Scott I. Aydin

Acute kidney injury in pediatric acute decompensated heart failure

Objective: Acute kidney injury in adult patients with acute decompensated heart failure is associated with increased mortality. There is limited literature in pediatric patients with acute decompensated heart failure and acute kidney injury. We aim to study acute kidney injury in the pediatric acute decompensated heart failure population and its association with specific outcomes. Design: Retrospective, case-control study. Setting: Cardiac ICU in a children’s tertiary care hospital. Patients: Index admissions of patients younger than 21 years with acute decompensated heart failure between January 2008 and December 2012. Interventions: None. Measurements and Main Results: Index admissions of patients younger than 21 years with acute decompensated heart failure between January 2008 and December 2012 were reviewed, and the presence or absence of acute kidney injury at admission was determined based on the Pediatric Risk, Injury, Failure, Loss, End-Stage criteria. Descriptive statistics and multivariate analyses were performed to determine the association between acute kidney injury and a composite outcome of cardiac transplantation and/or mortality. Fifty-seven patients, with median age 12 years (interquartile range, 1.1, 16), were included for study. The median left ventricular ejection fraction was 27% (interquartile range, 18, 48). Twenty-one patients (36%) underwent cardiac transplantation and five patients (8.7%) died. Of the 57 patients, 44 (77%) had evidence of acute kidney injury (41% Risk; 39% Injury; 20% Failure). Of the 44 patients with acute kidney injury, 25 (57%) met the composite outcome, compared with 1 (7%) without acute kidney injury. Multivariate analyses demonstrated that a left ventricular ejection fraction up to 25% was significantly associated with the presence of acute kidney injury (adjusted odds ratio, 12.3; 95% CI, 1.4–109; p = 0.03), and acute kidney injury was significantly associated with the composite outcome (adjusted odds ratio, 19.1; 95% CI, 2.3–160; p < 0.001). Conclusions: Acute kidney injury is common during the initial presentation of pediatric patients with acute decompensated heart failure. A left ventricular ejection fraction up to 25% is associated with acute kidney injury. The presence of acute kidney injury in this population is significantly associated with cardiac transplantation and/or death.

238: THE RELATIONSHIP OF PDA FLOW PATTERNS WITH CLINICAL PARAMETERS IN NEONATES ON VENOVENOUS ECMO

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Extracorporeal membrane oxygenation (ECMO) has been used in over 27,000 neonates with respiratory failure. Of these, approximately 6,700 have been treated with venovenous (VV) ECMO. Currently, more of these patients are being supported with VV ECMO, as ligation of the carotid artery is spared and central nervous system complications are lessened. Increases in pulmonary vascular resistance (PVR) may lead to extra-pulmonary shunting of blood via right-to-left (R-L) flow through the patent ductus arteriosus (PDA) and patent foramen ovale. Previous studies have shown that R-L flow before ECMO initiation is associated with lower survival rates. We hypothesized that the direction of flow within and size of the PDA while on VV ECMO would be associated with the need for conversion to VA ECMO and to survival. Methods: A retrospective chart review of patients supported with VV ECMO for neonatal respiratory failure from January 2011 through September 2015 in 3 academic children’s hospitals. PDA size, direction of blood flow, and estimation of pulmonary artery pressure (or PVR if the PDA was non-restrictive) were recorded by echocardiography closest to 48 hours on ECMO. Chisquared and Fisher Exact test were used where appropriate. Univariate and multivariate regression was performed to compare variables associated with survival and conversion from VV to VA ECMO. Results: 41 patients were initially supported on VV ECMO. Of these, 8 (19%) were converted to VA ECMO, and 30 (73%) survived. The average hour on ECMO for the echocardiogram was 71 hours (range 20–167 hours). On univariate analysis lower weight, a higher vasoactive infusion score (VIS), and use of iNO, milrinone, sildenafil and iloprost were associated with conversion to VA ECMO. The absence of renal or neurologic diagnosis, lower VIS, and no need for iNO, milrinone and sildenafil were associated with increased survival to 24 hours after decannulation. PDA size and direction of blood flow were not associated with conversion to VA ECMO or survival. No variables remained significant on multivariate analysis. Conclusions: PDA size and flow pattern in patients already on VV ECMO were not associated with conversion to VA ECMO or survival to 24 hours after decannulation. On univariate analysis other factors were associated with these endpoints.