M Sagy1, P Silver. 1. Division of Critical Care Medicine, Schneider Children's Hospital, Long Island Jewish Medical Center, New Hyde Park, NY 11040-1432, USA.
Abstract
OBJECTIVE: To describe a method of rapid fluid removal in children with anasarca and the acute respiratory distress syndrome (ARDS) secondary to sepsis or the systemic inflammatory response syndrome. DESIGN: Consecutive case series. SETTING: Pediatric Intensive Care Unit of a children's hospital. PATIENTS: Six patients with ARDS secondary to sepsis or systemic inflammatory response syndrome, who had persistent anasarca complicating their respiratory course despite intravenous diuretic therapy. INTERVENTIONS: Continuous flow peritoneal dialysis (CFPD) was instituted after percutaneously inserting two Tenckhoff dialysis catheters into the peritoneal cavity of each patient and tunneling them through the subcutaneous tissue to exit from opposite lower abdominal quadrants. A dialysis solution with 2.5% dextrose was administered continuously via one of the catheters at a rate ranging from 10-30 mL/kg/hr, and concomitantly drained via the other catheter. The concentration of the dialysis solution and rate of inflow were adjusted as needed to achieve the desired peritoneal outflow rate. CFPD was discontinued when adequate weight loss had occurred and the patient's daily urine output exceeded their daily fluid intake. The patient's overall fluid balance and change in weight were recorded daily. The PaO2/FiO2 ratio, alveolar-arterial oxygen gradient, and oxygenation index were also calculated daily. MEASUREMENTS AND MAIN RESULTS: Six patients with ARDS, mean age 18.7+/-37.0 months were mechanically ventilated for 8.0+/-4.0 days before CFPD, during which time average body weight increased to 63%+/-22% above admission body weight, despite the use of intravenous diuretic therapy. They underwent CFPD for 126.7+/-60.0 hrs, during which time their body weight decreased to 30%+/-12% above admission weight (p<.05). During dialysis, the dialysis outflow rate exceeded the inflow rate by 4.2+/-0.9 mL/kg/hr. When compared with values calculated immediately before starting CFPD, post-CFPD PaO2/FiO2 increased from 97.0+/-32.0 to 215.0+/-40.4 mm Hg (12.9+/-4.3 to 28.7+/-5.4 kPa) (p<.05), post-CFPD alveolar-arterial oxygen gradient decreased from 390.7+/-85.8 to 206.7+/-72.8 mm Hg (52.1+/-11.4 to 27.6+/-9.7 kPa) (p<.05), and post-CFPD the oxygenation index decreased from 29.6+/-9.8 to 11.8+/-5.6 (p<.05). There were no complications associated with dialysis catheter insertion or CFPD therapy. Four patients survived. Two patients had an irreversible course of infections and septic shock and died. CONCLUSION: Severe anasarca in the course of ARDS can be effectively treated in pediatric patients with continuous flow peritoneal dialysis, resulting in a significant improvement in respiratory status.
OBJECTIVE: To describe a method of rapid fluid removal in children with anasarca and the acute respiratory distress syndrome (ARDS) secondary to sepsis or the systemic inflammatory response syndrome. DESIGN: Consecutive case series. SETTING: Pediatric Intensive Care Unit of a children's hospital. PATIENTS: Six patients with ARDS secondary to sepsis or systemic inflammatory response syndrome, who had persistent anasarca complicating their respiratory course despite intravenous diuretic therapy. INTERVENTIONS: Continuous flow peritoneal dialysis (CFPD) was instituted after percutaneously inserting two Tenckhoff dialysis catheters into the peritoneal cavity of each patient and tunneling them through the subcutaneous tissue to exit from opposite lower abdominal quadrants. A dialysis solution with 2.5% dextrose was administered continuously via one of the catheters at a rate ranging from 10-30 mL/kg/hr, and concomitantly drained via the other catheter. The concentration of the dialysis solution and rate of inflow were adjusted as needed to achieve the desired peritoneal outflow rate. CFPD was discontinued when adequate weight loss had occurred and the patient's daily urine output exceeded their daily fluid intake. The patient's overall fluid balance and change in weight were recorded daily. The PaO2/FiO2 ratio, alveolar-arterial oxygen gradient, and oxygenation index were also calculated daily. MEASUREMENTS AND MAIN RESULTS: Six patients with ARDS, mean age 18.7+/-37.0 months were mechanically ventilated for 8.0+/-4.0 days before CFPD, during which time average body weight increased to 63%+/-22% above admission body weight, despite the use of intravenous diuretic therapy. They underwent CFPD for 126.7+/-60.0 hrs, during which time their body weight decreased to 30%+/-12% above admission weight (p<.05). During dialysis, the dialysis outflow rate exceeded the inflow rate by 4.2+/-0.9 mL/kg/hr. When compared with values calculated immediately before starting CFPD, post-CFPD PaO2/FiO2 increased from 97.0+/-32.0 to 215.0+/-40.4 mm Hg (12.9+/-4.3 to 28.7+/-5.4 kPa) (p<.05), post-CFPD alveolar-arterial oxygen gradient decreased from 390.7+/-85.8 to 206.7+/-72.8 mm Hg (52.1+/-11.4 to 27.6+/-9.7 kPa) (p<.05), and post-CFPD the oxygenation index decreased from 29.6+/-9.8 to 11.8+/-5.6 (p<.05). There were no complications associated with dialysis catheter insertion or CFPD therapy. Four patients survived. Two patients had an irreversible course of infections and septic shock and died. CONCLUSION: Severe anasarca in the course of ARDS can be effectively treated in pediatric patients with continuous flow peritoneal dialysis, resulting in a significant improvement in respiratory status.