Huijink, T.A.H. (2014) Renal and myocardial dysfunction in mechanically ventilated children during the era of lung-protective ventilation. thesis, Medicine.
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Abstract
Introduction: Mechanical ventilation (MV) is often lifesaving for patients who are no longer able to guarantee their own gas exchange, though it can also lead to the initiation or aggravation of lung injury (VILI). Despite the fact that lung protective forms of ventilation are used in adults nowadays, the morbidity and mortality of mechanical ventilation are still significant. Besides this, mechanical ventilation can also lead to multi organ failure (MODS). The main organs involved appear to be the heart and kidneys, whereas the effect of VILI on renal failure (acute kidney injury, AKI) is more clearly examined than the effect on myocardial injury. Because research has shown the positive effects of lung protective ventilation in adults, it is also applied to children. Nevertheless, there are no clinical data that supports this method of ventilation for (critically ill) children. In addition, the relationship between MV and MODS has not yet been studied in the pediatric subgroup. Therefore, the purpose of this study is to examine the prevalence and time course of renal failure and myocardial damage in mechanical ventilated children. In addition, the association between the ventilation settings and the onset of renal failure and myocardial damage was mapped, as well as the association between the existence of organ damage and the need for renal replacement therapy and mortality in mechanical ventilated children. Materials and methods: The study was designed as a single-center prospective cohort study in the period from October 1st 2013 to mid-February 2014, at the 20-bed PICU facility in the UMCG. Patients aged between 0-5 years with acute hypoxemic respiratory failure were enrolled if they were mechanically ventilated for more than 24 hours and had no pre-existing kidney- or heart failure. Renal failure was defined according to the pRIFLE criteria. Myocardial damage was assessed via hs Troponine T levels. Patients were divided into groups according to existence of AKI and myocardial damage. Every hour for 5 days, the minimum, maximum and mean of the tidal volume (VT), the positive inspiratory pressure (PIP) and the positive end-expiratory pressure (PEEP) were registered. These data were used to analyze the effect of mechanical ventilation settings in the different subgroups. The Student t test, Mann Whitney U test, Pearson's χ2 and Fisher's exact test were used for data analysis. IBM SPSS statistics (version 20.0 New York, USA) was used for the statistical analysis, in which the significance was put at P <0.05. Results: 36 patients were enrolled. 30.6% of the patients met the pRIFLE criteria at some point, of which 91 % were already RIFLE-classified on the day of admission. There was progression of AKI in 45% during the first 5 days. All of the patients with AKI had elevated Troponin-levels (P < 0.05). The presence of AKI was not associated with higher inotropic/vasopressor agent use, more renal replacement therapy (RRT) or higher mortality. The type of ventilation (HFO vs. conventional) and the ventilation settings (VT, PIP, PEEP) did not affect the onset or course of AKI. Myocardial damage (hsTroponineT > 14 ng / l) was found in 77% of the study population, of which 81 % had myocardial damage on the day of admission. 30% of the patients had progression of myocardial injury during admission. Both the form of mechanical ventilation and the ventilation settings had no significant effect on the initiation or course of myocardial injury. Finally, the presence of myocardial injury was not associated with higher inotropic/vasopressor agent use, more renal replacement therapy (RRT), or higher mortality. Conclusion: AKI and myocardial damage were frequently found in mechanically ventilated children admitted in the PICU, often already on the day of admission. No association was found between the mode of ventilation or ventilation settings and the presence of AKI or myocardial injury. Furthermore, no relationship has been found between the presence of organ dysfunction and either the need for renal replacement therapy or mortality. This research is a pilot study and follow-up with a larger sample size is needed to support these conclusions.
| Item Type: | Thesis (Thesis) |
|---|---|
| Supervisor name: | Kneyber, Dr. M.C.J. |
| Faculty: | Medical Sciences |
| Date Deposited: | 25 Jun 2020 10:44 |
| Last Modified: | 25 Jun 2020 10:44 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/538 |
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