Continuous renal replacement therapy in children with severe sepsis and multiorgan dysfunction - A pilot study on timing of initiation
Kanav Anand, Krishna Gulla, P.K. Pruthi
Humans, Intensive Care Units, multiple organ failure, pediatrics, renal replacement therapy, sepsis, treatment outcome
Citation Information :
Anand K, Gulla K, Pruthi P. Continuous renal replacement therapy in children with severe sepsis and multiorgan dysfunction - A pilot study on timing of initiation. Indian J Crit Care Med 2015; 19 (10):613-617.
Objective: Scanty literature is available regarding continuous renal replacement therapy (CRRT) utility in severe sepsis with multiorgan dysfunction syndrome (MODS) from developing countries. Author unit′s experience in pediatric CRRT is described and outcome of early initiation of CRRT with sepsis and MODS is assessed.
Materials and Methods: Children aged <16 years with sepsis and MODS who required CRRT from September 2010 to February 2015 were analyzed on demographic factors, timing of initiation of CRRT, mode of CRRT, effect of CRRT onhemodynamics, oxygenation parameters, and outcome.
Results: Twenty-seven children required CRRT (male - 16). The median age was 11 years (range 1.1-16). Twenty-one had severe sepsis with MODS. Eighteen patients were given CRRT within 48 h of admission to Intensive Care Unit (ICU). Statistically significant improvement in the P/F ratio, decrement in plateau pressure and vasoactive-inotropic score were noted in survivor group compared to nonsurvivor group (P = 0.022, 0.00, and 0.03, respectively). There was no statistically significant difference in duration of ICU stay, fluid overload, CRRT duration, PRISM score at 12 and 24 h, percentage of decrease in inotrope score, plateau pressure, and percentage of increase in P/F ratio in relation to timing of CRRT initiation. However, the survival rate was 61.1% (11/18) who received CRRT within 48 h of ICU admission compared to 33.3% (3/9) who received after 48 h (P = 0.0001).
Conclusion: Our study emphasizes the CRRT role in improving the oxygenation status and hemodynamics. Survival benefit may be expected in those children who receive CRRT early in the course of sepsis. However, multicenter RCTs are required to prove mortality benefit.
Sutherland SM, Alexander SR. Continuous renal replacement therapy in children. Pediatr Nephrol 2012;27:2007-16.
Peng Y, Yuan Z, Li H. Removal of inflammatory cytokines and endotoxin by veno-venous continuous renal replacement therapy for burned patients with sepsis. Burns 2005;31:623-8.
Khilnani P, Sarma D, Zimmerman J. Epidemiology and peculiarities of pediatric multiple organ dysfunction syndrome in New Delhi. India. Intensive Care Med 2006;32:1856-62.
Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005;6:2-8.
Gaies MG, Jeffries HE, Niebler RA, Pasquali SK, Donohue JE, Yu S, et al. Vasoactive-inotropic score is associated with outcome after infant cardiac surgery: An analysis from the pediatric cardiac critical care consortium and virtual PICU system registries. Pediatr Crit Care Med 2014;15:529-37.
Khandelwal P, Sharma S, Bhardwaj S, Thergaonkar RW, Sinha A, Hari P, et al. Experience with continuous renal replacement therapy. Indian J Pediatr 2015;82:752-4.
Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al. Sepsis in European intensive care units: Results of the SOAP study. Crit Care Med 2006;34:344-53.
Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 2009;76:422-7.
Vaara ST, Korhonen AM, Kaukonen KM, Nisula S, Inkinen O, Hoppu S, et al. Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: Data from the prospective FINNAKI study. Crit Care 2012;16:R197.
Sakr Y, Vincent JL, Reinhart K, Groeneveld J, Michalopoulos A, Sprung CL, et al. High tidal volume and positive fluid balance are associated with worse outcome in acute lung injury. Chest 2005;128:3098-108.
Merlin C Thomas, Harris DC. Problems and advantages of continuous renal replacement therapy. Nephrology 2002;7:110-4.
Prowle JR, Kirwan CJ, Bellomo R. Fluid management for the prevention and attenuation of acute kidney injury. Nat Rev Nephrol 2014;10:37-47.
Arikan AA, Zappitelli M, Goldstein SL, Naipaul A, Jefferson LS, Loftis LL. Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med 2012;13:253-8.
Goldstein S, Somers MJ, Baum M, Symons JM, Brophy PD, Blowey D, et al. Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 2005;67:653-8.
Proulx F, Gauthier M, Nadeau D, Lacroix J, Farrell CA. Timing and predictors of death in pediatric patients with multiple organ system failure. Crit Care Med 1994;22:1025-31.
Modem V, Thompson M, Gollhofer D, Dhar AV, Quigley R. Timing of continuous renal replacement therapy and mortality in critically ill childrenFNx01. Crit Care Med 2014;42:943-53.
Shi J, Chen Q, Yu W, Shen J, Gong J, He C, et al. Continuous renal replacement therapy reduces the systemic and pulmonary inflammation induced by venovenous extracorporeal membrane oxygenation in a porcine model. Artif Organs 2014;38:215-23.
Basu RK, Wheeler DS, Goldstein S, Doughty L. Acute renal replacement therapy in pediatrics. Int J Nephrol 2011;2011:785392.