Characteristics, Mortality, and Outcome of Acquired

Anasarca in the NICU

Joseph B. Philips III MD1, Joshua J. Lovvorn MD2, Laura H. Nye MD1, and Monica V.
Collins RN, BSN, MAED1
1
Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL
2
Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR

Address correspondence:
Joseph B. Philips, III, MD
Division of Neonatology
176F, Suite 9380
Birmingham, AL 35249-7335
E-mail: jphilips@uab.edu

Author Disclosure: The authors have nothing to disclose.

ABSTRACT
OBJECTIVE: To determine the incidence, etiology, demographics, and outcome of infants who develop anasarca
in a large NICU.

PATIENTS AND METHODS: We performed a retrospective chart review for the period 1/1/06 to 12/31/07 of
infants who manifested an increase in body weight of at least 30% over a ten day period. Charts were retrieved and
information regarding patient demographics, presumptive cause(s) of the condition, as well as outcome data was
recorded.

RESULTS: Thirty seven (1.3%) of 2834 infants met criteria. The mean birth weight was 1256g with a range of 420-
3920g, and mean gestation was 28 (23-39) weeks. The mean age at onset was 32 (0-166) days; mean time to
maximum weight gain was 16 (0-66) days. Infants gained an average of 106% (37-315) from weight at onset.
Overall, 78% (29 of 37) died. Of those with renal failure, 86% (19 of 22) died; 83% (19 of 23) with clinical or
confirmed sepsis expired; and 75% (9 of 12) with NEC died. All 6 infants with congenital heart disease died. Many
infants had more than one diagnosis.

CONCLUSIONS: Acquired anasarca in the NICU is uncommon, but not rare. The systemic inflammatory response
syndrome is a common cause of acquired anasarca. Renal failure is frequent in these infants and further complicates
management. As our supportive abilities have improved, more infants are surviving longer in the NICU and are
therefore more prone to complications such as anasarca which is associated with a high mortality rate, regardless of
etiology. Anasarca likely contributes to morbidity and mortality in this patient group.

Key Words: newborn, anasarca, NICU

INTRODUCTION

Acquired anasarca appears to us to be an revealed no systematic analyses of the

increasing problem in the NICU. However, incidence, causes, demographic
a computer search of the literature (PubMed) characteristics, or outcomes of infants who

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Anasarca in the NICU Philips JB, et al

develop massive edema. We therefore infant qualified for inclusion in the study.
conducted a retrospective chart review study Infants who were transferred to CoA from
to correct this knowledge deficiency. the RNICU were also evaluated in order to
have a complete data base. A data
METHODS collection form was devised which listed
pertinent demographic, diagnostic, and
Setting and Participants outcome data. An attempt was made to
determine the etiology of the anasarca in
The RNICU is a large academic level IIIc
each case.
NICU with a capacity of 110+ patients
located within a major university medical Statistical Analysis
center, admitting over 1,400 infants per
year. The majority of patients are inborn, Comparisons between infants who survived
many of whom were fetal referrals to our and those who died using the unpaired t-test
high-risk Maternal-Fetal Medicine service. did not show any statistically significant
Approximately 200 infants per year are differences at the p<0.05 level. Therefore,
transported in from outside hospitals. The results are presented as summary data.
University of Alabama at Birmingham
(UAB) participates in the multi-centered RESULTS
NICHD Neonatal Research Network. Our
morbidity and mortality outcomes compare Acquired anasarca developed in 37 of 2,834
favorably with the average outcomes of the admissions for a rate of 1.3%. A typical
Network. daily weight plot is shown in Figure 1.
None of the infants were diagnosed with
The Childrens of Alabama (CoA) NICU is congenital nephrotic syndrome and none
a 50+ bed level IIIc unit that houses infants were dialyzed. Twenty were male (54%),
with surgical needs, provides ECMO, and 17 were white, 16 African-American, 2
gives long term care to infants with severe Hispanic, and one was African-
bronchopulmonary dysplasia. The units at American/Hispanic. The mean birth weight
UAB and CoA are both attended by faculty of affected infants was 1,256g with a range
and fellows from the Division of of 420 to 3,920g, while mean gestational age
Neonatology in the Department of Pediatrics was 28 weeks with a range of 23 to 39
at UAB. This study was approved by the
UAB Institutional Review Board.
Data Collection
We searched the computerized medical
records (NeoData) for all UAB RNICU
admissions from 1/1/06 to 12/31/07.
Graphic plots of daily weights were
produced for each patient. Patients with
immune and non-immune hydrops fetalis
were excluded. Acquired anasarca was
defined as an increase in weight of > 30%
over a period of 10 days or less. Patient
charts were then reviewed and a
determination was made as to whether the

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Anasarca in the NICU
weeks. The average age at onset was 32 (0-
166) days of postnatal age and time to
maximum weight gain from onset was 16
(0-66) days. Overall weight gain was 106%
(37-315%) from baseline at onset and was
77% (45-174%) in survivors and 114% (33-
315%) in non-survivors.
Mortality was high with 29 deaths for a
mortality rate of 78%. Of those with renal
failure, 19 of 22 or 86% died, 9 of 12 (75%)
infants with necrotizing enterocolitis died,
19 of 23 (83%) with clinical or confirmed
sepsis expired, while all 6 infants with
congenital heart disease succumbed (n > 37
due to multiple diagnoses in some).
DISCUSSION
Acquired anasarca is an uncommon
condition in the NICU that is associated
with a high mortality rate regardless of
etiology. Anasarca can result from a
number of mechanisms, including low
serum albumin, free water retention from
renal failure, excess fluid administration,
and increased capillary permeability.1
Increased capillary permeability can ensue
from diffuse capillary injury following
cardiovascular collapse requiring
resuscitation or systemic inflammatory
response syndrome (SIRS) secondary to
septicemia or other severe infections.2
There were several causes of anasarca
involved in many of our babies such as SIRS
and renal failure in infants with NEC who
also required multiple crystalloid and colloid
infusions to support blood pressure during
shock.
There are no known therapies for increased
capillary permeability. The management
dilemma in infants who develop anasarca
from increased capillary permeability is that
they lose intravascular volume into the
interstitium, resulting in decreased blood
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Philips JB, et al
pressure and tissue perfusion. This in turn
dictates the use of volume expanders to
replete the intravascular volume; however,
these expanders rapidly leak out of the
vasculature and exacerbate the anasarca,
leading to the need for further volume
expansion. The result is often a vicious
cycle of repeated infusions of volume
expanders and progressive anasarca.
How much the anasarca contributes to
morbidity and mortality is unclear.
Peripheral edema is generally considered to
not be a significant contributor but
pulmonary edema may significantly increase
the need for higher conventional ventilator
settings and the use of jet or high frequency
oscillatory ventilation. The terminal event
in many infants with anasarca is inability to
oxygenate and/or ventilate, leading to
progressive hypoxemia, metabolic and
respiratory acidosis, eventuating in
cardiovascular collapse and death.
Whatever the cause of anasarca, the
prognosis must be guarded once the
condition develops. One of our primary
purposes in this report is to provide
objective data from a major NICU for
practitioners to use in counseling families
whose babies develop this condition
following birth. Our numbers are small,
especially for individual conditions, but the
overall mortality rate of 78% shows that
most infants who develop this condition will
not survive.
CONCLUSION
Severe generalized edema is uncommon but
not rare in the NICU and is associated with a
high mortality rate. Development of
effective preventive or ameliorative
therapies could significantly improve the
outcome of these critically ill infants.
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Anasarca in the NICU Philips JB, et al

REFERENCES

1. Colton DP. Pathophysiology of edema. In: Polin 2. Wynn J, Cornell TT, Wong HR, Shanley TP,
RA, Fox WW, Abman SH, editors. Fetal and Wheeler DS. The host response to sepsis and
Neonatal Physiology. Philadelphia, PA: developmental impact. Pediatrics, 2010;
Saunders; 2004. p 1357-61. 125(5):1031-41.

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