídrico acumulado asociada con los milímetros del edema medidos por ultrasonido, encontrando una R2 82% (IC 95% 1.47-3.70 p = 0.0001) interpretado como una fuerte asociación. Conclusiones: el signo de Godet se asoció fuertemente con los milímetros del edema medido por ultrasonido, además tiene una fuerte asociación entre el balance de líquido acumulado por día con los milímetros de edema que se incrementan en el tejido periférico por sobrecarga al día.

Abstract: Introduction: the administration of fluids represents a first-line therapeutic intervention. However, this often leads to fluid overload, which is associated with high mortality. Objective: to describe the association of peripheral edema measured by ultrasound with daily accumulated water balance and to compare its correlation with Godet's sign. Material and methods: adult patients admitted to the intensive care unit with more than 24 hours of stay and clinical data of fluid overload. Design: this is an observational, prospective, longitudinal, single-blind, pilot study. Sample calculation n = 72 patients. Results: the median age was 45 years, 96.6% were on mechanical ventilation, all patients presented their outcome in the adjusted multivariate analysis, and it was found that there is an association of Godet's sign with the measurement of edema by ultrasound, finding a strong correlation explained by an R2 87% p = 0.0001. Finally, another regression of milliliters of accumulated water balance associated with milliliters of edema measured by ultrasound was performed, finding an R2 82% (95% CI 1.47-3.70 p = 0.0001) interpreted as a strong association. Conclusions: Godet's sign was strongly associated with the millimeters of edema measured by ultrasound; it also has a strong association between the balance of fluid accumulated per day with the millimeters of edema that increase in the peripheral tissue due to overload per day.

Resumo: Introdução: a administração de fluidos representa uma intervenção terapêutica de primeira linha. No entanto, isso freqüentemente leva à sobrecarga hidríca, que está associada a alta mortalidade. Objetivo: descrever a associação do edema periférico medido pela ultrassonografia com o balanço hídrico diário acumulado e comparar sua correlação com o sinal de Godet. Material e métodos: pacientes adultos admitidos na unidade de terapia intensiva (UTI) com mais de 24 horas de internação e com quadro clínico de sobrecarga hídrica. Desenho: é um estudo observacional, prospectivo, longitudinal, simples-cego, piloto. Cálculo amostra n = 72 pacientes. Resultados: a idade média foi de 45 anos, 96.6% estavam em ventilação mecânica, todos os pacientes apresentaram seu desfecho na análise multivariada ajustada e constatou-se que há associação do sinal de Godet com a medida do edema pela ultrassonografia, encontrando forte correlação explicado por um R2 87% p = 0.0001. Finalmente, realizou-se outra regressão dos mililitros de balanço hídrico acumulado associado aos milímetros de edema medidos por ultrassom, encontrando um R2 82% (IC 95% 1.47-3.70 p = 0.0001) interpretado como uma forte associação. Conclusões: o sinal de Godet foi fortemente associado com os milímetros de edema medidos por ultrassom, também tem forte associação entre o balanço hídrico acumulado por dia com os milímetros de edema que aumentam nos tecidos periféricos devido à sobrecarga por dia.

Risk factors of hemodynamically significant patent ductus arteriosus in extremely preterm infants / 中国新生儿科杂志

Objective:To study the risk factors of hemodynamically significant patent ductus arteriosus (hsPDA) in extremely preterm infants (EPI).Method:From July 2017 to April 2020, EPI (gestational age <28 weeks) admitted to the Department of Neonatology of our hospital were included and analyzed retrospectively. According to whether hsPDA existed or not, the infants were assigned into non-hsPDA group and hsPDA group. Demographic findings and possible risk factors of hsPDA were collected.The cumulative fluid overload (FO) within 3 days after birth was calculated. Univariate and multivariate analysis were used to determine the risk factors of hsPDA.Result:A total of 79 infants with gestational age of (27.0±0.9) weeks and birth weight of (987±173)g were enrolled, including 23 cases in non-hsPDA group and 56 cases in hsPDA group. Univariate analysis showed that thrombocytopenia ( P=0.044), respiratory distress syndrome (RDS) treated with pulmonary surfactant (PS) ( P=0.006) and high FO level ( P=0.002) were associated with hsPDA. Multivariate analysis showed that RDS treated with PS ( OR=5.933, 95% CI 1.360~25.883, P=0.018) and high FO level ( OR=1.261, 95% CI 1.063~1.496, P=0.008) were independent risk factors for hsPDA in EPIs. ROC curve analysis showed that the cut-off value of FO was -0.2%, with 85.7% sensitivity and 56.5% specificity distinguishing the presence of hsPDA (AUC=0.712, Youden index=0.422). Conclusion:High level of FO within the first 3 days of life and RDS treated with PS are independent risk factors for hsPDA in EPI. After PS treatment, hemodynamic changes of infants with RDS should be monitored closely. During early fluid management of EPI, FO should be strictly monitored to avoid high FO level.

Utilidad de la terapia de acuaféresis / Aquapheresis: ¿works?

Resumen La terapia de acuaféresis ha sido estudiada como una herramienta terapéutica para pacientes con sobrecarga de volumen refractaria al tratamiento con diuréticos de asa. Su objetivo principal es mitigar el impacto clínico de esta sobrecarga en los pacientes con insuficiencia cardiaca descompensada y SCR, reconociendo de esta manera los balances acumulados positivos en los pacientes críticamente enfermos como un factor independiente de mortalidad. Se realizó una búsqueda en las principales bases de datos científicas sobre la terapia de acuaféresis. Se incluyeron guías de manejo, ensayos clínicos controlados, revisiones sistemáticas y metaanálisis. Las bases bibliográficas que arrojaron resultados relevantes fueron Web of Sciences, Scopus, PubMed y SciELO y en total se encontraron 47 referencias bibliográficas publicadas entre 2005 y 2017. La acuaféresis es una terapia de ultrafiltración patentada que mejora la sobrecarga refractaria en pacientes con insuficiencia cardiaca congestiva. Hay brechas en el conocimiento en relación a su costo-efectividad, a los eventos adversos graves que se le atribuyen y a los candidatos que beneficia, por tanto, se requieren más estudios de calidad para llegar a conclusiones sólidas. Hasta el momento no hay evidencia contundente que respalde el uso sistemático y rutinario de la terapia de acuaféresis en las unidades de cuidado intensivo.

Abstract The therapy of Aquapheresis has been studied as a therapeutic tool for patients with volume overload refractory to treatment with ASA diuretics, whose main objective is to mitigate the clinical impact of the same in patients with decompensated heart failure and cardiorenal syndrome, recognizing positive cumulative balances in critically ill patients as a factor regardless of mortality. A search was made in the main scientific databases for review articles, and studies that included the Acuapheresis strategy. Bibliographic references were found in databases from 2005 to 2017. Aquapheresis therapy is a patented ultrafiltration therapy aimed at improving refractory overload in patients with congestive heart failure. There are gaps in knowledge regarding cost-effectiveness therapy, real adverse adverse event relationships attributable to it and candidates will benefit, and we believe that more quality studies are required to reach solid conclusions. So far there is no compelling evidence to support Aquapheresis therapy to implement its routine and routine use of the ICU.

Des-resucitación en la sobrecarga de fluidos asociada a la lesión renal aguda / Des-resuscitation in the overload of fluids associated with acute kidney injury

Los resultados generales del tratamiento de la lesión renal aguda en los últimos años han mejorado casi de manera constante, aunque sin una comprensión completa de su fisiopatología. La respuesta a este interrogante radicaría en la comprensión del rol proactivo en lo que hace a la administración / remoción de los fluidos, abarcando todo el proceso de reanimación de los pacientes críticos, es decir no limitándose a la administración sino también al momento oportuno de la remoción de los mismos, buscando como principal objetivo mejorar la perfusión tisular. Se discute entre otros el papel clave que ejerce la integridad vascular en la sobrecarga de fluidos, haciendo hincapié en el papel del glicocálix endotelial. Las maniobras de des-resucitación activa con diuréticos o con terapias de soporte renal, podrían ser instrumentos cada vez más reconocidos en la aplicación de la sobrecarga de fluidos, en particular en aquellos pacientes con lesión renal aguda.

In the last few years the general results in the treatment of acute kidney injury has improved constantly, without a complete comprehension of its pathophysiology. With this paradigm in mind, in these last few years we have seen an evolving comprehension of the possible answers that may be based on recognizing the more proactive role of fluid management in the resuscitation of critical patients, not limited only to the delivery of fluids, but also to their active removal, having as the principal objective the improvement of tissue perfusion. The key role of vascular integrity in fluid overload is discussed, emphasizing the role of the endothelial glycocalyx. Active des-resuscitation maneuvers with diuretics or with renal support therapies could be increasingly recognized instruments in the management of fluid overload, particularly in those patients with acute kidney injury.

The application progress of fluid de-escalation therapy in abdominal infection-induced septic shock / 中华危重病急救医学

After adequate fluid resuscitation in the early stage of septic shock, excessive accumulation of fluid in the body leads to organ dysfunction, which prolongs hospitalization, mechanical ventilation time, and renal replacement therapy time, and is associated with poor prognosis. The fluid de-escalation therapy is an important fluid management strategy performed in the late stage of septic shock. It aims to clear excess fluid by restricting fluid infusion, using diuretics and renal replacement therapy to achieve a negative fluid balance. The fluid de-escalation therapy contributes to improve clinical outcome of septic shock patients and reduce the mortality. This review mainly discusses the current researches and application progress of the fluid de-escalation therapy of abdominal infection-induced septic shock through clarifying its origin, time and endpoint, method of the therapy, the relationship with the control of the source of abdominal infection and its impact on organ function and clinical outcome. Our study intends to provide guidance for the treatment of abdominal infection-induced septic shock in the late stage, and explore the novel research directions.

Rapidly reversing bilateral macular edema associated with fluid overload in a young type 1 diabetic

We report a case of sudden onset bilateral diminution of vision in a young lady with type 1 diabetes. She was administered intravenous fluids for correction of diabetic ketoacidosis (DKA) prior to onset of her ocular symptoms. Dramatic resolution of macular edema was noted within a very short period after correction of fluid input–output ratio. Visual acuity was restored to baseline after 3 days without any active ocular intervention.

Risk factors for early fluid overload following repair in pediatric patients with ALCAPA complicated with moderate or severe left ventricular dysfunction and the effect on clinical outcomes / 中华麻醉学杂志

Objective To identify the risk factors for early fluid overload (FO) following repair in the pediatric patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) complicated with moderate or severe left ventricular dysfunction (left ventricular ejection fraction [LVEF] ＜50％) and evaluate the effect on clinical outcomes.Methods Forty-three pediatric patients with ALCAPA complicated with moderate or severe left ventricular dysfunction,aged 2-128 months,weighing 4.5-34.5 kg,with New York Heart Association Ⅲ or Ⅳ,undergoing ALCAPA repair,were enrolled in this study.The pediatric patients were divided into FO ≥ 5％ group (n =14) and FO＜5％ group (n =29)according to the FO developed within 24 h after operation.The pediatric Risk,Injury,Failure,Loss,and End-Stage Renal Disease criterion was used to diagnose acute kidney injury developed after operation.Factors including age,height,weight,preoperative LVEF,preoperative biomarkers,operative data,postoperative ventilation time,duration of intensive care unit (ICU) stay and related postoperative clinical outcome parameters were recorded.The risk factors of which P values were less than 0.05 would enter the multivariate logistic regression analysis to stratify the risk factors for FO ≥ 5％ developed within 24 h after operation.The effect of FO≥5％ on postoperative severe acute kidney injury (Injury and Failure),ventilation time,duration of ICU stay and etc.was assessed.Results Fourteen cases developed early postoperative FO≥5％,and the incidence was 33％.The results of the logistic regression analysis showed that lower preoperative LVEF was an independent risk factor for early postoperative FO ≥ 5％ (P＜0.05).Compared with FO＜5％ group,the postoperative ventilation time and duration of ICU stay were significantly prolonged,the number of pediatric patients who developed pulmonary infection and required reintubation was increased,the number of pediatric patients in whom duration of ICU stay was more than 14 days was increased (P＜0.05),and no significant change was found in the other parameters of clinical outcomes in FO ≥ 5％ group (P＞0.05).Conclusion Lower preoperative LVEF is a risk factor for early postoperative FO in pediatric patients with ALCAPA complicated with a moderate or severe left ventricular dysfunction undergoing repair,and it is not helpful for clinical outcomes in pediatric patients when postoperative early FO≥5％ occurs.

Continuous Renal Replacement Therapy in Preterm Infants

PURPOSE: Despite the increasing use of continuous renal replacement therapy (CRRT) in the neonatal intensive care unit (NICU), few studies have investigated its use in preterm infants. This study evaluated the prognosis of preterm infants after CRRT and identified risk factors of mortality after CRRT. MATERIALS AND METHODS: A retrospective review was performed in 33 preterm infants who underwent CRRT at the NICU of Samsung Medical Center between 2008 and 2017. Data of the demographic characteristics, predisposing morbidity, cardiopulmonary function, and CRRT were collected and compared between surviving and non-surviving preterm infants treated with CRRT. Univariable and multivariable analyses were performed to identify factors affecting mortality. RESULTS: Compared with the survivors, the non-survivors showed younger gestational age (29.3 vs. 33.6 weeks), lower birth weight (1359 vs. 2174 g), and lower Apgar scores at 1 minute (4.4 vs. 6.6) and 5 minutes (6.5 vs. 8.6). At the initiation of CRRT, the non-survivors showed a higher incidence of inotropic use (93% vs. 40%, p=0.017) and fluid overload (16.8% vs. 4.0%, p=0.031). Multivariable analysis revealed that fluid overload >10% at CRRT initiation was the primary determinant of mortality after CRRT in premature infants, with an adjusted odds ratio of 14.6 and a 95% confidence interval of 1.10–211.29. CONCLUSION: Our data suggest that the degree of immaturity, cardiopulmonary instability, and fluid overload affect the prognosis of preterm infants after CRRT. Preventing fluid overload and earlier initiation of CRRT may improve treatment outcomes.

Risk factors for early fluid overload following repair in pediatric patients with ALCAPA complicated with moderate or severe left ventricular dysfunction and the effect on clinical outcomes / 中华麻醉学杂志

Objective@#To identify the risk factors for early fluid overload(FO)following repair in the pediatric patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) complicated with moderate or severe left ventricular dysfunction (left ventricular ejection fraction [LVEF]<50%) and evaluate the effect on clinical outcomes.@*Methods@#Forty-three pediatric patients with ALCAPA complicated with moderate or severe left ventricular dysfunction, aged 2-128 months, weighing 4.5-34.5 kg, with New York Heart Association Ⅲ or Ⅳ, undergoing ALCAPA repair, were enrolled in this study.The pediatric patients were divided into FO≥5% group (n=14) and FO<5% group (n=29) according to the FO developed within 24 h after operation. The pediatric Risk, Injury, Failure, Loss, and End-Stage Renal Disease criterion was used to diagnose acute kidney injury developed after operation. Factors including age, height, weight, preoperative LVEF, preoperative biomarkers, operative data, postoperative ventilation time, duration of intensive care unit(ICU)stay and related postoperative clinical outcome parameters were recorded.The risk factors of which P values were less than 0.05 would enter the multivariate logistic regression analysis to stratify the risk factors for FO≥5% developed within 24 h after operation.The effect of FO≥5% on postoperative severe acute kidney injury (Injury and Failure), ventilation time, duration of ICU stay and etc. was assessed.@*Results@#Fourteen cases developed early postoperative FO≥5%, and the incidence was 33%.The results of the logistic regression analysis showed that lower preoperative LVEF was an independent risk factor for early postoperative FO≥5% (P<0.05). Compared with FO<5% group, the postoperative ventilation time and duration of ICU stay were significantly prolonged, the number of pediatric patients who developed pulmonary infection and required reintubation was increased, the number of pediatric patients in whom duration of ICU stay was more than 14 days was increased (P<0.05), and no significant change was found in the other parameters of clinical outcomes in FO≥5% group (P>0.05).@*Conclusion@#Lower preoperative LVEF is a risk factor for early postoperative FO in pediatric patients with ALCAPA complicated with a moderate or severe left ventricular dysfunction undergoing repair, and it is not helpful for clinical outcomes in pediatric patients when postoperative early FO≥5% occurs.

Effect of fluid overload on the prognosis of patients with acute kidney injury receiving continuous renal replacement therapy / 中华急诊医学杂志

Objective To investigate the relationship between fluid overload(FO) and prognosis of critically ill patients with acute kidney injury (AKI) receiving continuous renal replacement therapy (CRRT), so as to provide a basis for the reasonable optimization of fluid management and improve the prognosis of critically ill patients with AKI. Methods We enrolled 261 adult AKI patients receiving CRRT who were admitted in ICU Department of the First Hospital of Jinlin University from January 2012 to June 2017. We retrospectively analyzed the clinical data of all enrolled patients and compared the clinical data between the survival group (n=149) and the death group (n=112). We screened and analyzed the risk factors of 30-day mortality after entering ICU of AKI critically ill patients receiving CRRT through multiple Logistic regression analysis. The Kaplan-Meier survival curve was used to compare the difference of 30-day mortality after entering ICU between the subgroups of fluid overload and non-fluid overload patients. Results ① The 30 day mortality was significantly higher in AKI patients receiving CRRT when the following situation existed: ％FO total ≥ 10％(OR=1.30, 95％CI:1.13-2.05, P=0.01), ventilator dependency(OR=1.65, 95％CI:1.01-2.55, P=0.03), oliguria(OR=1.55, 95％CI:1.13-2.15), SOFA ≥ 13(OR=1.15, 95％CI:1.01-1.20, P<0.01), the time from the diagnosis of AKI to the start of CRRT >3 days (OR=1.03, 95％CI:1.01-1.13, P=0.04) and mean arterial pressure<72 mmHg (OR=1.10, 95％CI:1.00-1.30, P=0.04). ② There was significant difference in the 30 day survival rate between the fluid overload group (n=92) and the non-fluid overload group (n=169) (P<0.01). ③ Sub group analysis:group1(n=130): ％FO pre-CRRT <10％ and ％FO total<10％; group 2 (n=39): ％FO pre-CRRT ≥ 10％and ％FO total<10％; group 3 (n=64): ％FO pre CRRT <10％ and ％FO total ≥ 10％; group 4 (n=28):％FO pre-CRRT ≥ 10％ and ％FO total ≥ 10％. There was a significant difference in the survival rate between the four groups, that was group 1 >group 2> group 3> group > 4 (P<0.01). ④ The 30 day survival rate was significantly different between fluid overload patients(n=62) and non-fluid overload patients (n=92) in the septic group (P<0.01), while in the non-septic group the 30-day survival rate had no significant difference between fluid overload patients (n=31) and non-fluid overload patients (n=76) (P=0.291). The 30-day survival rate was significant different between fluid overload patients (n=57) and non-fluid overload patients (n=78) in the SOFA ≥ 13 group (P=0.026), while in the SOFA<13 group the 30-day survival rate had no significant difference between fluid overload patients (n=35) and non-fluid overload patients (n=91) (P=0.074). Conclusions Fluid overload is closely associated with poor prognosis of critical ill patients with AKI. The removal of too much fluid through CRRT appears to reduce the mortality of severe AKI patients. The adverse effect of fluid overload on survival is more evident in AKI patients with sepsis or with more severe illness (SOFA ≥ 13).

Manejo de fluidos intravenosos: del uso indiscriminado y empírico al manejo racional y científico / Intravenous fluid management from indiscriminate and empirical use to rational and scientific manageme / Manejo de fluídos intravenosos do uso indiscriminado e empírico à administração racional e científica

Resumen: El fundamento básico de la terapia hídrica es aumentar el gasto cardiaco, mejorar la perfusión y la oxigenación tisular para garantizar el adecuado funcionamiento de órganos. La cantidad de líquidos administrada es esencial para el pronóstico; existe controversia sobre cuál solución es la mejor. La prescripción de fluidos intravenosos varía considerablemente a nivel mundial, la elección parece basarse en costumbres locales, comercialización, costos y disponibilidad de las soluciones; los registros globales de atención médica demuestran el uso indiscriminado de este recurso terapéutico de forma empírica, principalmente en la población adulta. Hoy se conocen, por múltiples estudios, los efectos adversos atribuidos a la sobrecarga hídrica, a las soluciones ricas en cloro y al impacto que tienen en los costos hospitalarios, la morbilidad y la mortalidad global. En este artículo se analizan todos estos factores y las nuevas directrices de manejo basadas en la evidencia científica.

Abstract: The basic basis of fluid therapy is to increase cardiac output, improve perfusion and tissue oxygenation to ensure proper organ function, the amount of fluids administered is critical to the prognosis and there is controversy over which fluid is better over the others. Globally, there is great variation in the prescription of intravenous fluids, the choice seems to be based on local customs, marketing, costs and availability of the solutions; The global records of health care demonstrate the indiscriminate use of this therapeutic resource in an empirical way mainly in the adult population, the adverse effects attributed to water overload, chloride rich solutions and the impact this leads to In hospital costs, morbidity and overall mortality. This article analyzes all these factors and the new management guidelines based on the scientific evidence.

Resumo: O fundamento básico da terapia hídrica é aumentar o débito cardíaco, melhorar a perfusão e a oxigenação tecidual para garantir o funcionamento adequado dos órgãos, a quantidade de fluído administrado é fundamental para o prognóstico e há controvérsia sobre qual solução é melhor do que as demais. A nível mundial, existe uma grande variação na prescrição de fluídos intravenosos, a escolha parece estar baseada nos costumes locais, comercialização, custos e disponibilidade de soluções; os registros globais de atenção médica demonstram o uso indiscriminado deste recurso terapêutico de forma empírica, principalmente na população adulta, hoje sabemos por meio de estudos múltiplos os efeitos adversos atribuídos à sobrecarga hídrica, as soluções ricas em cloro e ao impacto que isso leva nos custos hospitalares, morbidade e mortalidade global. Este artigo analisa todos esses fatores e as novas diretrizes de manejo baseadas em evidências científicas.

The risk factors and prognosis of septic shock patients treated with fluid overload / 中华急诊医学杂志

Objective To investigate the risk factors and prognosis of fl uid overload in patients with septic shock in order to provide guidelines for the reasonable optimization of fluid resuscitation to improve the prognosis of patients with septic shock. Methods A total of 203 septic shock patients admitted in ICU of the fi rst Hospital of Jinlin University from July 2013 to December 2016 were enrolled for retrospective study. The clinical data of all patients were collected to analyzed the differences in clinical settings and outcomes between fluid overload group (n=51) and non-fluid overload group (n=152). The risk factors of fluid overload were achieved using multiple logistic regression analysis. Results Compared with non-fl uid overload group, there were statistically higher levels of APACHE II score(27.5± 9.8 vs.22.7± 9.2,P=0.03),rate of congestive heart failure(17.6% vs.9.2%,P=0.02),rate of acute kidney injury(47.1% vs.29.6%, P=0.04), rate of liver cirrhosis(17.6% vs.9.2%,P=0.02), percentage of albumin≤20 g/L(39.2% vs.36.2%,P=0.03),percentage of blood transfusion(43.1% vs.15.1%,P=0.04), percentage of mechanical ventilation employed(64.7% vs.39.5%,P=0.02),volume of fluid infusion in 24 h(8.3 L vs.5.8 L,P=0.01),rate of renal replacement therapy(15.7% vs.7.9%,P=0.02),and mean duration of mechanical ventilation(4.5 d vs.2.6 d,P<0.01)found in fluid overload group.The hospital mortality of fluid overload group was higher than that of non-fluid overload group(45.1% vs.34.9%,P=0.01).The length of ICU stay in fluid overload group was longer than that of non-fluid overload group(6.8 d vs.3.8 d, P=0.02). The ICU re-admission rate within 48 h in fl uid overload group was higher than that in non-fluid overload group(7.8% vs.3.9%,P=0.03).with free fluid infusion without meticulous calculation of fluid volume(OR=2.65,95%CI:1.33-5.28,P=0.01)and serum albumin≤20 g/L(OR=2.35,95%CI:1.24-4.21,P=0.04)were more likely to develop fluid overload. Conclusion Fluid overload in septic shock patents is associated with poor prognosis. Free fl uid infusion without careful calculation of fl uid volume and severe hypo-albuminemia are the independent risk factors of fl uid overload in septic shock patients.

The method and challenge of combining extracorporeal membrane oxygenation and continuous renal replacement therapy / 中国小儿急救医学

Critical ill with cardiac and respiratory failure receiving extracorporeal membrane oxygenation ( ECMO ) often have comorbid of acute kidney injury and fluid overload. Continuous renal replacement therapy ( CRRT) is required. A variety of methods for combining ECMO and CRRT can be chosen. There are three major ways:performing CRRT through independent venous accessin-line connection ( connection of the hemofilter alone to the ECMO circuit ) , and a CRRT device connected to the ECMO circuit. The combination of ECMO and CRRT appears to be a safe and effective technique. The technique difficulties in concurrent extracorporeal life support system include CRRT device connection ways with ECMO by measuring intra-circuit pressure, anticoagulant use and monitoring access-related complications. The most important management is the CRRT inlet and outlet pressures deviating from the safety range at high ECMO circuit.