McCulloch-ResourcesScarce - Pediatric Continuous Renal
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Transcript McCulloch-ResourcesScarce - Pediatric Continuous Renal
Putting it all together:
When resources are scarce
Mignon McCulloch
Associate Professor
Department of Paediatric Critical Care
Red Cross Children’s Hospital (RXH)
University of Cape Town
Acknowledgements
Thanks to Stuart and Tim
Including all forms of CRRT
Disclosures
Passionate about PD
Access for children with AKI in poorly
resourced areas
Clinical Patients
2.5kg boy
Complex Congenital
Heart
Post-op surgical
No urine output x 8hrs
What next?
12year old boy
Meningococcal Sepsis
Shocked needing
inotropic support
Poor urine output x 12hrs
What next?
Less than 1km down the road…
Role of Fluid
FO >20% @ time of CRRT initiation
%FO = (Fluid In – Fluid Out) x 100%
(PICU Admission weight)
Goldstein et al(2005). KI 67:653-658
But what happens before?
Goal directed therapy
Study of Emergency Department Management
Rivers et al, N Engl J Med, 2001
de Oliveira CF et al, Intensive Care Med, 2008
de Oliveira CF et al, Intensive Care Med, 2008
Severe sepsis and septic shock
guidelines 2008
FEAST Trial ?
FEAST Study
(Fluid Expansion as Supportive Therapy)
NEJM June 30, 2011 Maitland et al
Severe febrile illness & impaired perfusion
randomised to:
Bolus 5% Albumin 20-40ml
Bolus 0,9% Saline
No bolus
Halt recruitment 3141/3600
48hour mortality
10.6% bolus vs 7.3% non-bolus(p=0.003)
Maitland et al, N Engl J Med, 2011
Maitland et al, N Engl J Med, 2011
Criticisms
NEJM Oct 6, 2011
Severely anaemic children - 32% Hb<5mg/dl
Acute haemodilution in pre-existing anaemia
Impaired oxygen delivery leading to organ failure
Malaria – 57% thus have sequestration of red cells
in microcirculation
Shock – not all forms are the same – related to
high CO or diminished O2
Compromised oxygen delivery – 77% thus
worsening cellular dysoxia
Malnutrition
Plans
Rapid triage and treatment
Monitoring in a low resource setting
What is physiologic fluid best for bolusing
What is possible? CVP
Blood vs fluid boluses
Choice of fluids BMJ 2010;341 Maitland,
Colloids vs Crystalloids for fluid resuscitation Cochrane
2012 – Perel P
Low-volume fluid resuscitation insufficient for
patients in shock – Inotropes?
Needed:
Observational Trial in Septic Shock
Fluid challenge – 10-20ml/kg…then
Observe response:
Heart rate and BP, Resp rate, Oxygen sats
Cardiac output in response to fluid
Portable Uscom/Echocardiography validation
Pulmonary oedema – Lung impedance
High flow Oxygen/CPAP/Ventilation
Inotropes – peripheral/central
AKI???
Renal Replacement Therapy
What we have done in Cape Town?
Initial Management
Urine output:
Aim for > 1ml/kg/hr
Fluid challenge
10ml/kg 0.9% Saline over 30 minutes and reassess
urine output
If no improvement & no signs of fluid overload,
repeat bolus
Clinical assessment regarding intravascular
volume status +/- invasive assessment
“Encouraging Agents”
Fluid and Perfusion
Furosemide ivi
Boluses 1 - 5mg/kg or
Infusion 0.1 – 1mg/kg
Mannitol/Metolazone
Aminophylline 1 - 5mg/kg ivi if stable
**Dopamine 2 – 5mcg/kg/min infusion
Kenya
Nigeria
Nigeria
IPNA/ISN Training for Africa
Benin
Ghana
Uganda
Challenges on Return
Poor Staffing
Lack of Facilities & Equipment
Radiology – Ultrasound only
Support from Home Institutions
Histology support
100%
86%
86%
71%
57%
Paradise ?
ISN Sister Program
PD Workshop
Accra, Ghana
04.12.2011
PD Catheters
Art of Medicine? Innovative and Creative
Cannulas
Naso-gastric tubes/Chest Drains
Venous Central lines
Rigid ‘Stick’ catheters
‘Peel away’ Tenchkoff
Flexible Multi-purpose drainage catheters
Auron A et al Am J Kidney Dis 2007
Devices for Peritoneal Dialysis
New Generation Cook Catheters
Kimal ‘Peel-away’ Tenchkoff
Tips for Success
Size matters…keep skin nick at minimum or nil at all
Else will leak!!!
Avoid metal needle that comes with pack
Rather Jelco/Venous access catheter
Withdraw needle 0.5mm as go thru peritoneum and
advance plastic sheath
Run fluid in freely to fill abdomen before wire and catheter
If not free-flowing pull needle back slightly
May be in bowel?....role of ultrasound
Don’t forget to empty bladder
Automated Dialysis
Home choice machine
Manual Dialysis with Fluid Warmer
Post Abdominal Surgery
8Fr Cook
Pigtail multi-purpose
drainage device
8Fr Cook PD
Catheter
Improvised equipment and solution
used in the procedure
4/7/2015
Dr S. Antwi: Paediatric Nephrologist KNUST-SMA/KATH
41
5-yr old with HUS
PD duration - 8 days
4/7/2015
Dr S. Antwi: Paediatric Nephrologist KNUST-SMA/KATH
42
PD progress in 1st 24 hrs
4/7/2015
Dr S. Antwi: Paediatric Nephrologist KNUST-SMA/KATH
43
PD in session
4/7/2015
Dr S. Antwi: Paediatric Nephrologist KNUST-SMA/KATH
44
CONCLUSION
Peritoneal dialysis as a form of acute renal
replacement therapy is:
Practical
Appropriate for developing countries
Results reflected suggest that due to ease of
use, it may also be appropriate for centers where
access to CVVH/D may not be available
due to lack of equipment or
trained staff
PRACTICAL SKILLS WORKSHOP
IPNA/ISN/SKCF/Saving Young Lives
…..and all other supporters
12-16 Nov 2012
Thank you to all my colleagues @
RXH
Thank you for your time and
attention !