Incidence and outcome of acute kidney injury by the pRIFLE criteria for children receiving extracorporeal membrane oxygenation after heart surgery.

BACKGROUND: Acute kidney injury (AKI) is common in patients treated with extracorporeal membrane oxygenation (ECMO). The RIFLE criteria demonstrate clinical relevance for diagnosing AKI and classifying its severity. OBJECTIVES: To systematically define the incidence, clinical course and outcome of AKI using the pediatric pRIFLE criteria. DESIGN: Retrospective, medical records review. SETTINGS: Pediatric cardiac surgical intensive care units at a tertiary care hospital in Riyadh. PATIENTS AND METHODS: We reviewed the records of all pediatric patients that underwent cardiac surgery and required ECMO postoperatively between 1 January 2011 and 1 January 2016. AKI was classified according to the pRIFLE criteria 48 hours after ECMO initiation. Demographics and concomitant therapies for all patients were collected. MAIN OUTCOME MEASURE(S): Outcome was assessed by recovery from AKI at time of discharge, ICU stay and mortality. RESULTS: Fifty-nine patients needed ECMO after cardiac surgery during the study period. Their mean (SD) age and weight was 11.0 (16.5) month and 5.5 (3.6) kg, respectively. All patients had a central venoarterial ECMO inserted. Fifty-three patients (90%) developed AKI after ECMO initiation. The majority of patients (57%) were categorized as pRIFLE-Failure, having a higher mortality rate (28/34 patients, 82%) in comparison to the pRIFLE-Injury and pRIFLE-Risk groups. Twenty-nine patients (49%) required either peritoneal dialysis (PD), or renal replacement therapy (RRT) or both. For AKI vs non-AKI patients, there was a statistically significant difference between mean (SD) ECMO duration (9.0 [8.00] vs 6.0 [2.0] days; P=.02) and ICU stay (37.0 [41.0] vs 21.0 [5.0] days; P=.03), respectively. The overall mortality rate was 58%, with a significant difference (P=.03) between AKI and non-AKI groups. All the patients who survived had normal creatinine clearance at hospital discharge. CONCLUSION: There is a high incidence of AKI in pediatric patients requiring ECMO after cardiac surgery, and it is associated with higher mortality, increased ECMO duration, and increased ventilator days. LIMITATIONS: Single-center retrospective analysis and the small sample size limited the precision of our estimates in sub-populations.

The efficacy of the COMFORT score and pain management protocol in ventilated pediatric patients following cardiac surgery.

BACKGROUND AND OBJECTIVES: An optimal scoring system for pain assessment in pediatric intensive care is necessary to determine the efficacy of analgesics. We assess the COMFORT scale in postoperative ventilated children and study the effect of pain and sedation protocols on their outcomes. PATIENTS AND METHODS: We included postoperative ventilated patients. The unit-based pain management protocol was used. The assessment of the COMFORT and FLACC scales was performed by 2-nurses at 2-h intervals on the day of surgery and at 4-h intervals during the first 2-postoperative days or until the patient was ex-tubated. The patients' outcomes were compared with age-matched and RACHS score matched patients prior to the application of the pain protocol. RESULTS: One-hundred-ten prospective patients were included. The mean age and weight was 24 months and 9.8 ± 8.4 kg, respectively. There was a weak, statistically significant correlation between the COMFORT and FLACC scales, with a range of (r = 0.01-0.7). The COMFORT scale demonstrated good internal consistency, with a Cronbach's alpha of 0.75. The mean ventilation days were 1.3 ± 3, with a mean ICU and hospital stay of 5 ± 5 and 10 ± 9 days, respectively. The 110 patients were compared to 50 retrospective matching patients. The prospective group demonstrated statistically less ventilation days, ICU stay time and hospital stay time, with P-values of 0.0004, 0.001 and 0.0003, respectively. CONCLUSION: The COMFORT scale is a valuable and reliable pain assessment tool for use in postoperative ventilated pediatric patients. The implementation of a pain and sedation protocol decreased the incidence of withdrawal and the duration of mechanical ventilation as well as ICU and hospital stays.