Transcript CRRT in Small Pediatric Patients: Practical Aspects

Acute Renal Replacement Therapy
for the Infant
Jordan M. Symons, MD
University of Washington School of Medicine
Children’s Hospital & Regional Medical Center
Seattle, WA
[email protected]
Objectives
• Indications and goals for acute renal
replacement therapy
• Modalities for renal replacement therapy
– Peritoneal dialysis
– Intermittent hemodialysis
– Continuous renal replacement therapy
(CRRT)
• Special issues related to the infant
Indications for Renal Replacement
•
•
•
•
Volume overload
Metabolic imbalance
Toxins (endogenous or exogenous)
Inability to provide needed daily fluids
due to insufficient urinary excretion
Goals of Renal Replacement
• Restore fluid, electrolyte and metabolic
balance
• Remove endogenous or exogenous
toxins as rapidly as possible
• Permit needed therapy and nutrition
• Limit complications
Renal Replacement for the Infant:
A Set of Special Challenges
• Small size of the patient
• Equipment designed for larger people
• Small blood volume will magnify effects
of any errors
• Achieving access may be difficult
• Staff may have infrequent experience
Modalities for Renal
Replacement
• Peritoneal dialysis
• Intermittent hemodialysis
• Continuous renal replacement
therapy (CRRT)
Modalities for Renal
Replacement
• Peritoneal dialysis
• Intermittent hemodialysis
• Continuous renal replacement
therapy (CRRT)
PD: Considerations for Infants
•
•
•
•
•
ADVANTAGES
Experience in the
chronic setting
No vascular access
No extracorporeal
perfusion
Simplicity
? Preferred modality
for cardiac patients?
•
•
•
•
•
DISADVANTAGES
Infectious risk
Leak
? Respiratory
compromise?
Sodium sieving
Dead space in tubing
Sodium Sieving: A Problem of Short Dwell PD
H2 O
Na+
H2 O
H2 O
Na+
H2 O
H2 O
Na+
Result: Hypernatremia
Na+
H2 O
H2 O
Na+
H2 O
H2O Na+
Na+
H2 O
H2O
Na+
Dead Space: A Problem
with Low Volume PD
Modalities for Renal
Replacement
• Peritoneal dialysis
• Intermittent hemodialysis
• Continuous renal replacement
therapy (CRRT)
IHD: Considerations for Infants
ADVANTAGES
• Rapid particle and fluid
removal; most efficient
modality
• Does not require
anticoagulation 24h/d
•
•
•
•
•
DISADVANTAGES
Vascular access
Complicated
Large extracorporeal
volume
Adapted equipment
? Poorly tolerated
Modalities for Renal
Replacement
• Peritoneal dialysis
• Intermittent hemodialysis
• Continuous renal replacement
therapy (CRRT)
Pediatric CRRT: Vicenza, 1984
CRRT for Infants:
A Series of Challenges
•
•
•
•
•
•
Small patient with small blood volume
Equipment designed for bigger people
No specific protocols
Complications may be magnified
No clear guidelines
Limited outcome data
Potential Complications of
Infant CRRT
•
•
•
•
•
•
Volume related problems
Biochemical and nutritional problems
Hemorrhage, infection
Thermic loss
Technical problems
Logistical problems
CRRT in Infants <10Kg: Outcome
N
Survivors
85
38%
Survival
69
32
41%
Survival
28
16
25%
Survival
4
Patients <10kg
Patients 3-10kg
Am J Kid Dis, 18:833-837, 2003
Patients <3kg
ppCRRT Data of Infants <10Kg:
Demographic Information
Number of Subjects 84
(51 boys (61%))
(33 girls (39%))
Age
Median 69 days
(1 d - 2.9 y)
ICU Admit weight
Median 4.4 kg
(1.3 - 10 kg)
ppCRRT Data of Infants <10Kg:
Primary Diagnoses
10%
35%
15%
19%
Sepsis
Cardiac
Pulmonary
21%
GI/Hepatic
Inborn Error of Metabolism
ppCRRT Data of Infants <10Kg:
Indications for CRRT
Fluid Overload and Electrolyte Imbalance
84%
Other (Endogenous Toxin Removal)
16%
N=84
ppCRRT Data of Infants <10Kg:
Clinical Data
Parameter
Days in ICU prior to CRRT
PRISM score — ICU admit
PRISM score — CRRT start
Inotrope number — CRRT start
Urine output — CRRT start
(ml/kg/hr over prior 24hrs)
% Fluid overload from ICU
admission to CRRT start
Median Range
2
0 - 135
17.5
0 - 48
20
0 - 48
1
0-4
0.7
0 - 12
13.7
-28 - 220
ppCRRT Data of Infants <10Kg:
Technical Characteristics of CRRT
Catheter Site
N=84
Femoral
Internal Jugular
Subclavian
Modality
CVVHD
CVVH
CVVHDF
Anticoagulation Citrate
Heparin
Prime
Blood
Saline
Albumin
60%
28%
12%
59%
18%
23%
55%
45%
87%
8%
5%
ppCRRT Data of Infants <10Kg:
CRRT Treatment Data
Parameter
Blood Flow (ml/kg/min)
Fluid Flow (ml/kg/hour)
Average CRRT Clearance (ml/hr/1.73M2)
Aggregate CRRT Clearance (ml/hr/1.73M2)
CRRT duration (days)
N=84
Median Range
8
1.7-46
67
7-571
2582 135-19319
3540
5
135-12713
0-83
ppCRRT Data of Infants <10Kg:
Survival by Weight
70%
p=0.001
60%
p=1.0
50%
40%
30%
44%
42%
43%
64%
< 5 kg
5-10 kg
< 10 kg
> 10 kg
20%
10%
0%
ppCRRT Data of Infants <10Kg:
Factors Effecting Survival
Clinical Variable
Admission PRISM score
GI/Hepatic disease
Survivors Non-Survivors
P
16
21
<0.05
8%
31%
0.01
Multiorgan dysfunction
Pressor Dependency
Mean Airway Pressure
Initial urine output (ml/kg/hr)
68%
36%
11
2.4
91%
69%
20
1.0
0.04
<0.01
<0.001
0.02
%Fluid Overload at Start
>10% Overload at Start
15%
43%
34%
71%
0.02
0.02
ppCRRT Data of Infants <10Kg:
Survival by Return to Dry Weight
90%
80%
78%
65%
70%
60%
50%
40%
D ry Weight A c hieved
D ry Weight N ot A c hieved
35%
30%
22%
20%
10%
0%
Survivors
N on-s urvivors
Infant CRRT at Children’s Hospital &
Regional Medical Center, Seattle
Infant CRRT in Seattle: Overview
•
•
•
•
Coordinated by nephrology
Performed in infant/pediatric ICU
Set up by dialysis nurses
Run at the bedside by neonatology or
critical care nurses
• Dedicated CRRT device
– BM-25: 1999 – 2005
– Prisma: 2005 - present
CRRT Access in the Neonate:
What Works?
• Hemodialysis Line: 7 Fr double lumen
• Two single lumen lines:
– 5 Fr catheters or introducers
• Umbilical lines:
– 5 Fr UAC; 7 Fr UVC
• Leg position - be creative
• Tape on the skin - may need to get
creative
PRISMA
• Dedicated CRRT device
• Highly automated
• Designed for ease of use
at the bedside
CRRT Filter Sets for Prisma
Surface Priming
Area
Volume
Membrane
M-10*
0.042m2
50ml
AN-69
M-60
0.6m2
90ml
AN-69
M-100
0.9m2
107ml
AN-69
HF-1000
1.15m2
128ml
Polyarylethersulfone
(PAES)
* Not available in US
Bradykinin Release Syndrome
• Mucosal congestion, bronchospasm,
hypotension at start of CRRT
• Resolves with discontinuation of CRRT
• Thought to be related to bradykinin release
when patient’s blood contacts hemofilter
• Exquisitely pH sensitive
Bypass System to Prevent
Bradykinin Release Syndrome
PRBC
Waste
Modified from Brophy, et al. AJKD, 2001.
Recirculation System to Prevent
Bradykinin Release Syndrome
Normalize pH
D
Recirculation
Plan:
Qb 200ml/min
Qd ~40ml/min
Time 7.5 min
Normalize K+
Based on Pasko, et al. Ped Neph 18:1177-83, 2003
Waste
Simple Systems to Limit Likelihood
of Bradykinin Release Syndrome
• Don’t prime on with blood
• Don’t use the AN-69 membrane
Thermal Regulation
•
•
•
•
Hotline® blood warming tubing
Place at venous return to patient
Leave on at set temperature of 39 C
Treat temp elevations if they occur
Infant CRRT in Seattle:
CRRT Staffing
•
•
•
•
Dialysis RN sets-up & initiates therapy
PICU/IICU RN manages patient
Nephrology/Dialysis RN on call 24/7
Acuity assigned to pump as if a
separate patient
• Staffing determined by acuity
Infant CRRT in Seattle: How to
Handle a Rare Procedure
• Developed an Acute Initiation Checklist
defining specific roles/actions for:
– Infant ICU MD
– Nephrology MD
– Infant ICU RN
– Dialysis RN
– IV access MD
Acute Initiation Checklist: Example
Infant ICU Nurse
• Time Zero:
– Move pt to room with dialysis
water
– Get orders from resident for
IV fluids to keep access open
• 20 – 40 min:
– Meet MD; discuss RRT plan
• 60 – 120 min:
– Meet ICU team
Dialysis Nurse
• 10 – 60 min:
– Arrive and begin setup
• 20 – 40 min:
– Meet MD; discuss RRT plan
• 60 – 120 min:
– Complete prime; ready for
access
– Begin RRT
– Meet ICU team
Acute Initiation Checklist: Example
Nephrology MD
• Time Zero:
– Contact dialysis nurse to start
RRT urgently
• 10 – 20 min:
– Bring catheters to ICU
– Enter orders for RRT
• 20 – 40 min:
– Meet ICU MDs & RNs,
discuss plan
• 60 – 120 min:
– Present in ICU for initiation
– Meet ICU team
IV Access MD
• 10 – 30 min:
– Arrive and begin insertion of
dialysis access
• 60 min (or when circuit is
ready for Rx)
– Complete insertion of access
– Connect ports to heparin IV
solutions
Infant RRT: Summary
•
•
•
•
All modalities of RRT possible for infants
No modality is perfect
Technical challenges can be met
Careful planning with institution, program,
and individuals improves care
• Cooperation, communication, and
collaboration will increase our success
Thanks!