Objective To describe post-operative fluid overload patterns and correlate degree of fluid overload with intensive care morbidity and mortality in infants undergoing congenital heart surgery. Design Prospective, observational study. Fluid overload (%) was calculated by two methods: 1. (Total fluid In – Total fluid Out)/(Pre-op weight) x 100; and 2. (Current weight – Pre-op weight)/(Pre-op weight) x 100. Composite poor outcome included: need for renal replacement therapy, upper quartile time to extubation or intensive care length of stay (> 6.5 and 9.9 days, respectively), or death ≤ 30 days post-surgery. Setting University hospital pediatric cardiac intensive care unit. Patients Forty-nine infants < 6 months of age undergoing congenital heart surgery with cardiopulmonary bypass during the period of July 2009 to July 2010. Interventions None Measurements and Main Results Patients had a median age of 53 days (21 neonates) and mean weight of 4.5±1.3 kg. 42 patients (86%) developed acute kidney injury by meeting at least AKIN/KDIGO stage 1 criteria (SCr rise of 50% or ≥0.3 mg/dL). The patients with adverse outcomes (N=17, 35%) were younger [7 (5–10) vs. 98 (33–150) days, p=0.001], had lower pre-operative weight (3.7±0.7 vs. 4.9±1.4 kg, p=0.0002), higher post-operative mean peak serum creatinine (0.9±0.3 vs. 0.6±0.3 mg/dL, p=0.005), and higher mean maximum fluid overload by both method 1 (12±10 vs. 6±4%, p=0.03) and method 2 (24±15 vs. 14±8%, p=0.02). Predictors of a poor outcome from multivariate analyses were cardiopulmonary bypass time, use of circulatory arrest, and increased vasoactive medication requirements post-operatively. Conclusions Early post-operative fluid overload is associated with suboptimal outcomes in infants following cardiac surgery. Since the majority of patients developed kidney injury without needing renal replacement therapy, fluid overload may be an important risk factor for adverse outcomes with all degrees of acute kidney injury.

Objective To assess the ability of urinary acute kidney injury biomarkers and renal near-infrared spectroscopy (NIRS) to predict outcomes in infants following congenital heart surgery. Methods Urinary levels of neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1), and cystatin C were measured pre- and post-operatively in 49 infants <6 months of age. Renal NIRS was monitored for the first 24 h following surgery. A composite poor outcome was defined as death, the need for renal replacement therapy, prolonged time to first extubation, or prolonged ICU length of stay. Results Forty-two patients (86%) developed acute kidney injury by meeting at least AKIN/KDIGO stage 1 criteria, and 17 (35%) patients experienced poor outcomes, including three deaths. With the exception of KIM-1, all biomarkers demonstrated significant increases within 24 h post-operatively among patients with poor outcomes. Low levels of NGAL and IL-18 demonstrated high negative predictive values (91%) within 2 h post-operatively. Poor outcome infants had greater cumulative time with NIRS saturations <50% (60 vs. 1.5 min, p=0.02) in the first 24 h. Conclusions Within the first 24 h following cardiopulmonary bypass, infants at increased risk for poor outcomes demonstrated elevated urinary NGAL, IL-18, and cystatin C, and increased time with low NIRS saturations. These findings suggest that urinary biomarkers and renal NIRS may differentiate patients with good vs. poor outcomes in the early post-operative period which could assist clinicians when counseling families and inform the development of future clinical trials.

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