Systemic Fluid removal improves ECMO outcomes and reduces acute kidney injury in children

USA: There is a reduced incidence of Acute Kidney Injury (AKI) in pediatric patients associated with the application of a fluid management algorithm supported with extracorporeal membrane oxygenation (ECMO), a study has revealed.

The researchers have shown that there is an association between AKI and mortality. They added that there is an increased risk of AKI-associated mortality with an increasing percentage of Fluid Overload (FO) at ECMO initiation.

The study published in the European Journal of Pediatrics further stated that incorporating a systematic fluid management protocol supported by ECMO proves feasible in children.

It is already known that AKI and fluid overload are associated with morbidity and mortality in children supported by ECMO, with a higher incidence of AKI ranging from 50 to 75 %. This Extracorporeal advanced mechanical circulatory support is used in critically ill neonates and children who do not respond to conventional medical therapies and have acute respiratory or cardiovascular failure.

Considering this, Dr Megan M. SooHoo, from the Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Anschutz Medical Campus, USA and colleagues aimed to evaluate and determine whether fluid management algorithm reduces AKI and mortality in children supported by ECMO. This retrospective study included pediatric patients aged birth to 25 years. It had a fluid management algorithm for protocolized fluid removal after deriving a daily fluid goal using a combination of diuretics and ultrafiltration.

For this, Data was collected for the first ten days of ECMO support. Patients were divided into four categories based on the primary reason, namely "Respiratory", "Shock", "Cardiac", and "ECPR".

Fluid balance goals were directed in 24-h increments. Using UF(ultrafiltration), the ECMO specialist titrated the diuretic infusion and/or mechanical fluid removal. The target was to achieve a minimum urine output of 1 mL/kg/h (every two h).

Daily algorithm compliance was defined as ≥ 12 h on the algorithm daily. The primary and secondary outcomes were AKI and mortality, respectively.

The study led to the following findings:

• ECMO was required by two hundred and ninety-nine children of median age 5.3 months and 45% male.

• The fluid algorithm was applied to 74 patients.

• During ECMO, the overall AKI rate was recorded as 38% (26% severe—stage 2/3).

• Patients managed on the algorithm had a lower incidence of AKI and mortality with p values of 0.02 and 0.05, respectively and was significant.

• The algorithm utilization was related to lower odds of AKI (aOR: 0.40 and p = 0.005, after adjusting for confounders.

• The algorithm utilization was not associated with mortality reduction (after adjusting for confounders).

• Algorithm compliance (80–100%) was associated with a 54% reduction in mortality (aOR:0.46 and p = 0.05) in the sub-analysis.

The findings indicate that fluid management algorithm usage reduces the odds of AKI and mortality is lower on achieving better compliance with the algorithm.

This implies that systematic fluid removal may improve ECMO-related outcomes.

The study added to the previous research that a protocolized approach for fluid removal in children supported by extracorporeal membrane oxygenation is associated with a reduced incidence of Acute kidney injury. The more adherence to the protocol, the more reduced the incidence of mortality.

The researchers believed that their findings are a vital construct with the overall goal of reducing FO and AKI-related poor outcomes in children supported by ECMO.

Further reading:

SooHoo, M.M., Shah, A., Mayen, A. et al. Effect of a standardized fluid management algorithm on acute kidney injury and mortality in pediatric patients on extracorporeal support. Eur J Pediatr (2022).