Department of Pediatrics & Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI.
Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL.
Pediatr Crit Care Med. 2017 Dec;18(12):1126-1135. doi: 10.1097/PCC.0000000000001349.
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.
Retrospective cohort study.
Six tertiary children's hospital ICUs.
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.
None.
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.
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.
描述液体超负荷的流行病学特征及其与儿童体外膜肺氧合治疗患者死亡率和体外膜肺氧合持续时间的关系。
回顾性队列研究。
6 家三级儿童医院重症监护病房。
2007 年 1 月 1 日至 2011 年 12 月 31 日，756 名年龄小于 18 岁、接受体外膜肺氧合治疗超过 24 小时的儿童。
无。
体外膜肺氧合脱管和出院的总生存率分别为 74.9%（n=566）和 57.7%（n=436）。体外膜肺氧合启动时的中位液体超负荷为 8.8%（四分位间距，0.3-19.2），在医院存活者和非存活者之间存在差异，尽管在体外膜肺氧合存活者和非存活者之间不存在差异。体外膜肺氧合时的中位峰值液体超负荷为 30.9%（四分位间距，15.4-54.8）。在体外膜肺氧合过程中，84.8%的患者出现了大于或等于 10%的峰值液体超负荷；67.2%的患者出现了大于或等于 20%的峰值液体超负荷，29%的患者出现了大于或等于 50%的峰值液体超负荷。在体外膜肺氧合存活的患者（27.2%比 44.4%；p<0.0001）和存活至出院的患者（24.8%比 43.3%；p<0.0001）中，峰值液体超负荷中位数较低。调整急性肾损伤、体外膜肺氧合开始时的 pH 值、非肾并发症、体外膜肺氧合模式、支持类型、中心和患者年龄后，体外膜肺氧合时的液体超负荷程度（p=0.05）和体外膜肺氧合时的峰值液体超负荷（p<0.0001）预测了存活患者的体外膜肺氧合持续时间。多变量分析显示，体外膜肺氧合时的峰值液体超负荷（调整比值比，1.09；95%可信区间，1.04-1.15）预测体外膜肺氧合死亡率；体外膜肺氧合时的液体超负荷（调整比值比，1.13；95%可信区间，1.05-1.22）和峰值液体超负荷（调整比值比，1.18；95%可信区间，1.12-1.24）均预测了医院死亡率。
液体超负荷在广泛的儿科体外膜肺氧合人群中很常见，与不良结局独立相关，包括死亡率增加和体外膜肺氧合持续时间延长。这些结果表明，液体超负荷是改善体外膜肺氧合患儿预后的潜在干预靶点。
