Fluid Overload Is Associated With Late Poor Outcomes in Neonates Following Cardiac Surgery*

Abstract

Objective Acute kidney injury (AKI) is a severe complication of cardiac surgery associated with increased morbidity and mortality, yet AKI classification for neonates remains challenging. We characterized patterns of post-operative fluid overload (FO) as a surrogate marker for AKI and as a risk factor of poor post-operative outcomes in neonates undergoing cardiac surgery. Design Retrospective cohort study. Setting Single, congenital heart center destination program. Patients 435 neonates undergoing cardiac surgery with cardiopulmonary bypass from January 2006 through December 2010. Interventions None Measurements and Main Results Demographics, diagnosis, and perioperative clinical variables were collected, including daily weights and serum creatinine (SCr) levels. A composite poor clinical outcome (death, need for renal replacement therapy (RRT), or extracorporeal life support (ECLS) within 30 post-operative days) was considered the primary outcome measure. Twenty-one neonates (5%) had a composite poor outcome with 7 (2%) requiring RRT, 8 (2%) requiring ECLS, and 14 (3%) dying between 3 and 30 days post-surgery. Neonates with a composite poor outcome had significantly higher maximum FO (>20%) and were slower to diurese. A receiver-operating characteristic curve determined that FO ≥ 16% and SCr ≥ 0.9 on post-operative day 3 were the optimal cutoffs for significant discrimination on the primary outcome (area under the curve = 0.71 and 0.76, respectively). In multivariable analysis, FO ≥ 16% (adjusted odds ratio [AOR] = 3.7) and SCr ≥ 0.9 (AOR = 6.6) on post-operative day 3 remained an independent risk factor for poor outcome. FO ≥ 16% was also significantly associated with cardiac arrest requiring cardiopulmonary resuscitation, prolonged intensive care unit stay, and chest re-exploration. Conclusions This study highlights the importance of monitoring fluid balance in the neonatal cardiac surgical population, and suggests that daily FO, a readily-available, non-invasive marker of renal function, may be a sensitive and specific predictor of adverse outcomes.

Acute kidney injury in the fetus and neonate

“…For example, in a retrospective chart review of 80 children with mean ages 58.7 ± 73 months with respiratory failure, Arikan et al found that fluid overload of ≥15% was independently associated with longer hospital stay, longer duration of ventilation, and worse oxygenation index [66]. A recent retrospective study analyzed data from 435 neonates who underwent cardiac surgery with cardiopulmonary bypass and found that fluid overload of ≥16% was an independent risk factor for worse outcomes [67]. …”

Peritoneal dialysis during congenital heart surgery admissions: insights from a large database

“…Fluid overload and acute kidney injury are serious complications in children after congenital heart surgery, with a documented prevalence as high as 45%. 14 No consensus has been reached as to how to best prevent fluid overload or acute kidney injury or how to manage these conditions if they develop. Peritoneal dialysis appears as a reasonable strategy to help manage fluid removal and clearance from a physiological point of view, but limited data exist to demonstrate that this provides benefit when compared to fluid restriction and dieresis.…”

“…21,23 Historically and currently, the prophylactic placement of a peritoneal dialysis catheter has depended on physician preference. 14,26 This decision is often based on thorough assessment of the likelihood that fluid overload or acute kidney injury may develop in the post-operative setting based on characteristics such as age, complexity of the congenital heart surgery, and duration of cardiopulmonary bypass. 27 Thus, disease severity or the perception of severity still appears to be the major factors for determining the use of peritoneal dialysis.…”

Consenso de lesión renal aguda en el recién nacido Comité Nacional de Nefrología (2018-2019)

“…En un estudio en el que se incluyeron más de 400 neonatos sometidos a cirugía cardíaca que presentaron LRA, se determinó que una sobrecarga de líquidos superior al 16 % estuvo asociada de manera estadísticamente significativa a mal pronóstico (mayor mortalidad, días de hospitalización y prolongación en días de asistencia respiratoria mecánica). 13 Estadío prerrenal: se recomienda la administración endovenosa de solución salina isotónica a razón de 10-20 ml/kg en una-dos horas. 14 IRA intrínseca: para los RN con oliguria o anuria, el aporte se limita a pérdidas insensibles más la eventual diuresis.…”