Early Right Ventricular Systolic Dysfunction and Pulmonary Hypertension Are Associated With Worse Outcomes in Pediatric Acute Respiratory Distress Syndrome

Objectives: The prevalence and importance of early right ventricular dysfunction and pulmonary hypertension in pediatric acute respiratory distress syndrome are unknown. We aimed to describe the prevalence of right ventricular dysfunction and pulmonary hypertension within 24 hours of pediatric acute respiratory distress syndrome diagnosis and their associations with outcomes. Design: Retrospective, single-center cohort study. Setting: Tertiary care, university-affiliated PICU. Patients: Children who had echocardiograms performed within 24 hours of pediatric acute respiratory distress syndrome diagnosis. Interventions: None. Measurements and Main Results: Between July 1, 2012, and June 30, 2016, 103 children met inclusion criteria. Echocardiograms were analyzed using established indices of right ventricular and left ventricular systolic function and for evidence of pulmonary hypertension. Echocardiographic abnormalities were common: 26% had low right ventricular fractional area change, 65% had low tricuspid annular plane systolic excursion, 30% had low left ventricular fractional shortening, and 21% had evidence of pulmonary hypertension. Abnormal right ventricular global longitudinal strain and abnormal right ventricular free wall strain were present in 35% and 40% of patients, respectively. No echocardiographic variables differed between or across pediatric acute respiratory distress syndrome severity. In multivariable analyses, right ventricular global longitudinal strain was independently associated with PICU mortality (odds ratio, 3.57 [1.33–9.60]; p = 0.01), whereas right ventricular global longitudinal strain, right ventricular free wall strain, and the presence of pulmonary hypertension were independently associated with lower probability of extubation (subdistribution hazard ratio, 0.46 [0.26–0.83], p = 0.01; subdistribution hazard ratio, 0.58 [0.35–0.98], p = 0.04; and subdistribution hazard ratio, 0.49 [0.26–0.92], p = 0.03, respectively). Conclusions: Early ventricular dysfunction and pulmonary hypertension were detectable, prevalent, and independent of lung injury severity in children with pediatric acute respiratory distress syndrome. Right ventricular dysfunction was associated with PICU mortality, whereas right ventricular dysfunction and pulmonary hypertension were associated with lower probability of extubation. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/29S62lw). Supported, in part, by the Department of Anesthesiology and Critical Care Medicine at the Children's Hospital of Philadelphia. Presented, in part, as a STAR Research Presentation at the 47th Critical Care Congress of the Society of Critical Care Medicine, San Antonio, TX, on February 25, 2018. Drs. Himebauch and Conlon received funding from the Society of Critical Care Medicine (honoraria and travel costs). Dr. Yehya's institution received funding from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI) grant (K23 HL-136688). Drs. Yehya and Mercer-Rosa received support for article research from the NIH. Dr. McGowan received funding from Merck. Dr. Mercer-Rosa's institution received funding from NIH/NHLBI grant K01 HL-125521 and from the Pulmonary Hypertension Association. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: himebaucha@email.chop.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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