DETERMINANTS OF SURVIVAL IN PEDIATRIC CONTINUOUS HEMOFILTRATION

Continuous hemofiltration (CH) is being used in increasing numbers of pediatric intensive care unit patients. Experience with 114 CH treatme nts in 98 critically ill children from March 1988 to March 1993 is pre sented in this study. Ages ranged from 1 day to 23 yr (mean +/- SE = 7 .1 +/- 0.7 yr), and 54% of patients were male. Seventeen percent of al l treatments were performed in neonates under 1 month of age. The most common primary diagnoses were sepsis and adult respiratory distress s yndrome (11 patients each), liver transplantation and hypoplastic left heart syndrome (10 patients each), and hemolytic uremic syndrome (9 p atients). The most frequent indications for CH were fluid overload and acute renal failure (42% each). Choices for CH included: continuous a rteriovenous hemofiltration (CAVH, 50%), continuous arteriovenous hemo diafiltration (CAVH-D, 23%), continuous venovenous hemofiltration (CVV H, 18%), and continuous venovenous hemodiafiltration (CVVH-D, 9%). Cho ices for anticoagulation included: none (47%), regional (49%), and sys temic (4%). Treatment duration ranged from 1 to 25 days (mean = 5.3 +/ - 0.4 days). Mean filter life span for 363 filters was 0.94 +/- 0.1 fi lters/patient per day. Despite an overall survival rate of 43%, surviv al to discharge varied greatly (0 to 100%) among the 24 diagnostic gro ups: tumor lysis syndrome and systemic lupus erythematosus (3/3 patien ts each, 100%), hemolytic uremic syndrome (8/9 patients, 89%). This co mpares with: bone marrow transplantation (0/6 patients, 0%), hypoplast ic left heart syndrome (2/10 patients, 20%), and leukemia (1/4 patient s, 25%). Survival to hospital discharge was better in patients who did not receive pressors (P < 0.005) and in patients treated with combine d ultrafiltration and dialysis (CAVH-D, CVVH-D) compared with ultrafil tration alone (CAVH, CVVH) (P < 0.005), but was not notably affected b y patient age, sex, use of anticoagulation, filter life span, blood pu mp-assisted versus spontaneous CH, or duration of therapy. Filter life span was not affected by use of anticoagulation, but was remarkably l onger in patients with arteriovenous versus venovenous CH (P < 0.004). It was concluded that: (1) empirical anticoagulation of patients trea ted with CH is not necessary; (2) children with a minority of underlyi ng diseases and those requiring presser support at initiation of CH ap pear to have relatively poor survival rates despite the technically ef fective use of CH; and (3) the addition of countercurrent dialysis to routine CH may enhance patient survival to hospital discharge.