1. Fluid Overload Prior To Continuous Hemofiltration and Survival in Critically Ill Children
J Foland, J Fortenberry, B Warshaw,
R Pettignano, R Merritt, M Heard, K Rogers,
C Reid, A Tanner, K Easley
Children’s Healthcare of Atlanta at Egleston
Emory University School of Medicine
Atlanta, Georgia
Accepted for publication in Critical Care Medicine, August 2004

2. Background
Renal replacement therapy is used for primary and secondary renal failure
Continuous venovenous hemofiltration (CVVH) is the preferred modality in our ICUs

3. Background Goldstein et al. (Pediatrics, 2000)
21 ICU children on CVVH(D)
 Survival associated with  ICU fluid overload prior to CVVH
GFR had no association with survival
Lane et al. (Bone Marrow Transplant, 1994)
30 pediatric BMT recipients
Survival associated with < 10% weight gain from baseline

4. Hypotheses
CVVH survivors have less fluid overload than non-survivors prior to CVVH
Increasing fluid overload prior to CVVH is associated with decreasing survival

5. Methods
Database of all Egleston patients receiving CVVH from Nov ‘97 to Dec ‘02 (excluding ECMO)
Review of
Demographics
Diagnoses
Clinical & laboratory findings
Indication for CVVH

6. Total Input - Total Output (L)*
Definitions
Total fluid overload (%)
For 7 days prior to CVVH
GFR: Schwartz Formula
Total Input - Total Output (L)*
Ideal Body Weight (kg)
X 100

7. Total Input - Total Output (L)*
Definitions
ICU fluid overload (%)
From ICU admission to CVVH initiation
Total Input - Total Output (L)*
Ideal Body Weight (kg)
X 100

8. Results 113 patients received CVVH Median 71% intubated
Age: 9.6 years (2.5, 14.3)
Number of days on CVVH: 4 (2.0, 10.0)
PRISM III: 13 (9.0, 17.0)
%Fluid Overload: 10.9 (2.8, 22.1)
Creatinine: 3.1 (1.7, 4.9) mg/dL
71% intubated
70% vasoactive infusions

9. Patient Diagnoses

10. CVVH Indications

11. Patient Survival * 
*p= vs. Primary Renal Failure

12. Severity of Illness Survival‡ * †
PRISM III
Intubated
Vasoactive
Infusions
* p<0.001
† p<0.001
‡ p=0.009

13. Days in Hospital Prior to CVVH All Patients*
Survival
*p<0.001

14. Days in ICU prior to CVVH All Patients*
Survival
*p=0.03

15. Median % Fluid Overload All Patients
Total % Fluid Overload *
Survival
*p=0.02

16. Median % Fluid Overload MODS &  3 Organ Involvement
Total % Fluid Overload *
Survival
*p=0.01

17. Patient Outcomes No survival difference seen with... Duration of CVVH
Ultrafiltration rates
Membrane Type
Estimated GFR
Age adjusted serum creatinine
P/F ratios

18. Multivariable Analysis Factors Associated with Mortality

19. Multivariable Analysis Factors Associated with Mortality

20. Multivariable Analysis Factors Associated with Mortality

21. Conclusions CVVH survivors had Less fluid overload prior to CVVH
Less cardiovascular support
Less respiratory support

22. Conclusion: Fluid Overload
Our review suggests that increasing fluid overload is associated with decreased survival in pediatric patients receiving CVVH, particularly those with  3 organ MODS

23. Speculation
Total percent fluid overload prior to CVVH may be a better predictor of survival than other indicators of severity of illness in select patients

24. Speculation
Earlier use of CVVH, prior to excessive fluid overload, in critically ill children may be associated with increased survival

25. Questions?